HESI RN
HESI RN Exit Exam Capstone
1. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy. Which assessment finding indicates that the client's oxygenation is improving?
- A. Pulse oximetry reading of 94%
- B. Heart rate increases from 80 to 90 beats per minute
- C. Respiratory rate increases from 16 to 20 breaths per minute
- D. Client reports increased energy levels
Correct answer: A
Rationale: A pulse oximetry reading of 94% indicates adequate oxygenation. Monitoring oxygen saturation is the most objective way to assess the effectiveness of oxygen therapy. Choices B, C, and D do not directly reflect the client's oxygenation status. An increase in heart rate or respiratory rate may indicate increased work of breathing or stress on the body. The client reporting increased energy levels is subjective and may not directly correlate with improved oxygenation.
2. The nurse is providing discharge instructions to a client with chronic venous insufficiency. Which recommendation should the nurse include to help prevent complications?
- A. Use a heating pad on the legs
- B. Wear compression stockings
- C. Massage the legs daily
- D. Elevate legs for 10 minutes every hour
Correct answer: B
Rationale: The correct recommendation for a client with chronic venous insufficiency to prevent complications is to wear compression stockings. Compression stockings help improve venous circulation and prevent the worsening of symptoms. While elevating the legs is also beneficial, the priority intervention in preventing complications is wearing compression stockings. Using a heating pad on the legs can actually worsen the condition by dilating blood vessels, and massaging the legs daily can potentially damage fragile skin in clients with chronic venous insufficiency.
3. A client with heart failure is prescribed digoxin and reports nausea. What is the nurse's first action?
- A. Administer an anti-nausea medication as prescribed.
- B. Assess the client's digoxin level immediately.
- C. Assess the client’s apical pulse and hold the next dose if it's below 60 bpm.
- D. Instruct the client to reduce their fluid intake.
Correct answer: B
Rationale: When a client on digoxin reports nausea, it can be a sign of digoxin toxicity. The priority action for the nurse is to assess the client's digoxin level immediately. This assessment will help determine if the nausea is related to digoxin toxicity, requiring a dosage adjustment. Administering an anti-nausea medication (Choice A) does not address the underlying issue of potential digoxin toxicity. Assessing the client's apical pulse (Choice C) is important in general digoxin monitoring but not the first action when nausea is reported. Instructing the client to reduce fluid intake (Choice D) is not the initial response to nausea in a client taking digoxin.
4. An adult male is brought to the emergency department following a motorcycle accident, presenting with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse?
- A. Rebound abdominal tenderness.
- B. Diminished bilateral breath sounds.
- C. Rib pain with deep inspiration.
- D. Nausea with projectile vomiting.
Correct answer: D
Rationale: In this scenario, the patient's presentation with periorbital bruising and bloody ear drainage suggests a basilar skull fracture. Projectile vomiting, as described in choice D, is concerning for increased intracranial pressure due to the skull fracture. This finding warrants immediate intervention to prevent further neurological compromise. Choices A, B, and C are not the priority in this situation. Rebound abdominal tenderness (choice A) is indicative of intra-abdominal injury but is not as urgent as managing potential intracranial issues. Diminished breath sounds (choice B) and rib pain with deep inspiration (choice C) may suggest underlying chest injuries, which need attention but are not as immediately life-threatening as increased intracranial pressure.
5. A client with diabetic ketoacidosis (DKA) is receiving an insulin infusion. Which finding indicates that the treatment is effective?
- A. Potassium level of 4.0 mEq/L.
- B. Blood glucose level of 180 mg/dL.
- C. Urine output of 50 mL/hour.
- D. Absence of ketones in the urine.
Correct answer: D
Rationale: The correct answer is D: Absence of ketones in the urine. In a client with diabetic ketoacidosis (DKA) receiving an insulin infusion, the absence of ketones in the urine indicates that ketoacidosis is resolving. This is a crucial finding as it shows that the insulin therapy is effectively addressing the metabolic imbalance causing DKA. Choices A, B, and C are incorrect: A potassium level of 4.0 mEq/L is within normal range but does not directly reflect the resolution of DKA; a blood glucose level of 180 mg/dL, while improved, is still high and does not specifically indicate the resolution of ketoacidosis; urine output of 50 mL/hour is within normal limits but does not directly point to the resolution of DKA.
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