HESI RN
HESI RN Exit Exam 2023 Capstone
1. The nurse is caring for a client following a craniotomy. Which finding should the nurse report immediately?
- A. Pupils equal and reactive to light.
- B. Sudden increase in urine output.
- C. Diminished breath sounds bilaterally.
- D. Increase in blood pressure by 20 mmHg.
Correct answer: C
Rationale: The correct answer is C, 'Diminished breath sounds bilaterally.' This finding should be reported immediately as it could indicate a serious complication such as increased intracranial pressure or respiratory compromise. In a post-craniotomy client, changes in breath sounds may be a sign of developing issues that need prompt intervention. Choices A, B, and D are not as critical in the immediate post-craniotomy period. Pupils equal and reactive to light are expected findings, a sudden increase in urine output may require monitoring but not immediate reporting, and a small increase in blood pressure may not be alarming unless it is significantly high or accompanied by other concerning signs.
2. A client is receiving 30 mg of enoxaparin subcutaneously twice a day. In assessing adverse effects of the medication, which serum laboratory value is most important for the nurse to monitor?
- A. Hemoglobin level
- B. Platelet count
- C. Activated partial thromboplastin time (aPTT)
- D. Prothrombin time (PT)
Correct answer: B
Rationale: The correct answer is B: Platelet count. Enoxaparin can cause heparin-induced thrombocytopenia (HIT), making it crucial to monitor the platelet count for signs of thrombocytopenia. Monitoring the platelet count helps in early detection of this serious adverse effect. Choices A, C, and D are less relevant in this context. Hemoglobin level checks are more indicative of bleeding issues rather than thrombocytopenia caused by enoxaparin. Activated partial thromboplastin time (aPTT) and prothrombin time (PT) are less impacted by enoxaparin and are not typically used to monitor for HIT.
3. A client who had a vasectomy is in the post-recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse?
- A. Until the healthcare provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception.
- B. This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen, and no sperm are in your ejaculate.
- C. After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days.
- D. The healthcare provider at this clinic recommends rest, ice, an athletic supporter, or over-the-counter pain medication to relieve any discomfort.
Correct answer: A
Rationale: The most important point to reinforce after a vasectomy is to continue using contraception until the healthcare provider confirms the absence of sperm in the ejaculate. Choice A is correct because it emphasizes the necessity of another form of contraception until sperm absence is confirmed. Choice B is incorrect because it focuses on how a vasectomy works anatomically rather than the need for ongoing contraception. Choice C is incorrect as it discusses post-vasectomy care but does not address the need for continued contraception. Choice D is also incorrect as it refers to general post-procedure recommendations but does not highlight the crucial aspect of using contraception until sperm absence is confirmed.
4. While changing a client's chest tube dressing, the nurse notes a cracking sensation when gentle pressure is applied to the skin at the insertion site. What should the nurse do next?
- A. Apply a pressure dressing at the chest tube site.
- B. Administer an oral antihistamine per PRN order.
- C. Assess the client for allergies to topical cleaning agents.
- D. Measure the area of crackling and swelling.
Correct answer: D
Rationale: Measuring the area of crackling and swelling is essential in monitoring the progression of subcutaneous emphysema, which can result from air leaking into the tissues around the chest tube insertion site. This technique helps evaluate the extent of the issue and guides further interventions. Applying a pressure dressing (choice A) might exacerbate the condition by trapping more air. Administering an oral antihistamine (choice B) is not indicated for subcutaneous emphysema. Assessing for allergies to topical cleaning agents (choice C) is not the priority in this situation compared to evaluating and managing the subcutaneous emphysema.
5. A client at 12 weeks gestation is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum. Which action is most important for the nurse to implement?
- A. Provide emotional support
- B. Monitor daily weight
- C. Encourage small frequent meals
- D. Initiate prescribed intravenous fluids
Correct answer: D
Rationale: Hyperemesis gravidarum, characterized by severe nausea and vomiting, leads to dehydration and electrolyte imbalances. The priority intervention is initiating IV fluids to correct these imbalances. Providing emotional support is important for the client's well-being, but addressing fluid and electrolyte imbalances takes precedence. Monitoring daily weight and encouraging small frequent meals are beneficial interventions but are not the priority when managing hyperemesis gravidarum.
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