HESI RN
RN HESI Exit Exam Capstone
1. A client has been receiving hydromorphone every six hours for four days. What assessment should the nurse prioritize?
- A. Increase the dosage of the medication.
- B. Auscultate bowel sounds.
- C. Monitor the client's blood pressure.
- D. Check the client's respiratory rate.
Correct answer: B
Rationale: The correct answer is B. Hydromorphone can cause constipation, a common side effect of opioids. Therefore, it is crucial to auscultate bowel sounds to monitor for signs of decreased gastrointestinal motility. Monitoring blood pressure (choice C) and respiratory rate (choice D) are important but not the priority in this scenario as constipation is a common issue with opioid use. Increasing the dosage of the medication (choice A) is not appropriate without assessing the client's bowel function first.
2. A client with atrial fibrillation is prescribed warfarin, and their INR is elevated. What is the nurse's priority action?
- A. Administer a dose of vitamin K to reverse the effects of warfarin.
- B. Monitor the client for signs of bleeding, such as bruising or nosebleeds.
- C. Increase the client’s warfarin dosage to prevent clot formation.
- D. Notify the healthcare provider immediately and hold the next dose of warfarin.
Correct answer: D
Rationale: An elevated INR in clients taking warfarin increases the risk of bleeding, indicating the dose may be too high. The nurse's priority action is to notify the healthcare provider immediately and hold the next dose of warfarin to prevent bleeding complications. Administering vitamin K is not the first-line intervention for an elevated INR. Monitoring for signs of bleeding is important but not the priority over contacting the healthcare provider. Increasing the warfarin dosage can exacerbate the risk of bleeding and is contraindicated.
3. Which of these clients, all in the terminal stage of cancer, is least appropriate to suggest the use of patient-controlled analgesia (PCA) with a pump?
- A. A young adult with a history of Down syndrome
- B. A teenager who reads at a 4th-grade level
- C. An elderly client with numerous arthritic nodules on the hands
- D. A preschooler with intermittent alertness episodes
Correct answer: D
Rationale: The correct answer is D. A preschooler with intermittent alertness episodes is not a suitable candidate for patient-controlled analgesia (PCA) due to their inability to effectively manage the system. In the context of terminal cancer, it is crucial for the patient to be able to utilize the PCA system appropriately to manage pain effectively. Preschoolers may not have the cognitive ability or understanding to operate a PCA pump compared to the other clients. Choices A, B, and C present clients with conditions that do not inherently impede their ability to use a PCA pump effectively.
4. After a spider bite on the lower extremity, a client is admitted to treat an infection that is spreading up the leg. Which admission assessment findings should the nurse report to the healthcare provider?
- A. Swollen lymph nodes in the groin
- B. Core body temperature of 100.5°F
- C. All of the above
- D. Elevated white blood cell count
Correct answer: C
Rationale: All of the above findings should be reported to the healthcare provider for prompt evaluation and treatment. Swollen lymph nodes in the groin indicate regional lymphatic involvement, a core body temperature of 100.5°F suggests a mild fever response, and an elevated white blood cell count indicates an ongoing infection process. These findings collectively point towards the spread of infection and require immediate attention to prevent further complications.
5. A client is admitted with pneumonia and is started on antibiotics. After 3 days, the client reports difficulty breathing and a rash. What is the nurse's first action?
- A. Administer epinephrine
- B. Discontinue the antibiotic
- C. Assess the client's oxygen saturation
- D. Call the healthcare provider
Correct answer: B
Rationale: The client's difficulty breathing and rash suggest a possible allergic reaction to the antibiotic. The first action the nurse should take is to discontinue the antibiotic to prevent further exposure. Administering epinephrine should only be done in severe cases of anaphylaxis, which is not indicated solely by difficulty breathing and rash. While assessing the client's oxygen saturation is important, discontinuing the potential allergen takes precedence. Contacting the healthcare provider should be done after discontinuing the antibiotic and assessing the client to report the situation and seek further guidance.
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