HESI RN
RN HESI Exit Exam Capstone
1. A client receiving radiation therapy for breast cancer reports dry, peeling skin at the treatment site. What action should the nurse recommend?
- A. Apply lotion to the treatment area.
- B. Use mild soap and water to cleanse the area.
- C. Cover the area with a sterile dressing.
- D. Allow the skin to air dry after washing.
Correct answer: B
Rationale: The correct recommendation for a client with dry, peeling skin at a radiation therapy treatment site is to use mild soap and water to cleanse the area. This approach helps in preventing skin irritation and reduces the risk of infection. Applying lotion (Choice A) may further irritate the skin due to the chemicals present in the lotion. Covering the area with a sterile dressing (Choice C) is not necessary unless there is an open wound that needs protection. Allowing the skin to air dry after washing (Choice D) may lead to further dryness and peeling.
2. A client recovering from a stroke is demonstrating slurred speech. What action should the nurse take?
- A. Consult the healthcare provider to order speech therapy.
- B. Administer a dose of aspirin to prevent further neurological damage.
- C. Encourage the client to use communication aids, such as writing.
- D. Encourage the client to eat soft foods to avoid choking.
Correct answer: C
Rationale: The correct action for a client recovering from a stroke demonstrating slurred speech is to encourage the client to use communication aids, such as writing. This intervention can help the client effectively communicate while working on regaining speech abilities. Consulting the healthcare provider to order speech therapy (choice A) is a valid option, but immediate encouragement of using communication aids is beneficial. Administering aspirin (choice B) without healthcare provider orders is not recommended. Encouraging the client to eat soft foods (choice D) is important for preventing aspiration but doesn't directly address the communication issue.
3. When assessing a client, why is it important for the nurse to be informed about cultural issues related to the client's background?
- A. Normal patterns of behavior may be labeled as deviant, immoral, or insane
- B. The meaning of the client's behavior can be derived from conventional wisdom
- C. Personal values will guide the interaction between individuals from different cultures
- D. The nurse should rely on her knowledge of different developmental mental stages
Correct answer: A
Rationale: Being aware of cultural differences is crucial because normal behaviors in one culture may be perceived as deviant, immoral, or insane in another. This awareness helps the nurse avoid misunderstandings or misinterpretations of behaviors that are considered acceptable in the client's cultural context but may be viewed differently in another. Choices B, C, and D are incorrect because understanding cultural issues goes beyond deriving meanings from conventional wisdom, personal values guiding interactions, or relying solely on knowledge of developmental mental stages.
4. A client who gave birth 48 hours ago has decided to bottle-feed the infant. The nurse observes that both breasts were swollen, warm, and tender on palpation during the assessment. Which instruction should the nurse provide?
- A. Take warm showers to reduce swelling
- B. Wear a tight-fitting bra for support
- C. Apply ice to the breasts for comfort
- D. Express milk manually to relieve discomfort
Correct answer: C
Rationale: The correct answer is to advise the client to apply ice to the breasts for comfort. Applying ice can help reduce swelling and discomfort associated with engorgement in a woman who is not breastfeeding. Expressing milk manually would stimulate further milk production, which is not desired in this case. Wearing a tight bra could increase discomfort by putting pressure on the engorged breasts. Warm showers may actually increase swelling due to the vasodilation effect of heat.
5. A client receiving chemotherapy has severe neutropenia. What snack is best for the nurse to recommend?
- A. Baked apples with raisins.
- B. Yogurt with fresh berries.
- C. Avocados and cheese.
- D. Fresh fruit salad.
Correct answer: B
Rationale: For a client with severe neutropenia, it is crucial to recommend a snack that is low in bacteria to reduce the risk of infection. Yogurt with fresh berries is an excellent choice as it is not only low in bacteria but also provides nutritional value. Baked apples with raisins (choice A) may not be ideal as the preparation process could introduce bacteria. Avocados and cheese (choice C) may not be the best option due to their potential bacterial content. Fresh fruit salad (choice D) may have a higher risk of bacterial contamination compared to yogurt with fresh berries.
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