HESI RN
HESI RN Exit Exam 2024 Quizlet Capstone
1. The client provides three positive responses to the CAGE questionnaire. Which interpretation should the nurse provide?
- A. The CAGE is a tool for identifying substance abuse.
- B. Two positive responses suggest alcohol dependence.
- C. One positive response indicates potential alcohol issues.
- D. All responses must be positive for alcohol dependence.
Correct answer: B
Rationale: The CAGE questionnaire is a widely used screening tool for alcohol dependence. Two or more positive responses suggest a higher likelihood of alcohol dependence. One positive response may indicate potential alcohol issues, but two or more significantly increase the likelihood of dependence. Therefore, choice B is the most appropriate interpretation. Choice A is incorrect because the CAGE questionnaire specifically focuses on alcohol-related issues, not substance abuse in general. Choice C is incorrect as one positive response does not indicate addiction but rather raises a concern. Choice D is incorrect as not all responses need to be positive to suggest alcohol dependence.
2. A client with chronic obstructive pulmonary disease (COPD) presents with a respiratory rate of 32 breaths per minute and an oxygen saturation of 86%. What is the nurse's first action?
- A. Administer oxygen at 2 L/min via nasal cannula.
- B. Notify the healthcare provider immediately.
- C. Position the client in high Fowler's position.
- D. Suction the client's airway.
Correct answer: A
Rationale: Administering oxygen at 2 L/min via nasal cannula is the nurse's first action when a client with COPD presents with a respiratory rate of 32 breaths per minute and an oxygen saturation of 86%. Oxygen therapy helps improve oxygen saturation in patients with COPD and respiratory distress. While notifying the healthcare provider is important, immediate intervention to improve oxygenation takes priority. Positioning the client in high Fowler's position can also assist with breathing but is not the initial action in this scenario. Suctioning the airway is not indicated unless there are secretions obstructing the airway, which is not mentioned in the scenario.
3. The nurse instructs a client to use an incentive spirometer. The client performs a return demonstration as seen in the video. Which action should the nurse take in response to the return demonstration?
- A. Instruct the client to inhale more deeply
- B. Remind the client to cough after using the spirometer
- C. Praise the client for correct usage
- D. Suggest increasing the frequency of spirometer use
Correct answer: B
Rationale: The correct action for the nurse to take in response to the return demonstration of using an incentive spirometer is to remind the client to cough after using the device. Coughing helps clear secretions from the lungs and promotes lung expansion. Instructing the client to inhale more deeply (Choice A) is not necessary as the primary focus after using the spirometer is to clear secretions. Praising the client for correct usage (Choice C) is positive but does not address the essential step of coughing. Suggesting increasing the frequency of spirometer use (Choice D) is not the immediate action needed after the demonstration.
4. A nurse finds a pregnant client at 33 weeks gestation in cardiac arrest. What modification to cardiopulmonary resuscitation (CPR) should the nurse implement?
- A. Administer chest compressions at a faster rate.
- B. Position a firm wedge under the client’s pelvis and thorax at a 30-degree tilt.
- C. Position the client flat with legs elevated.
- D. Call for immediate assistance and prepare for a cesarean section.
Correct answer: B
Rationale: In a pregnant client at 33 weeks gestation, performing CPR requires tilting the pelvis and thorax at a 30-degree angle to relieve pressure on the vena cava, ensuring proper circulation during compressions. Administering chest compressions at a faster rate (Choice A) may not address the specific needs of a pregnant client in cardiac arrest. Positioning the client flat with legs elevated (Choice C) is not recommended as it can worsen vena cava compression. Calling for immediate assistance and preparing for a cesarean section (Choice D) should be considered only after initiating appropriate CPR modifications.
5. A client with deep vein thrombosis (DVT) is prescribed heparin. What lab value should the nurse monitor to assess the effectiveness of the therapy?
- A. Prothrombin time (PT).
- B. Partial thromboplastin time (PTT).
- C. International Normalized Ratio (INR).
- D. Hemoglobin and hematocrit.
Correct answer: B
Rationale: The correct answer is B: Partial thromboplastin time (PTT). PTT is the lab value used to monitor the effectiveness of heparin therapy in clients with DVT. It measures the intrinsic pathway of coagulation and is prolonged by heparin therapy. Prothrombin time (PT) and International Normalized Ratio (INR) are primarily used to monitor warfarin therapy, not heparin. Checking hemoglobin and hematocrit levels is important but does not directly assess the effectiveness of heparin therapy in DVT.
Similar Questions
Access More Features
HESI RN Basic
$69.99/ 30 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $69.99
HESI RN Premium
$149.99/ 90 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $149.99