HESI RN
HESI RN Exit Exam Capstone
1. The nurse is caring for a client with deep vein thrombosis (DVT) who is receiving anticoagulant therapy. Which intervention should the nurse implement to prevent complications?
- A. Elevate the affected leg
- B. Encourage early ambulation
- C. Perform frequent range-of-motion exercises
- D. Apply ice packs to the affected leg
Correct answer: A
Rationale: Elevating the affected leg is crucial in managing deep vein thrombosis (DVT) as it helps to reduce swelling and improve venous return. This intervention is essential for preventing complications such as pulmonary embolism. Encouraging early ambulation is generally beneficial for preventing DVT but is secondary to leg elevation. Performing range-of-motion exercises can be helpful for maintaining joint mobility but is not the priority intervention in this case. Applying ice packs to the affected leg is not recommended in DVT management as it can cause vasoconstriction and potentially worsen the condition.
2. The nurse is providing care for a client with schizophrenia who receives haloperidol decanoate 75 mg IM every 4 weeks. The client begins developing puckering and smacking of the lips and facial grimacing. Which intervention should the nurse implement?
- A. Discontinue the medication immediately
- B. Increase the dose of haloperidol
- C. Complete the abnormal involuntary movement scale (AIMS)
- D. Monitor the client for signs of agitation
Correct answer: C
Rationale: These symptoms are characteristic of tardive dyskinesia, a side effect of long-term antipsychotic use. The nurse should assess the severity of these movements using the AIMS scale and report to the healthcare provider for further management. Discontinuing the medication abruptly (Choice A) can lead to withdrawal symptoms and worsening of the condition. Increasing the dose of haloperidol (Choice B) can exacerbate the symptoms of tardive dyskinesia. Monitoring for signs of agitation (Choice D) is important but does not address the specific side effect described.
3. The nurse is caring for a client with acute pancreatitis who is reporting severe abdominal pain. Which nursing intervention should the nurse implement first?
- A. Assess the client's bowel sounds
- B. Administer prescribed pain medication
- C. Encourage the client to sit upright
- D. Provide clear fluids to the client
Correct answer: B
Rationale: In a client with acute pancreatitis experiencing severe abdominal pain, the priority nursing intervention is to provide pain relief. Administering prescribed pain medication is essential to improve comfort and reduce pain, which can help stabilize the client's condition. Assessing bowel sounds (Choice A) may be necessary but is not the immediate priority over pain management. Encouraging the client to sit upright (Choice C) and providing clear fluids (Choice D) are not the primary interventions for addressing severe abdominal pain in acute pancreatitis.
4. A client is receiving morphine for postoperative pain. What is the nurse's priority assessment?
- A. Monitor the client's respiratory rate.
- B. Monitor the client's level of consciousness.
- C. Assess the client's level of pain.
- D. Monitor the client's blood pressure.
Correct answer: A
Rationale: The correct answer is to monitor the client's respiratory rate. Morphine can cause respiratory depression, so assessing the respiratory rate is crucial to detect this potential side effect early. Monitoring the client's level of consciousness (Choice B) is important but comes after ensuring adequate breathing. Assessing the client's pain level (Choice C) is essential but not the priority when dealing with the side effects of morphine. Monitoring the client's blood pressure (Choice D) is also important but not the priority assessment when the focus is on respiratory depression.
5. 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.
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