HESI RN
HESI RN Exit Exam 2023 Capstone
1. A client is admitted to isolation with active tuberculosis. What infection control measures should the nurse implement?
- A. Initiate protective environment precautions.
- B. Use droplet precautions only.
- C. Ensure a positive pressure environment in the room.
- D. Implement negative pressure and contact precautions.
Correct answer: D
Rationale: When caring for a client with active tuberculosis, it is crucial to implement negative pressure rooms and contact precautions to prevent the spread of infection. Choice A, initiating protective environment precautions, is incorrect as this is not the recommended approach for tuberculosis. Choice B, using droplet precautions only, is insufficient as tuberculosis requires additional precautions. Choice C, ensuring a positive pressure environment in the room, is incorrect because negative pressure rooms are necessary to contain airborne pathogens like tuberculosis. Therefore, the most appropriate measures include implementing negative pressure rooms and contact precautions.
2. A client has been taking oral corticosteroids for the past five days because of seasonal allergies. Which assessment finding is of most concern to the nurse?
- A. White blood count of 10,000/mm³.
- B. Serum glucose of 115 mg/dL.
- C. Purulent sputum.
- D. Excessive hunger.
Correct answer: C
Rationale: The correct answer is C: Purulent sputum. Corticosteroids can suppress the immune system, increasing the risk of infections. Purulent sputum suggests a possible respiratory infection, which can rapidly progress and lead to complications, making it the most concerning finding. Choice A, a white blood count of 10,000/mm³, is within the normal range and not typically a cause for immediate concern. Choice B, a serum glucose level of 115 mg/dL, is also normal and not directly related to corticosteroid use. Choice D, excessive hunger, is a common side effect of corticosteroids but is not as concerning as a sign of infection indicated by purulent sputum.
3. A 7-year-old is admitted to the hospital with persistent vomiting, and a nasogastric tube attached to low intermittent suction is applied. Which finding is most important for the nurse to report to the healthcare provider?
- A. Gastric output of 100 mL in the last 8 hours.
- B. Shift intake of 640 mL IV fluids plus 30 mL PO ice chips.
- C. Serum potassium of 3.0 mEq/L.
- D. Serum pH of 7.45.
Correct answer: C
Rationale: A serum potassium level of 3.0 mEq/L is significantly low and indicates hypokalemia, which can lead to serious complications such as cardiac arrhythmias. Therefore, it is crucial for the nurse to report this finding promptly to the healthcare provider for immediate intervention. The other findings are not as critical in this situation. Gastric output of 100 mL in the last 8 hours may be expected in a patient with persistent vomiting. The shift intake of IV fluids and ice chips indicates fluid replacement, which is important but not as urgent as correcting electrolyte imbalances. A serum pH of 7.45 is within the normal range and does not indicate an immediate concern.
4. A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during the first 12 hours after admission?
- A. Side-lying on the left with the head elevated 10 degrees
- B. Side-lying on the left with the head elevated 35 degrees
- C. Side-lying on the right with the head elevated 10 degrees
- D. Side-lying on the right with the head elevated 35 degrees
Correct answer: A
Rationale: The correct position for a client with viral pneumonia affecting 2/3 of the right lung is side-lying on the left with the head elevated 10 degrees. This position helps maximize lung expansion and oxygenation in cases of pneumonia affecting the right lung. Choice B is incorrect as excessive elevation can put pressure on the lung, and choices C and D are incorrect as side-lying on the right would not be beneficial for a client with pneumonia in the right lung.
5. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which intervention should the nurse implement first?
- A. Administer a bronchodilator as prescribed.
- B. Assess the client's respiratory rate.
- C. Assess the client's oxygen saturation.
- D. Elevate the head of the bed.
Correct answer: C
Rationale: Assessing the client's oxygen saturation is crucial in a client with COPD receiving supplemental oxygen to ensure adequate oxygenation. This assessment helps determine if the current oxygen therapy is effective or if adjustments are necessary. While administering a bronchodilator is important in managing COPD, assessing oxygen saturation takes precedence to address the client's immediate oxygen needs. Assessing the respiratory rate is also important but evaluating oxygen saturation provides more direct information about the client's oxygen status. Elevating the head of the bed can improve ventilation but is not the priority when assessing oxygen saturation in a client with COPD receiving supplemental oxygen.