HESI RN
HESI RN Exit Exam 2023 Capstone
1. The nurse is providing care for a client with heart failure who is prescribed furosemide. Which laboratory value should the nurse monitor closely?
- A. Calcium level
- B. Sodium level
- C. Magnesium level
- D. Potassium level
Correct answer: D
Rationale: The correct answer is D: Potassium level. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Monitoring potassium levels is crucial to prevent complications such as cardiac arrhythmias. While calcium, sodium, and magnesium levels are important in various conditions and treatments, they are not the primary electrolyte affected by furosemide.
2. While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse’s best response?
- A. As you urinate more, you will need less medication to control fluid.
- B. You will have to take this medication for about a year.
- C. The medication must be continued so the fluid problem is controlled.
- D. Please talk to your health care provider about medications and treatments.
Correct answer: C
Rationale: Diuretics must be continued as long as the fluid problem persists to prevent heart failure symptoms.
3. A client presents to the clinic with a large abscess on the right thigh. The healthcare provider incises and drains the abscess. Which instruction should the nurse provide to the client upon discharge?
- A. Avoid showering until the wound is completely closed
- B. Perform daily wound care and dressing changes
- C. Apply heat to the wound for 15 minutes twice a day
- D. Take the prescribed antibiotic until the wound is fully healed
Correct answer: B
Rationale: After incision and drainage of an abscess, it is crucial to perform daily wound care and dressing changes to prevent infection and promote healing. Avoiding showering until the wound is completely closed (choice A) may not be practical or necessary. Applying heat to the wound (choice C) can increase the risk of infection and delay healing. While taking the prescribed antibiotic (choice D) is important, wound care and dressing changes are more directly related to promoting healing and preventing complications.
4. A client in heart failure (HF) presents with weakness and poor urine output. Which assessment finding requires immediate action?
- A. Heart rate of 122 bpm and respiratory rate of 28.
- B. Yellow sputum expectorated.
- C. Temperature of 100.5°F (38.1°C).
- D. Shortness of breath on exertion.
Correct answer: C
Rationale: An elevated temperature may indicate infection and should be treated immediately in a client with heart failure.
5. A client with a fractured femur is placed in skeletal traction. What action should the nurse prioritize?
- A. Ensure that the weights are freely hanging.
- B. Place pillows under the client's knees.
- C. Adjust the weights to alleviate discomfort.
- D. Ensure that the traction ropes are free of knots.
Correct answer: A
Rationale: The correct action the nurse should prioritize when a client is placed in skeletal traction for a fractured femur is to ensure that the weights are freely hanging. This is crucial to maintain proper alignment of the bone and prevent complications. Placing pillows under the client's knees (Choice B) is not a priority in skeletal traction. Adjusting the weights to alleviate discomfort (Choice C) should not be done without proper orders from the healthcare provider. Ensuring that the traction ropes are free of knots (Choice D) is important but ensuring the weights hang freely is the priority to maintain traction effectiveness.
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