HESI RN
HESI RN Exit Exam 2023 Capstone
1. In the critical care unit, which client should receive the most care hours by a registered nurse (RN)?
- A. A client with a newly inserted Foley catheter and Alzheimer's disease
- B. A 55-year-old with chronic kidney disease
- C. An 82-year-old client with a newly fractured femur and soft wrist restraints
- D. A 72-year-old with pneumonia and sepsis on antibiotics
Correct answer: C
Rationale: The client with a newly fractured femur and soft wrist restraints should receive the most care hours as they have physical limitations due to the fracture and mental limitations due to being restrained. This client requires continuous monitoring, support, and frequent assessments to prevent complications. Choices A, B, and D do not have the same level of physical and mental care needs as the client with the newly fractured femur and soft wrist restraints.
2. In a client with moderate, persistent, chronic neuropathic pain due to diabetic neuropathy who takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily, if Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented?
- A. Continue gabapentin.
- B. Discontinue ibuprofen.
- C. Add aspirin to the protocol.
- D. Add oral methadone to the protocol.
Correct answer: A
Rationale: In the presence of moderate, persistent, chronic neuropathic pain, the WHO pain relief ladder recommends continuing gabapentin, as it is effective for managing both anxiety and pain. Ibuprofen, a nonsteroidal anti-inflammatory drug, is not the mainstay for neuropathic pain relief according to the ladder and can be discontinued if needed. Aspirin is not typically added to the protocol for neuropathic pain management at this step. Methadone is reserved for severe pain and is not the standard choice at Step 2 of the WHO pain relief ladder for neuropathic pain.
3. An older female client tells the nurse that her muscles have gradually been getting weaker. What is the best initial response by the nurse?
- A. Explain that this is an expected occurrence with aging.
- B. Observe the lower extremities for signs of muscle atrophy.
- C. Review the medical record for recent diagnostic test results.
- D. Ask the client to describe the changes that have occurred.
Correct answer: D
Rationale: The best initial response by the nurse when the client reports muscle weakness is to ask the client to describe the changes that have occurred. This approach allows the nurse to gain a better understanding of the client's experience, the extent of weakness, any associated symptoms, and potential triggers. By actively listening to the client's description, the nurse can gather valuable information that will aid in a comprehensive assessment and development of a tailored care plan. Choice A is incorrect because assuming muscle weakness is solely due to aging without further assessment can lead to overlooking potential underlying causes. Choice B is incorrect as observing for signs of muscle atrophy should come after gathering information directly from the client. Choice C is incorrect as reviewing diagnostic test results should not be the initial step when the client's current experience is being shared.
4. A 2-year-old child is admitted with severe dehydration due to gastroenteritis. Which assessment finding indicates that the child's condition is improving?
- A. Decreased heart rate.
- B. Sunken fontanelle.
- C. Increased urine output.
- D. Dry mucous membranes.
Correct answer: C
Rationale: Increased urine output is a positive sign indicating that the child's hydration status is improving. It suggests that the kidneys are functioning more effectively and able to excrete urine, which is a crucial indicator of improved hydration levels in a dehydrated patient. Decreased heart rate (Choice A) can be a sign of possible shock. A sunken fontanelle (Choice B) is a sign of dehydration. Dry mucous membranes (Choice D) are also indicative of dehydration.
5. During the admission assessment of a 3-year-old with bacterial meningitis and hydrocephalus, which assessment finding is evidence of increased intracranial pressure (ICP)?
- A. Low blood pressure
- B. Increased respiratory rate
- C. Normal pupil reaction
- D. Sluggish and unequal pupillary responses
Correct answer: D
Rationale: Sluggish and unequal pupillary responses are indicative of increased intracranial pressure (ICP) in a child with bacterial meningitis and hydrocephalus. This finding suggests that the optic nerve is being compressed due to increased ICP, causing a delay in pupillary reactions. Such a delay is a critical sign of worsening ICP and necessitates immediate intervention. Low blood pressure and increased respiratory rate can occur in various conditions but are less specific to increased ICP than sluggish and unequal pupillary responses, which directly reflect neurological compromise.