HESI RN
HESI Exit Exam RN Capstone
1. Which intervention should be prioritized by the nurse when assessing tissue perfusion post-above knee amputation (AKA)?
- A. Evaluate the closest proximal pulse.
- B. Observe color and amount of wound drainage.
- C. Observe for swelling around the stump.
- D. Assess the skin elasticity of the stump.
Correct answer: A
Rationale: The correct answer is to evaluate the closest proximal pulse when assessing tissue perfusion post-above knee amputation (AKA). Checking the closest proximal pulse provides the best indication of tissue perfusion in the extremities after an AKA procedure. Observing the color and amount of wound drainage (Choice B) is important for wound care but does not directly assess tissue perfusion. Observing for swelling around the stump (Choice C) may indicate inflammation or fluid accumulation but is not the most direct way to assess tissue perfusion. Assessing the skin elasticity of the stump (Choice D) is more related to skin integrity and wound healing rather than tissue perfusion.
2. A client is prescribed alendronate (Fosamax) for the treatment of osteoporosis. Which instruction should the nurse provide to the client?
- A. Take the medication at bedtime.
- B. Take the medication with a full glass of water.
- C. Lie down for 30 minutes after taking the medication.
- D. Take the medication with food to avoid gastrointestinal upset.
Correct answer: B
Rationale: The correct instruction for a client prescribed alendronate (Fosamax) for osteoporosis is to take the medication with a full glass of water first thing in the morning. It should be taken at least 30 minutes before any food, beverage, or other medication. The client should also remain upright for at least 30 minutes after taking the medication to prevent esophageal irritation. Taking alendronate at bedtime or with food is not recommended as it may reduce its absorption and effectiveness.
3. The nurse is monitoring a client who is receiving continuous ambulatory peritoneal dialysis. The nurse should notify the physician of which of the following findings?
- A. Clear dialysate outflow.
- B. Cloudy dialysate outflow.
- C. Decreased urine output.
- D. Increased blood pressure.
Correct answer: B
Rationale: Cloudy dialysate outflow is an indication of peritonitis, a serious complication of peritoneal dialysis that requires immediate medical attention. Clear dialysate outflow is a normal finding indicating proper dialysis function and should not raise concern. Decreased urine output may be expected in a client undergoing dialysis due to the removal of excess fluids from the body. Increased blood pressure is a common complication in clients with kidney disease but is not directly related to cloudy dialysate outflow.
4. After breastfeeding for 10 minutes at each breast, a new mother calls the nurse to the postpartum room to help change the newborn's diaper. As the mother begins the diaper change, the newborn spits up the breast milk. What action should the nurse implement first?
- A. Wipe away the spit-up and assist the mother with the diaper change.
- B. Sit the newborn upright and burp by rubbing or patting the upper back.
- C. Place the newborn in a position with the head lower than the feet.
- D. Turn the newborn to the side and use bulb suction for the mouth and nares.
Correct answer: B
Rationale: After a newborn spits up breast milk following feeding, the priority action for the nurse is to sit the newborn upright and burp by rubbing or patting the upper back. This position helps release trapped air and reduces the likelihood of further spit-up or aspiration. It is essential to address this first to prevent potential complications and ensure the newborn's comfort and safety.
5. Which of the following best describes the nurse's role in maintaining patient dignity?
- A. The nurse ensures that the patient is treated with respect and that their personal beliefs and values are considered in their care.
- B. The nurse maintains the patient's dignity by ensuring privacy during personal care activities.
- C. The nurse ensures that the patient's personal information is kept private and only shared with those directly involved in their care.
- D. The nurse ensures that the patient is involved in decisions about their care and that their preferences are respected.
Correct answer: A
Rationale: The correct answer is A. The nurse's role in maintaining patient dignity goes beyond just privacy during personal care activities. It involves treating the patient with respect, considering their personal beliefs and values in their care. While privacy is important for dignity, respecting personal beliefs and values is equally crucial. Choice B focuses solely on privacy, overlooking the broader aspects of dignity maintenance. Choices C and D, although important in patient care, do not fully capture the comprehensive approach needed for maintaining patient dignity as described in choice A.