HESI RN
RN HESI Exit Exam Capstone
1. An 11-year-old client admitted to the mental health unit after threatening self-harm. What is the best activity to establish rapport and promote coping?
- A. Bring the client to the team meeting to discuss the treatment plan.
- B. Play a board game with the client and start discussing stressors.
- C. Explain the purpose of each medication the client is taking.
- D. Ask the client to write feelings in a journal and review together.
Correct answer: B
Rationale: Playing a board game with the client is an effective way to establish rapport in a relaxed setting, allowing the client to open up about stressors. This activity promotes coping by creating a safe and engaging environment for the client to express their feelings. Choices A, C, and D may not be suitable initially as they involve more formal or intrusive approaches that may not be suitable for building rapport with a client experiencing emotional distress.
2. A client reports dizziness when standing up quickly. What advice should the nurse give?
- A. Encourage the client to drink more fluids.
- B. Change positions slowly to prevent dizziness.
- C. Report the symptom to the healthcare provider immediately.
- D. Limit physical activity to avoid triggering dizziness.
Correct answer: B
Rationale: The correct advice for a client experiencing dizziness when standing up quickly is to change positions slowly to prevent dizziness. This symptom is suggestive of postural hypotension, where a sudden change in position can lead to a drop in blood pressure, causing dizziness. Encouraging the client to drink more fluids (Choice A) may be beneficial for other conditions but is not directly related to the prevention of dizziness in this case. Reporting the symptom to the healthcare provider immediately (Choice C) is important if the dizziness is persistent or severe, but the immediate action to prevent it is to change positions slowly. Limiting physical activity (Choice D) may not necessarily address the underlying cause of dizziness in this context.
3. In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client’s respiratory rate is 14 breaths/minute. What action should the nurse implement?
- A. Remove the mask immediately
- B. Document the assessment data
- C. Increase the oxygen flow
- D. Increase the respiratory rate setting
Correct answer: B
Rationale: The correct answer is to document the assessment data. In a partial rebreather mask, it is normal for the oxygen reservoir bag not to deflate completely during inspiration. Additionally, a respiratory rate of 14 breaths/minute falls within the normal range. Therefore, these findings indicate that the mask is functioning as intended. Removing the mask immediately is unnecessary as there are no signs of distress. Increasing the oxygen flow or adjusting the respiratory rate setting is not warranted based on the assessment findings, as they are within normal parameters.
4. A client with a history of chronic kidney disease presents with increased swelling and shortness of breath. What is the nurse's priority action?
- A. Administer oxygen at 2 liters per nasal cannula.
- B. Administer a diuretic as prescribed.
- C. Monitor the client's vital signs.
- D. Reposition the client to improve lung expansion.
Correct answer: B
Rationale: The correct answer is to administer a diuretic as prescribed. In a client with chronic kidney disease experiencing increased swelling and shortness of breath, the priority action is to address fluid retention. Administering a diuretic helps reduce fluid overload, alleviate symptoms, and prevent complications associated with fluid buildup. Option A is not the priority in this situation as addressing fluid retention takes precedence over providing oxygen. While monitoring vital signs is important, it is secondary to addressing the underlying cause of symptoms. Repositioning the client may help with comfort but does not directly address the fluid overload seen in chronic kidney disease.
5. The nurse is providing care for a client with a percutaneous endoscopic gastrostomy (PEG) tube. Which intervention should the nurse implement to prevent complications associated with the tube?
- A. Elevate the head of the bed to 15 degrees during feedings
- B. Aspirate gastric contents before administering medications
- C. Clamp the tube between feedings
- D. Flush the tube with water before and after feedings
Correct answer: D
Rationale: Flushing the PEG tube with water before and after feedings helps prevent clogging and maintains tube patency. Proper flushing is essential for avoiding complications related to tube blockages. Elevating the head of the bed is important for preventing aspiration during and after feedings, not specifically related to PEG tube complications. Aspirating gastric contents before administering medications is not routinely recommended for PEG tube care. Clamping the tube between feedings can lead to tube occlusion and is not a standard practice in PEG tube care.
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