HESI RN
RN HESI Exit Exam Capstone Questions
Question 1 of 5
A client receiving codeine for pain every 4 to 6 hours over 4 days. Which assessment should the nurse perform before administering the next dose?
Correct Answer: A
Rationale: The correct answer is A: Auscultate the bowel sounds. Codeine is known to cause constipation, so it is essential to assess bowel sounds before administering another dose to monitor for potential constipation or bowel motility issues. Palpating the ankles for edema (Choice B) is not directly related to codeine use or its side effects. Observing the skin for bruising (Choice C) is important but not specifically associated with codeine administration. Measuring body temperature (Choice D) is not a priority assessment related to codeine use; monitoring for constipation is more critical in this case.
Question 2 of 5
Which statement made by the client indicates an understanding of the instructions regarding the administration of alendronate (Fosamax)?
Correct Answer: B
Rationale: The correct answer is B. Alendronate (Fosamax) should be taken with a full glass of water in the morning to prevent esophageal irritation and ensure proper absorption. Choice A is incorrect because taking alendronate at bedtime increases the risk of esophageal irritation due to lying down. Choice C is incorrect because patients should remain upright for at least 30 minutes after taking alendronate to prevent esophageal irritation. Choice D is incorrect because alendronate should be taken on an empty stomach, not with food, to enhance absorption.
Question 3 of 5
The nurse is caring for a client who had a myocardial infarction 6 hours ago. The primary goal of care at this time is to
Correct Answer: A
Rationale: The correct answer is A: 'Limit the effects of tissue damage.' After a myocardial infarction, the primary goal of care is to limit the damage to the heart muscle. This includes interventions to improve blood flow, oxygenation, and prevent further complications. Choice B ('Relieve pain and anxiety') is important but secondary to addressing tissue damage. Choice C ('Prevent arrhythmias') is also crucial but falls under the broader goal of limiting tissue damage. Choice D ('Reduce anxiety') is essential for holistic care but is not the primary goal immediately after a myocardial infarction.
Question 4 of 5
The nurse is feeding an older adult who was admitted with aspiration pneumonia. The client is weak and begins coughing while attempting to drink through a straw. Which intervention should the nurse implement?
Correct Answer: B
Rationale: When an older adult with aspiration pneumonia coughs while attempting to drink, it may indicate aspiration. Aspiration can lead to serious complications. Therefore, the appropriate intervention for the nurse in this situation is to stop feeding immediately and assess the client for signs of aspiration. Encouraging the client to drink more slowly (Choice A) may not address the risk of aspiration. Elevating the head of the bed further (Choice C) is generally beneficial to prevent aspiration but is not the priority when immediate assessment is needed. Teaching coughing and deep breathing exercises (Choice D) is not appropriate when the client is actively coughing during feeding and requires immediate assessment for potential aspiration.
Question 5 of 5
A client who gave birth 48 hours ago has decided to bottle-feed the infant. The nurse observes that both breasts were swollen, warm, and tender on palpation during the assessment. Which instruction should the nurse provide?
Correct Answer: C
Rationale: The correct answer is to advise the client to apply ice to the breasts for comfort. Applying ice can help reduce swelling and discomfort associated with engorgement in a woman who is not breastfeeding. Expressing milk manually would stimulate further milk production, which is not desired in this case. Wearing a tight bra could increase discomfort by putting pressure on the engorged breasts. Warm showers may actually increase swelling due to the vasodilation effect of heat.
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