HESI RN
HESI RN Exit Exam 2024 Capstone
1. A client receiving IV heparin reports tarry stools and abdominal pain. What interventions should the nurse implement?
- A. Prepare to administer warfarin.
- B. Assess the characteristics of the client's pain.
- C. Obtain recent partial thromboplastin time results.
- D. Monitor stool for the presence of blood.
Correct answer: D
Rationale: The correct intervention for the client receiving IV heparin who reports tarry stools and abdominal pain is to monitor the stool for the presence of blood. This is crucial to assess for gastrointestinal bleeding, a potential complication of heparin therapy. Assessing the characteristics of the client's pain may be helpful but is not the priority when signs of GI bleeding are present. Administering warfarin is not appropriate without a thorough assessment and confirmation of the cause of symptoms. While obtaining recent partial thromboplastin time results is important in monitoring heparin therapy, in this scenario, the immediate concern is to assess for possible GI bleeding.
2. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client?
- A. The tube will drain fluid from your chest.
- B. The tube will remove excess air from your chest.
- C. The tube controls the amount of air that enters your chest.
- D. The tube will seal the hole in your lung.
Correct answer: B
Rationale: The correct answer is B: 'The tube will remove excess air from your chest.' In a spontaneous pneumothorax, air accumulates in the pleural space, causing lung collapse. The chest tube is inserted to remove this excess air, allowing the lung to re-expand. Choices A, C, and D are incorrect because the primary purpose of a chest tube in pneumothorax is to evacuate air, not fluid, control air entry, or seal a lung hole.
3. A diet rich in _______ controls menopause symptoms:
- A. Carbohydrates
- B. Soya items
- C. Fruits and veggies
- D. Eggs and meat
Correct answer: B
Rationale: A diet rich in soya items can help control menopause symptoms. Soya contains phytoestrogens, which are plant-based compounds that mimic the hormone estrogen in the body. These compounds may help alleviate menopause symptoms such as hot flashes and night sweats. Choice A, Carbohydrates, do not specifically target menopause symptoms. Choice C, Fruits and veggies, while generally healthy, do not have the same impact on menopause symptoms as soya. Choice D, Eggs and meat, do not contain phytoestrogens like soya, making them less effective in managing menopause symptoms.
4. When reassigned to the emergency department, a nurse should understand that gastric lavage is a priority in which situation?
- A. An infant who has been identified to have botulism
- B. A toddler who ate a number of ibuprofen tablets
- C. A preschooler who swallowed powdered plant food
- D. A school-aged child who took a handful of vitamins
Correct answer: A
Rationale: The correct answer is A because gastric lavage is a priority for infants with botulism to remove toxins from the stomach. Botulism is a serious condition caused by a toxin produced by Clostridium botulinum bacteria. Gastric lavage helps in removing the toxin from the stomach. Choice B is incorrect because gastric lavage is not typically indicated for ibuprofen ingestion. Choice C is incorrect because gastric lavage is not the first-line treatment for ingesting powdered plant food. Choice D is incorrect because gastric lavage is not routinely performed for vitamin ingestion.
5. An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care?
- A. Do not massage any reddened areas.
- B. Encourage passive range of motion exercises on extremities.
- C. Position the client laterally, supine, and prone in sequence.
- D. Gently lift the client when moving into a desired position.
Correct answer: D
Rationale: The essential nursing measure for a client with a fractured left hip on strict bedrest is to gently lift the client when moving into a desired position (D). This helps to avoid shearing forces and prevents further injury. Massaging reddened areas (A) should be avoided to prevent skin damage. Active range of motion exercises (B) may be limited due to pain and muscle spasms in the affected leg. The position described in (C) is contraindicated for a client with a fractured left hip as it may cause additional harm.