HESI RN
HESI RN Exit Exam 2024 Capstone
1. A client is admitted with a large pleural effusion. Which procedure should the nurse prepare the client for?
- A. Thoracentesis.
- B. Endotracheal intubation.
- C. Chest tube insertion.
- D. Bronchoscopy.
Correct answer: A
Rationale: Corrected Rationale: The correct procedure for a client with a large pleural effusion is thoracentesis. Thoracentesis is a diagnostic and therapeutic procedure used to remove fluid from the pleural space, which can help relieve symptoms associated with pleural effusion. Choice B (Endotracheal intubation) is incorrect as it is a procedure to secure the airway by placing a tube into the trachea. Choice C (Chest tube insertion) is incorrect as it is typically done to drain air or fluid from the pleural space over a longer period. Choice D (Bronchoscopy) is incorrect as it is a procedure used to visualize the airways and diagnose lung conditions, not specifically for pleural effusion removal.
2. During the initial visit to a client with MS who is bed-bound and lifted by a hoist, which intervention is most important for the nurse to implement?
- A. Determine how the client is cared for when the caregiver is not present.
- B. Develop a client needs assessment and review it with the caregiver.
- C. Evaluate the caregiver's ability to care for the client's needs.
- D. Review with the caregiver the interventions provided each day.
Correct answer: A
Rationale: During the initial visit, the most crucial intervention for the nurse is to determine how the client is cared for when the caregiver is not present. This is essential to ensure the client's safety and well-being, especially during times when the caregiver is not available. Option B is not the most important as it focuses on assessment rather than immediate safety concerns. Option C, while important, is secondary to ensuring continuous care. Option D is less critical during the initial visit compared to ensuring care continuity in the caregiver's absence.
3. Which two items react during cellular respiration?
- A. Glucose and water
- B. Carbon dioxide and water
- C. Carbon dioxide and oxygen
- D. Glucose and oxygen
Correct answer: D
Rationale: The correct answer is D: Glucose and oxygen. During cellular respiration, glucose and oxygen react in the presence of enzymes to produce carbon dioxide, water, and energy in the form of ATP. Choice A (Glucose and water) is incorrect because water is a product of cellular respiration, not a reactant. Choice B (Carbon dioxide and water) is incorrect as carbon dioxide is produced during cellular respiration, not a reactant. Choice C (Carbon dioxide and oxygen) is incorrect because oxygen is a reactant in cellular respiration, not a product.
4. A client with diabetes mellitus is experiencing hyperglycemia. What laboratory value should the nurse monitor to evaluate long-term glucose control?
- A. Blood glucose level
- B. Glycosylated hemoglobin (A1C)
- C. Urine output
- D. Serum ketone level
Correct answer: B
Rationale: The correct answer is B: Glycosylated hemoglobin (A1C). Glycosylated hemoglobin reflects long-term glucose control over the past three months. Monitoring blood glucose levels provides information on the current glucose status and immediate control, but it does not give a comprehensive view of long-term control. Urine output and serum ketone levels are important indicators for other aspects of diabetes management, such as hydration status and ketone production during hyperglycemic episodes, but they do not directly reflect long-term glucose control.
5. A client in the oliguric phase of acute renal failure (ARF) has a 24-hour urine output of 400 ml. How much oral intake should the nurse allow this client to have during the next 24 hours?
- A. Encourage oral fluids as tolerated
- B. Decrease oral intake to 200 ml
- C. Allow the client to have exactly 400 ml oral intake
- D. Limit oral intake to 900 to 1,000 ml
Correct answer: D
Rationale: In the oliguric phase of acute renal failure (ARF), the goal is to prevent fluid overload. Since the client has a low urine output of 400 ml in 24 hours, limiting oral intake to 900 to 1,000 ml is appropriate. Encouraging unrestricted oral fluids (Choice A) can exacerbate fluid overload. Decreasing oral intake to 200 ml (Choice B) would be too restrictive and may lead to dehydration. Allowing the client to have exactly 400 ml oral intake (Choice C) would not account for other sources of fluid intake and output, potentially resulting in fluid imbalance.