HESI RN
HESI RN Exit Exam Capstone
1. A client with pneumonia is prescribed antibiotics. What is the most important teaching point for the nurse to provide?
- A. Instruct the client to rest as much as possible.
- B. Encourage increased fluid intake to thin secretions.
- C. Explain the importance of completing the entire course of antibiotics.
- D. Instruct the client to stop taking antibiotics once symptoms subside.
Correct answer: C
Rationale: The correct answer is C. Antibiotics must be taken for the entire prescribed duration to ensure that the infection is completely eradicated. Stopping antibiotics early, even if symptoms improve, can lead to a recurrence of the infection or antibiotic resistance. Choice A is incorrect because though rest is important, completing the antibiotic course is crucial. Choice B is incorrect as while hydration is beneficial, completing the antibiotics is the priority. Choice D is incorrect as stopping antibiotics prematurely can have negative consequences.
2. A client with multiple sclerosis is admitted with an acute exacerbation. What is the nurse's priority action?
- A. Monitor the client’s vital signs every hour.
- B. Assess for changes in the client’s muscle strength.
- C. Administer prescribed corticosteroids to reduce inflammation.
- D. Educate the client on managing fatigue and preventing relapses.
Correct answer: C
Rationale: The correct answer is C. Administering prescribed corticosteroids to reduce inflammation is the priority action when a client with multiple sclerosis is admitted with an acute exacerbation. Corticosteroids help manage symptoms during exacerbations and reduce inflammation. Monitoring vital signs and assessing muscle strength are important aspects of care but not the priority during an acute exacerbation. Educating the client on managing fatigue and preventing relapses is essential but can be addressed after the acute exacerbation has been managed.
3. A client receiving IV antibiotics for sepsis reports itching and has a rash on the chest. What is the nurse's first action?
- A. Administer an antihistamine as prescribed.
- B. Stop the infusion and notify the healthcare provider.
- C. Slow the infusion rate and monitor the client.
- D. Administer epinephrine subcutaneously.
Correct answer: B
Rationale: The correct action for the nurse to take first when a client receiving IV antibiotics for sepsis reports itching and a rash on the chest is to stop the infusion and notify the healthcare provider. This is crucial in preventing the allergic reaction from worsening. Administering an antihistamine (choice A) may address the symptoms but does not address the primary concern of stopping the infusion. Slowing the infusion rate and monitoring the client (choice C) may not be sufficient if the reaction is severe. Administering epinephrine subcutaneously (choice D) is not the first-line intervention for this situation.
4. 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.
5. The nurse is preparing to administer a blood transfusion to a client. Which action is most important for the nurse to take before starting the transfusion?
- A. Administer pre-transfusion medication
- B. Ensure the client has an adequate fluid intake
- C. Monitor the client's vital signs
- D. Verify the blood type with another nurse
Correct answer: D
Rationale: Verifying the blood type with another nurse is critical before starting a blood transfusion to prevent a potentially life-threatening transfusion reaction. This step ensures that the client receives the correct blood product. Administering pre-transfusion medication, ensuring adequate fluid intake, and monitoring vital signs are important steps during the transfusion process, but verifying the blood type is the most crucial step to ensure patient safety.
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