HESI RN
HESI RN Exit Exam 2024 Quizlet Capstone
1. A client who recently underwent a tracheostomy is being prepared for discharge to home. Which instructions are most important for the nurse to include in the discharge plan?
- A. Teach signs of infection
- B. Teach tracheal suctioning techniques
- C. Educate on humidifying air
- D. Discuss the use of a speaking valve
Correct answer: B
Rationale: The correct answer is B: Teach tracheal suctioning techniques. Tracheal suctioning is crucial for maintaining a clear airway in clients with a tracheostomy. Without proper suctioning, secretions can accumulate and cause airway obstruction or respiratory infections. Educating the client on how to perform suctioning safely is a priority for discharge planning. Choices A, C, and D are important aspects of tracheostomy care, but teaching tracheal suctioning techniques takes precedence due to its direct impact on airway patency and preventing complications.
2. At 16 weeks of pregnancy, the breast changes include:
- A. Montgomery's tubercles are prominent.
- B. Darkening of the nipple.
- C. Prickling, tingling sensation.
- D. Colostrum can be expressed.
Correct answer: C
Rationale: At 16 weeks of pregnancy, the sensation of prickling and tingling in the breasts is common due to hormonal changes. Montgomery's tubercles becoming prominent is more characteristic of early pregnancy, typically around the first trimester. Darkening of the nipple, known as areola darkening, can occur but is more commonly observed later in pregnancy. The expression of colostrum, the first milk produced by the mammary glands, usually happens closer to the end of pregnancy or after childbirth, not typically at 16 weeks.
3. A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the deceased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time?
- A. Not sleeping for several days.
- B. Wishing to be with the deceased significant other.
- C. Lack of interest in usual activities.
- D. Eating very little.
Correct answer: A
Rationale: The most important client statement for the RN to explore in this scenario is the client not sleeping for several days. The lack of sleep is a critical indicator of possible severe depression or suicidal ideation that requires immediate attention. While expressing a wish to be with the deceased significant other, having a lack of interest in usual activities, and eating very little are concerning, the immediate focus should be on the client's severe sleep disturbance as it can pose an immediate risk to their well-being and safety.
4. The nurse is teaching a group of clients about managing diabetes. Which of the following should be emphasized as a goal for all diabetics?
- A. Frequent exercise and weight control
- B. Prevent eye damage
- C. Keep insulin refrigerated at all times
- D. Prevent the development of complications
Correct answer: A
Rationale: The correct answer is A: Frequent exercise and weight control. These should be emphasized as a goal for all diabetics because they help prevent complications and manage blood sugar levels. Regular physical activity and maintaining a healthy weight are crucial in managing diabetes as they can improve insulin sensitivity, regulate blood sugar levels, and reduce the risk of cardiovascular complications. Choice B, preventing eye damage, is important but is more specific to diabetic retinopathy and not a general goal for all diabetics. Choice C, keeping insulin refrigerated, is essential for insulin storage but not a primary goal for all diabetics. Choice D, preventing the development of complications, is too broad and does not provide a specific actionable goal for all diabetics.
5. A client who is bedridden after a stroke is at risk for developing pressure ulcers. Which nursing intervention is most important in preventing this complication?
- A. Apply lotion to the skin every 4 hours.
- B. Reposition the client every 2 hours.
- C. Elevate the head of the bed 30 degrees.
- D. Massage the skin at least twice a day.
Correct answer: B
Rationale: Repositioning the client every 2 hours is crucial in preventing pressure ulcers in bedridden clients. This intervention helps in relieving pressure on specific areas of the body, promoting circulation, and reducing the risk of tissue damage. Applying lotion every 4 hours (Choice A) may not address the root cause of pressure ulcers. Elevating the head of the bed (Choice C) is beneficial for some conditions but not specifically targeted at preventing pressure ulcers. Massaging the skin at least twice a day (Choice D) can actually increase the risk of skin breakdown in individuals at risk for pressure ulcers by causing friction and shearing forces on the skin.