HESI RN
HESI RN Exit Exam 2023 Capstone Questions
Question 1 of 5
What information should the nurse include in the client's health record after a fall in the bathroom?
Correct Answer: D
Rationale: The correct answer is D because the nurse should document factual, objective information such as the injury sustained by the client. Reporting the specific injury, like a fracture to the left hip, is crucial for accurate medical records. Choices A, B, and C lack specific detail about the injury and focus on different aspects of the fall that are not as pertinent for the health record. Choice A only mentions the fall without specifying the injury, choice B introduces blame without focusing on the client's condition, and choice C adds unnecessary information about the client's pulse which is not directly related to the fall injury.
Question 2 of 5
The nurse is performing a functional assessment for a client requiring nursing home care. Which action should the nurse implement?
Correct Answer: A
Rationale: The correct answer is A: Question the client about the frequency of falls. In the elderly population, falls are a significant risk factor that can impact their functional abilities and safety. By assessing the frequency of falls, the nurse can identify potential risks and implement interventions to prevent future falls. Choices B, C, and D are incorrect because they do not directly address the primary focus of a functional assessment for nursing home care, which is to evaluate the client's functional status and identify areas that may require assistance or intervention.
Question 3 of 5
A client with chronic obstructive pulmonary disease (COPD) is receiving supplemental oxygen. The client reports feeling short of breath and has a respiratory rate of 28 breaths per minute. What should the nurse do first?
Correct Answer: D
Rationale: Elevating the head of the bed promotes lung expansion and improves oxygenation, making it the priority intervention for a client with shortness of breath. This position helps in maximizing lung expansion and aiding ventilation-perfusion matching in patients with COPD. Increasing the oxygen flow rate may be necessary but should come after optimizing the client's positioning. Notifying the healthcare provider and administering a bronchodilator are not the initial interventions for addressing shortness of breath in a client with COPD.
Question 4 of 5
A male client reports that he took tadalafil 10 mg two hours ago and now feels flushed. What action should the nurse take?
Correct Answer: B
Rationale: The correct answer is B: Reassure the client that flushing is a common side effect. Tadalafil, a medication used for erectile dysfunction, can cause flushing as a common side effect. In this situation, the nurse should provide reassurance to the client that the flushing is expected and not necessarily a cause for concern. Increasing oral fluid intake (choice A) may be beneficial for other conditions but is not directly related to tadalafil-induced flushing. Advising the client to take nitroglycerin (choice C) is incorrect, as nitroglycerin is not indicated for flushing. Asking the client to come to the emergency room (choice D) is unnecessary at this point since flushing is a known side effect and does not typically require urgent medical attention.
Question 5 of 5
A client with atrial fibrillation is prescribed warfarin. What is the most important instruction the nurse should give?
Correct Answer: D
Rationale: The correct answer is D. Clients taking warfarin should avoid alcohol and over-the-counter medications without consulting their healthcare provider, as these can interact with warfarin and increase the risk of bleeding. Aspirin, in particular, can exacerbate this risk. Choice A is incorrect because taking warfarin with aspirin can increase the risk of bleeding. Choice B is incorrect as while green leafy vegetables contain vitamin K which can interact with warfarin, it is more important to maintain a consistent intake rather than increase it. Choice C is incorrect because foods high in potassium do not directly impact the bleeding risk associated with warfarin.
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