HESI RN
HESI RN Exit Exam 2024 Capstone
1. A client is receiving IV fluid therapy for dehydration. Which assessment finding indicates that the client's fluid status is improving?
- A. Urine output increases to 50 mL/hour
- B. Client reports feeling more thirsty
- C. Blood pressure decreases from 120/80 to 110/70
- D. Heart rate increases from 80 to 100 beats per minute
Correct answer: A
Rationale: An increase in urine output is a positive sign that the client's hydration status is improving. It indicates that the kidneys are functioning well and that fluid therapy is effective. Increased urine output helps to eliminate excess fluid and waste products from the body. Choices B, C, and D are incorrect. Feeling more thirsty (choice B) is a sign of dehydration, not improvement. A decrease in blood pressure (choice C) and an increase in heart rate (choice D) are not typically indicative of improving fluid status during IV fluid therapy for dehydration.
2. Basal body temperature rise of _____ is seen in the luteal phase due to the thermogenic effects of a metabolite of progesterone in a normal cycle:
- A. 0.1-0.5
- B. 0.2-0.5
- C. 1.0-2.0
- D. 1.5-2.0
Correct answer: B
Rationale: A basal body temperature rise of 0.2-0.5 degrees Celsius is typically seen in the luteal phase of the menstrual cycle due to the thermogenic effects of a metabolite of progesterone. This temperature rise helps to indicate ovulation has occurred. Choices A, C, and D are incorrect as they do not reflect the usual range of temperature increase observed during the luteal phase. A rise of 0.1-0.5 degrees Celsius is too narrow (eliminating choice A), while ranges of 1.0-2.0 and 1.5-2.0 degrees Celsius are too high and not consistent with the expected basal body temperature changes during the menstrual cycle.
3. During a woman's first prenatal visit, the nurse reviews her health care record, noting a history of chickenpox as a child and syphilis as a teenager. Which action is most important for the nurse to take?
- A. Obtain blood and urine for prenatal screens.
- B. Schedule prenatal visits to occur monthly.
- C. Explain common complications of pregnancy.
- D. Obtain baseline blood pressure and weight.
Correct answer: A
Rationale: Obtaining blood and urine for prenatal screens is crucial in identifying any potential infections or conditions that may require monitoring throughout the pregnancy. Screening for infections such as syphilis is essential to ensure appropriate management and prevent adverse outcomes. This action helps in early detection and timely intervention, promoting the health and well-being of both the mother and the developing fetus. The other options, while important during prenatal care, are not as critical as obtaining prenatal screens to assess for any existing infections that could impact the pregnancy.
4. Which bed position is preferred for use with a client in an extended care facility on a falls risk prevention protocol?
- A. All 4 side rails up, wheels locked, bed closest to door
- B. Lower side rails up, bed facing the doorway
- C. Knees bent, head slightly elevated, bed in the lowest position
- D. Bed in the lowest position, wheels locked, place bed against the wall
Correct answer: D
Rationale: The correct answer is D. Placing the bed in the lowest position, ensuring wheels are locked, and positioning it against the wall is the preferred bed position for a client in an extended care facility on a falls risk prevention protocol. This setup helps minimize the risk of falls by providing a stable and secure environment. Choices A, B, and C do not address key factors such as having the bed in the lowest position and placing it against the wall, which are crucial in preventing falls in such a setting.
5. The healthcare provider prescribes a sepsis protocol for a client with multi-organ failure caused by a ruptured appendix. Which intervention is most important for the nurse to include in the care plan?
- A. Ensure early ambulation
- B. Administer antibiotics as prescribed
- C. Maintain strict intake and output
- D. Monitor blood glucose levels
Correct answer: C
Rationale: In sepsis with multi-organ failure, monitoring intake and output is critical to assess renal function and fluid balance, as organ failure can cause fluid shifts and decreased kidney function. Antibiotics are essential to treat the infection, but monitoring intake and output provides real-time insight into the client's status, helping to detect early signs of worsening organ function. Early ambulation and blood glucose monitoring are important aspects of care but are not as crucial as maintaining strict intake and output in this situation.