HESI RN
HESI RN Exit Exam 2023 Capstone
1. A client has suspected compartment syndrome of the right lower leg. What is the nurse’s priority intervention?
- A. Elevate the right leg to reduce swelling.
- B. Loosen any restrictive dressings on the leg.
- C. Prepare the client for emergency surgery.
- D. Administer pain medication as prescribed.
Correct answer: B
Rationale: In a suspected case of compartment syndrome, the nurse's priority intervention is to loosen any restrictive dressings on the leg. This action helps to relieve pressure within the affected compartment, improve circulation, and prevent permanent damage. Elevating the leg may further increase pressure, preparing for emergency surgery is premature without proper assessment and diagnosis, and administering pain medication should come after addressing the primary issue of relieving pressure.
2. While palpating the gallbladder of a mildly obese client, what finding does the nurse expect if the gallbladder is inflamed?
- A. Severe tenderness and guarding
- B. Slight discomfort upon palpation
- C. A sensation of fullness
- D. No symptoms unless the gallbladder is extremely inflamed
Correct answer: A
Rationale: Correct. If the gallbladder is inflamed, the nurse would expect to find severe tenderness and guarding, which are typical signs of acute cholecystitis. This indicates an inflammatory process in the gallbladder. Choices B, C, and D are incorrect because slight discomfort, a sensation of fullness, or no symptoms unless extremely inflamed are not typical findings associated with gallbladder inflammation.
3. The nurse is caring for a client with a history of congestive heart failure (CHF) who is receiving digoxin therapy. The client reports seeing halos around lights. Which action should the nurse take?
- A. Assess the client's digoxin level
- B. Increase the client's fluid intake
- C. Check the client's blood pressure
- D. Administer a dose of potassium
Correct answer: A
Rationale: Seeing halos around lights is a classic symptom of digoxin toxicity. The nurse should assess the client's digoxin level to determine if the dose needs to be adjusted or if the medication should be held. Increasing fluid intake or checking blood pressure would not directly address the symptom of halos around lights. Administering a dose of potassium is not indicated without knowing the digoxin level and could potentially worsen the toxicity.
4. A client with Parkinson's disease is prescribed levodopa/carbidopa. The nurse instructs the client to take the medication with meals. Which rationale should the nurse provide for taking the medication with food?
- A. It enhances the effectiveness of the medication
- B. It helps to improve absorption
- C. It prevents orthostatic hypotension
- D. It reduces gastrointestinal upset
Correct answer: D
Rationale: The correct answer is D: 'It reduces gastrointestinal upset.' Levodopa/carbidopa can cause nausea and other gastrointestinal side effects. Taking the medication with food can help reduce these side effects and improve the client's comfort. Choices A, B, and C are incorrect because taking the medication with food does not primarily enhance effectiveness, improve absorption, or prevent orthostatic hypotension. The main reason for advising to take the medication with meals is to minimize gastrointestinal upset.
5. A client with dysphagia is having difficulty swallowing medications. What is the nurse's best intervention?
- A. Crush the medications and mix them with applesauce.
- B. Encourage the client to drink water with each dose.
- C. Consult with the healthcare provider about switching to liquid medications.
- D. Offer the client soft foods to reduce difficulty swallowing.
Correct answer: C
Rationale: The best intervention for a client with dysphagia experiencing difficulty swallowing medications is to consult with the healthcare provider about switching to liquid medications. Liquid medications are often easier to swallow and can reduce the risk of choking and aspiration in clients with dysphagia. Crushing medications can alter their effectiveness, encouraging the client to drink water may not be sufficient, and offering soft foods is not directly related to improving medication swallowing.
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