HESI RN
RN HESI Exit Exam Capstone
1. The nurse is assessing a client with a new diagnosis of hyperthyroidism. Which assessment finding should the nurse expect?
- A. Decreased heart rate
- B. Increased appetite
- C. Cold intolerance
- D. Weight gain
Correct answer: B
Rationale: In hyperthyroidism, there is an increase in metabolism, leading to symptoms such as increased appetite, weight loss, and heat intolerance. Therefore, the nurse should expect an increased appetite in a client with hyperthyroidism. Choices A, C, and D are incorrect because decreased heart rate and cold intolerance are more commonly associated with hypothyroidism, while weight gain is not typically seen in hyperthyroidism.
2. The nurse is caring for a client with fluid overload. The most reliable indicator of fluid volume status is
- A. Body weight
- B. Intake and output
- C. Daily weight
- D. Skin turgor
Correct answer: C
Rationale: Daily weight is the most reliable indicator of fluid volume status as it reflects changes in body fluid balance accurately. Body weight alone can fluctuate due to various factors, including food intake and bowel movements, which may not accurately represent fluid status. Intake and output provide information on fluid balance over time but may not reflect immediate changes. Skin turgor is a physical assessment finding that indicates hydration status, not overall fluid volume status.
3. A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to the child, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. Which action should the nurse take?
- A. Involve the older brother in supporting the child
- B. Ask the older brother how he felt during the incident
- C. Ask the parents for more information about the brother's behavior
- D. Reassure the brother that everything is fine now
Correct answer: B
Rationale: The older brother's withdrawal likely indicates emotional trauma or stress from the near-drowning event. Asking how he felt provides an opportunity for emotional support and allows the child to express feelings that may need addressing. Involving him in supporting the child may be overwhelming and not address his emotional needs directly. Asking the parents for more information may not allow the older brother to express his own feelings. Simply reassuring him that everything is fine now may dismiss his emotional experience without providing a chance for him to process his feelings.
4. A client with cirrhosis is admitted with ascites and peripheral edema. Which intervention should the nurse implement first?
- A. Elevate the legs to reduce swelling.
- B. Restrict fluids to reduce fluid overload.
- C. Administer furosemide to reduce fluid overload.
- D. Monitor the client's intake and output.
Correct answer: C
Rationale: Administering a diuretic like furosemide is the priority intervention for a client with cirrhosis, ascites, and peripheral edema. Furosemide helps reduce fluid overload by promoting diuresis. Elevating the legs may provide some symptomatic relief but does not address the underlying issue of fluid overload. Restricting fluids is not appropriate initially as the client needs proper hydration while managing fluid balance. Monitoring intake and output is important but not the first action to address the immediate fluid overload in this client.
5. In monitoring tissue perfusion in a client following an above the knee amputation (AKA), which action should the nurse include in the plan of care?
- A. Evaluate closest proximal pulse.
- B. Note amount and color of wound drainage.
- C. Observe for swelling around the stump.
- D. Assess skin elasticity of the stump.
Correct answer: A
Rationale: After an amputation, monitoring the pulse closest to the stump is crucial in evaluating tissue perfusion and the overall health of the limb. Swelling and changes in perfusion can indicate complications such as blood clots or infection. Assessing the proximal pulse helps the nurse ensure adequate blood flow to the remaining limb, thereby preventing further complications. Choices B, C, and D are less directly related to monitoring tissue perfusion in this scenario and are more focused on wound healing and stump care.
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