HESI RN
HESI Exit Exam RN Capstone
1. A client presents with three positive responses to the CAGE questionnaire. What interpretation should the nurse provide?
- A. CAGE is a tool for general substance abuse screening.
- B. Two positive responses suggest alcohol dependence.
- C. One positive response does not indicate alcohol addiction.
- D. All four responses must be positive to suggest alcohol dependence.
Correct answer: B
Rationale: Two positive responses on the CAGE questionnaire strongly suggest alcohol dependence. Choice A is incorrect as the CAGE questionnaire specifically targets alcohol abuse. Choice C is incorrect because one positive response is not enough to indicate alcohol addiction. Choice D is incorrect because alcohol dependence can be suggested with two positive responses, not all four.
2. What is the typical measurement of the anterior wall of the vaginal canal?
- A. 10 cm
- B. 11 cm
- C. 11.5 cm
- D. 7.5 cm
Correct answer: D
Rationale: The typical measurement of the anterior wall of the vaginal canal is 7.5 cm. This measurement is anatomically accurate, making choice D the correct answer. Choices A, B, and C provide measurements that are larger than the typical measurement of the anterior wall of the vaginal canal and are therefore incorrect.
3. A client is being treated with a tricyclic antidepressant (TCA). Which side effect should the nurse monitor for?
- A. Constipation and urinary retention.
- B. Increased appetite and weight loss.
- C. Sedation and blurred vision.
- D. Insomnia and dry mouth.
Correct answer: A
Rationale: The correct answer is A: Constipation and urinary retention. Tricyclic antidepressants (TCAs) are known to have anticholinergic side effects, which include constipation and urinary retention. These side effects occur due to the inhibition of cholinergic receptors, leading to decreased gastrointestinal motility and relaxation of the detrusor muscle in the bladder. Choices B, C, and D are incorrect because increased appetite, weight loss, sedation, blurred vision, insomnia, and dry mouth are not typically associated with the use of TCAs. Monitoring for constipation and urinary retention is essential to prevent complications and ensure the client's safety.
4. A client with polycystic kidney disease (PKD) is being discharged. Which statements should the nurse include in this client’s discharge teaching? (Select all that apply.)
- A. Take your blood pressure every morning.
- B. Weigh yourself at the same time each day.
- C. Contact your provider if you have visual disturbances.
- D. All of the above
Correct answer: D
Rationale: A client with polycystic kidney disease (PKD) should be educated on monitoring their blood pressure daily and weighing themselves consistently to detect any changes promptly. It is essential to contact the healthcare provider if visual disturbances occur, as this could indicate a complication such as a berry aneurysm associated with PKD. Foul-smelling or bloody urine should also prompt notification to the provider as they could signify urinary tract infections or glomerular injury. Choices A, B, and C are correct as they address crucial aspects of managing PKD and its potential complications. Choices A and B help in monitoring for changes in blood pressure and fluid status, while choice C focuses on detecting possible neurological complications. Choices A, B, and C are relevant to PKD management and should be included in the client's discharge teaching. Choices that mention diarrhea and renal stones are not directly associated with PKD; therefore, teaching related to these conditions would be irrelevant in this context.
5. What is the most common site for an ectopic pregnancy?
- A. Isthmus
- B. Ampulla
- C. Interstitial
- D. Infundibulum
Correct answer: C
Rationale: The correct answer is C, Interstitial. An ectopic pregnancy most commonly occurs in the interstitial portion of the fallopian tube. This is because the interstitial part is narrow and not suitable for the growing embryo, leading to implantation outside the uterus. Choices A, B, and D are incorrect because although ectopic pregnancies can occur in various locations, the interstitial portion of the fallopian tube is the most frequent site for such pregnancies.