HESI RN
HESI 799 RN Exit Exam Capstone
1. The nurse administers an antibiotic for a respiratory tract infection. To evaluate the medication's effectiveness, which laboratory values should the nurse monitor?
- A. Platelet count and red blood cell count.
- B. White blood cell count and sputum culture.
- C. Hemoglobin A1c and glucose tolerance test.
- D. Arterial blood gases and serum electrolytes.
Correct answer: B
Rationale: The correct answer is B: White blood cell count and sputum culture. Monitoring white blood cell count and sputum cultures is essential to assess the effectiveness of the antibiotic in treating the respiratory tract infection. Changes in white blood cell count can indicate the body's response to infection, while sputum cultures help determine if the antibiotic is targeting the specific pathogens causing the infection. Choices A, C, and D are incorrect because platelet count, red blood cell count, hemoglobin A1c, glucose tolerance test, arterial blood gases, and serum electrolytes are not directly related to evaluating the effectiveness of an antibiotic in treating a respiratory tract infection.
2. A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking in hot baths at night with no relief of his discomfort. Which action should the nurse take?
- A. Instruct the client to use a moisturizer immediately after the bath
- B. Advise the client to take shorter baths with less water
- C. Suggest taking antihistamines for the pruritus
- D. Encourage the client to use cooler water and apply calamine lotion after soaking
Correct answer: D
Rationale: In this situation, the client's pruritus (itching) is likely exacerbated by hot baths, which can worsen the itching sensation. Using cooler water will help soothe the skin and reduce pruritus. Additionally, applying calamine lotion after soaking can provide further relief. Instructing the client to use a moisturizer immediately after the bath (Choice A) may not address the root cause of pruritus aggravated by hot baths. Advising the client to take shorter baths with less water (Choice B) might not be as effective in relieving the itching sensation caused by cirrhosis. Suggesting antihistamines for the pruritus (Choice C) may not directly address the impact of hot baths on the client's discomfort.
3. 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.
4. The nurse is preparing to administer an intramuscular injection to an adult client. Which site should the nurse select?
- A. Deltoid muscle
- B. Ventrogluteal muscle
- C. Vastus lateralis muscle
- D. Dorsogluteal muscle
Correct answer: B
Rationale: The ventrogluteal site is preferred for intramuscular injections in adults because it is free from major blood vessels and nerves, reducing the risk of injury. The deltoid muscle can be used for smaller volumes of medication, primarily vaccines. The vastus lateralis muscle is commonly used in infants, toddlers, and young children. The dorsogluteal muscle site is discouraged due to its proximity to the sciatic nerve, increasing the risk of injury or nerve damage.
5. A client with anxiety disorder is experiencing increased anxiety prior to vaginal delivery. What should the nurse’s initial action be?
- A. Increase the client's sedative dose
- B. Encourage the client to express her feelings and provide emotional support
- C. Initiate breathing techniques to manage anxiety
- D. Administer anxiolytic medication to calm the client
Correct answer: B
Rationale: The correct initial action for a client with anxiety disorder experiencing increased anxiety prior to vaginal delivery is to encourage the client to express her feelings and provide emotional support. Emotional support is crucial in reducing anxiety during childbirth. Initiating breathing techniques or administering medications should come after emotional support has been provided. Increasing sedative doses may not address the underlying emotional needs of the client and can have potential risks.
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