HESI RN
HESI RN Exit Exam 2024 Quizlet Capstone
1. A client is being prepared for surgery and has been placed on NPO status. Which of the following is the nurse's priority assessment?
- A. Assess the client's understanding of the procedure
- B. Monitor the client's compliance with NPO status
- C. Check the client's vital signs
- D. Ensure the client's consent form is signed
Correct answer: B
Rationale: The correct answer is B. Monitoring the client's compliance with NPO status is the priority assessment. Ensuring the client remains NPO (nothing by mouth) is crucial to reduce the risk of aspiration during surgery. Assessing the client's understanding of the procedure is important but not the priority at this moment. Checking vital signs is also essential but ensuring NPO status takes precedence for patient safety. Ensuring the client's consent form is signed is necessary but not the priority assessment compared to maintaining NPO status.
2. The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning?
- A. An 8-year-old living in a housing project.
- B. A 2-year-old playing on aging playground equipment.
- C. An adolescent working in a paint factory.
- D. A 10-year-old with Type 1 diabetes.
Correct answer: B
Rationale: The correct answer is B. Young children, like the 2-year-old playing on aging playground equipment, are more susceptible to lead poisoning from environmental sources due to their behaviors like hand-to-mouth contact and exploratory behaviors. Choices A, C, and D are less likely to be at high risk for lead poisoning compared to young children due to differences in exposure levels and behaviors related to potential sources of lead contamination.
3. A combination multi-drug cocktail is being considered for an asymptomatic HIV-infected client with a CD4 cell count of 500. Which nursing assessment of the client is most crucial in determining whether therapy should be initiated?
- A. Presence of viral symptoms
- B. Engages in high-risk behaviors
- C. Willingness to comply with complex drug schedules
- D. History of opportunistic infections
Correct answer: C
Rationale: The most crucial nursing assessment in determining whether therapy should be initiated for an asymptomatic HIV-infected client with a CD4 cell count of 500 is the client's willingness to comply with complex drug schedules. Adherence to antiretroviral therapy is essential for its effectiveness. Assessing the client's willingness and ability to comply with the complex medication regimen is crucial to ensure successful treatment and prevent drug resistance. Choices A, B, and D, although important in the overall care of the client, are not as crucial as assessing the client's willingness to adhere to the prescribed drug regimen.
4. Which of these findings would the nurse more closely associate with anemia in a 10-month-old infant?
- A. Hemoglobin level of 12 g/dL
- B. Pale mucosa of the eyelids and lips
- C. Hypoactivity
- D. A heart rate between 140 to 160
Correct answer: B
Rationale: The correct answer is B. Pale mucous membranes, such as those of the eyelids and lips, are a classic sign of anemia in infants. Anemia leads to decreased oxygen-carrying capacity, resulting in tissue hypoxia, which can manifest as pale mucosa. Choice A, a hemoglobin level of 12 g/dL, is within the normal range for a 10-month-old infant and would not necessarily indicate anemia. Choice C, hypoactivity, is a non-specific finding and can be present in various conditions, not specifically anemia. Choice D, a heart rate between 140 to 160, is within the normal range for an infant and is not a specific finding associated with anemia.
5. A client with schizophrenia is experiencing paranoia. What is the nurse's priority intervention?
- A. Reassure the client that their fears are unfounded.
- B. Place the client in a private room to reduce stimuli.
- C. Provide the client with a distraction to redirect their attention.
- D. Encourage the client to express their concerns and validate their feelings.
Correct answer: D
Rationale: Encouraging clients with paranoia to express their concerns and validating their feelings is crucial as it helps establish trust and reduce anxiety. This approach also aids in building a therapeutic relationship. Reassuring the client that their fears are unfounded (Choice A) may invalidate their feelings and worsen trust. Placing the client in a private room to reduce stimuli (Choice B) may be helpful in some situations but does not address the underlying issue of paranoia. Providing a distraction (Choice C) may temporarily shift the client's focus but does not address the root cause of the paranoia. Therefore, the priority intervention is to encourage the client to express their concerns and validate their feelings.
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