HESI RN
HESI Exit Exam RN Capstone
1. A 4-year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first?
- A. Notify the healthcare provider
- B. Readjust the traction
- C. Administer the ordered PRN medication
- D. Reassess the foot in fifteen minutes
Correct answer: A
Rationale: A pale foot with no pulse suggests a compromised blood supply, indicating a potential vascular emergency. The nurse's immediate priority is to notify the healthcare provider to address the situation promptly. Readjusting the traction, administering PRN medication, or waiting to reassess the foot later could lead to serious complications due to the compromised blood supply, making choices B, C, and D incorrect in this critical situation.
2. A client with chronic liver disease is prescribed lactulose. Which laboratory value should the nurse monitor to evaluate the effectiveness of this medication?
- A. Bilirubin level
- B. Serum ammonia level
- C. Serum potassium level
- D. Albumin level
Correct answer: B
Rationale: The correct answer is B: Serum ammonia level. Lactulose is used to lower serum ammonia levels in clients with chronic liver disease, particularly in cases of hepatic encephalopathy. Monitoring serum ammonia levels is crucial to evaluate the effectiveness of lactulose in managing hepatic encephalopathy. Choices A, C, and D are incorrect because they are not directly related to the action or evaluation of lactulose in chronic liver disease.
3. At 42-weeks gestation, a client refuses induction and desires a natural delivery. What is the most important action for the nurse to take?
- A. Discuss alternative ways to support her birth plan.
- B. Explain the indications for induction in post-term pregnancy.
- C. Discuss the differences between labor with oxytocin and natural labor.
- D. Ask the healthcare provider to discuss the issue with the client.
Correct answer: A
Rationale: The correct answer is to discuss alternative ways to support her birth plan. It is crucial to respect the client's autonomy and desires while ensuring their safety and well-being. Choice B is incorrect because while educating the client about the indications for induction is important, it is not the most immediate action to take in this scenario. Choice C is incorrect as it focuses on comparing labor types rather than supporting the client's birth plan. Choice D is incorrect as the nurse should first engage with the client directly before involving the healthcare provider.
4. A client on long-term corticosteroid therapy for rheumatoid arthritis presents with weakness and hypotension. What is the nurse's first action?
- A. Administer a PRN dose of corticosteroids.
- B. Place the client in a supine position.
- C. Encourage oral fluid intake.
- D. Review the client's recent medication history.
Correct answer: A
Rationale: Administering a PRN dose of corticosteroids is the correct first action when a client on long-term corticosteroid therapy presents with weakness and hypotension. In this scenario, the client is likely experiencing adrenal insufficiency due to prolonged corticosteroid use. Administering corticosteroids promptly can help correct this insufficiency and improve the client's symptoms. Placing the client in a supine position may be necessary for symptomatic hypotension, but addressing the root cause with corticosteroids is more crucial initially. Encouraging oral fluid intake is important for many conditions but is not the priority in this case. Reviewing the client's recent medication history can provide valuable information but is not the first action needed to address the client's current presentation.
5. A client with pheochromocytoma is admitted to the hospital. Which intervention has the highest priority?
- A. Monitor blood pressure frequently
- B. Start intravenous fluids at a fast rate
- C. Administer pain medication to reduce discomfort
- D. Give antihypertensive medications as prescribed
Correct answer: B
Rationale: The correct answer is B: Start intravenous fluids at a fast rate. In a client with pheochromocytoma, the highest priority intervention is to ensure adequate intravascular volume before initiating any other treatment. This helps prevent a sudden drop in blood pressure that can occur due to the release of catecholamines during tumor manipulation. While monitoring blood pressure frequently is essential, ensuring adequate intravascular volume takes precedence. Administering pain medication and antihypertensive medications are important but are not the highest priority in the initial management of pheochromocytoma.
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