HESI RN
HESI RN Exit Exam Capstone
1. A client with COPD and a history of emphysema presents with increasing shortness of breath. What action should the nurse implement first?
- A. Notify the healthcare provider of the client's distress.
- B. Auscultate the client's lung sounds and oxygen saturation.
- C. Determine if the client is experiencing anxiety.
- D. Assess the oxygen delivery system.
Correct answer: B
Rationale: The correct action for the nurse to implement first is to auscultate the client's lung sounds and oxygen saturation. This helps in assessing the respiratory status of the client, which is crucial in managing COPD and emphysema exacerbations. Checking for any abnormalities in lung sounds and monitoring oxygen saturation levels can provide important information for immediate intervention. Option A is not the first action to take in this situation as directly assessing the client's respiratory status is more immediate. Option C, determining if the client is experiencing anxiety, is important but should come after assessing the physical respiratory status. Option D, assessing the oxygen delivery system, is also essential but should follow the direct assessment of the client's respiratory status.
2. A client scheduled for a bronchoscopy in the morning is anxious and asking the nurse numerous questions about the procedure. Which intervention has the highest priority in preparing the client for the procedure?
- A. Provide detailed education about the procedure
- B. Administer prescribed anti-anxiety medication
- C. Instruct client to write down the questions
- D. Reassure the client about the safety of the procedure
Correct answer: C
Rationale: Encouraging the client to write down questions is the highest priority as it allows the nurse to address concerns systematically, reducing anxiety. This approach empowers the client and ensures that all concerns are covered before the procedure, reducing the risk of miscommunication or unaddressed fears. Providing detailed education about the procedure (choice A) is important but may not address the client's immediate anxiety. Administering anti-anxiety medication (choice B) should only be done if other interventions are ineffective or if prescribed by the healthcare provider. Reassuring the client about the safety of the procedure (choice D) is essential but may not address the specific questions and concerns causing anxiety.
3. A male client with HIV on saquinavir and other antiretrovirals reports increased hunger and thirst but weight loss. Which action should the nurse take?
- A. Use a glucometer to assess capillary glucose.
- B. Explain to the client that an increased dose of medication is needed.
- C. Reassure the client that weight will improve as viral load decreases.
- D. Teach the client how to measure his weight accurately.
Correct answer: A
Rationale: Increased thirst and hunger while losing weight may indicate hyperglycemia, a common side effect of saquinavir and other antiretrovirals. Using a glucometer to assess capillary glucose levels is essential to evaluate for hyperglycemia. Choice B is incorrect because increasing the dose of medication without assessing blood glucose levels can be dangerous. Choice C is incorrect because weight loss may not necessarily improve with viral load reduction and doesn't address the immediate concern of hyperglycemia. Choice D is irrelevant to the presenting symptoms and should not be a priority over assessing for hyperglycemia.
4. At 0600 while admitting a woman for a scheduled repeat cesarean section, the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?
- A. Cancel the surgery
- B. Inform the anesthesia care provider
- C. Ask the client if she has had any other liquids
- D. Proceed with routine preparations
Correct answer: B
Rationale: Drinking liquids before surgery can increase the risk of aspiration during anesthesia. Therefore, the anesthesia care provider must be informed immediately to determine how to proceed, as this could delay or alter the surgical plan. Canceling the surgery without consulting the anesthesia care provider would be premature and could potentially lead to unnecessary actions. Asking the client if she has had any other liquids is important but not the first priority. Proceeding with routine preparations without addressing the potential issue of ingesting liquids before surgery could compromise the client's safety.
5. The nurse is teaching a client about postoperative care following a total knee arthroplasty. What instruction should the nurse prioritize?
- A. Begin ambulation as soon as possible.
- B. Use continuous passive motion therapy to maintain joint mobility.
- C. Avoid putting weight on the affected leg.
- D. Apply ice packs to reduce pain and swelling.
Correct answer: B
Rationale: The correct answer is B: 'Use continuous passive motion therapy to maintain joint mobility.' Continuous passive motion therapy is crucial in postoperative care following a total knee arthroplasty as it helps prevent stiffness and maintain joint mobility. Ambulation is important but should be guided and not immediate. Avoiding putting weight on the affected leg is also essential initially to prevent complications. Applying ice packs can help reduce pain and swelling, but it is not the priority instruction for maintaining joint mobility and preventing stiffness.
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