HESI RN
HESI RN Exit Exam 2024 Quizlet Capstone
1. A child has a nosebleed (epistaxis) while playing soccer. In what position should the nurse place the child?
- A. Position the child lying flat and apply pressure to the bridge of the nose.
- B. Position the child sitting up and leaning forward.
- C. Have the child tilt the head back and pinch the nose.
- D. Position the child lying on their side and apply ice to the nose.
Correct answer: B
Rationale: The correct answer is to position the child sitting up and leaning forward. This position helps prevent blood from flowing down the throat, reducing the risk of choking or vomiting. Choice A is incorrect because lying flat can cause blood to flow down the throat. Choice C is wrong as tilting the head back may lead to blood entering the throat. Choice D is also incorrect as applying ice is not recommended for nosebleeds and lying on the side may not prevent blood from flowing down the throat.
2. The nurse is preparing an older adult for discharge following cataract extraction. What is the most important instruction?
- A. Avoid straining, bending, or lifting heavy objects.
- B. Limit exposure to sunlight for the first 2 weeks.
- C. Use direct lighting when reading for 6 weeks.
- D. Irrigate the conjunctiva with saline before applying ointment.
Correct answer: A
Rationale: The most important instruction for a patient following cataract extraction is to avoid straining, bending, or lifting heavy objects. These activities can increase intraocular pressure and potentially lead to complications such as bleeding or dislocation of the intraocular lens. Choices B, C, and D are not as critical in the immediate post-operative period. Limiting sunlight exposure and using direct lighting when reading are important but not as crucial as avoiding activities that can increase intraocular pressure. Irrigating the conjunctiva with saline before applying ointment is not a standard post-cataract surgery instruction.
3. After administering a proton pump inhibitor, which action should the nurse take to evaluate the effectiveness of the medication?
- A. Monitor gastrointestinal pain
- B. Ask the client about pain levels
- C. Check the client's vital signs
- D. Assess for signs of bleeding
Correct answer: B
Rationale: The correct answer is to ask the client about pain levels. Proton pump inhibitors (PPIs) work by reducing stomach acid to alleviate gastrointestinal pain. By inquiring about the client's pain experience, the nurse can directly assess the effectiveness of the medication. Monitoring bowel movements (Choice A) is not directly related to evaluating the effectiveness of a PPI. Checking vital signs (Choice C) may not reflect the medication's effectiveness in reducing stomach acid. Assessing for signs of bleeding (Choice D) is important but not the most direct way to evaluate the effectiveness of a PPI.
4. The nurse is providing discharge teaching to a client with newly diagnosed hypertension. Which lifestyle modification should the nurse emphasize to the client?
- A. Increase sodium intake to improve fluid balance
- B. Engage in regular physical activity
- C. Increase caffeine intake to improve energy
- D. Reduce potassium intake to lower blood pressure
Correct answer: B
Rationale: Engaging in regular physical activity is a crucial lifestyle modification for managing hypertension. Regular exercise helps improve cardiovascular health, lower blood pressure, and contribute to overall well-being. Choices A, C, and D are incorrect. Increasing sodium intake is not recommended for hypertension as it can worsen fluid retention and elevate blood pressure. Increasing caffeine intake is also not advised as it may lead to increased heart rate and blood pressure. Reducing potassium intake is not beneficial as potassium is essential for maintaining healthy blood pressure levels.
5. A client with cirrhosis is experiencing ascites and peripheral edema. What is the nurse's priority intervention?
- A. Administer furosemide as prescribed.
- B. Administer albumin to increase oncotic pressure.
- C. Elevate the client's legs to reduce swelling.
- D. Administer a sodium-restricted diet.
Correct answer: A
Rationale: The correct answer is A: Administer furosemide as prescribed. Administering furosemide, a loop diuretic, is the priority intervention in a client with cirrhosis experiencing ascites and peripheral edema. Furosemide helps promote diuresis and reduce fluid buildup in the body. Choice B, administering albumin to increase oncotic pressure, may be beneficial in some cases but is not the priority intervention for immediate fluid removal. Elevating the client's legs (Choice C) and administering a sodium-restricted diet (Choice D) are important aspects of managing edema and ascites but are not the priority interventions in this situation.
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