HESI RN
HESI RN Exit Exam 2024 Capstone
1. A client with a venous leg ulcer is receiving compression therapy. What assessment finding requires immediate intervention?
- A. Decreased pain and increased redness around the ulcer.
- B. Increased serous drainage from the ulcer site.
- C. Cool extremities and weak peripheral pulses.
- D. Pitting edema around the ulcer site.
Correct answer: C
Rationale: The correct answer is C. Cool extremities and weak peripheral pulses indicate compromised circulation, possibly due to inadequate arterial blood supply. This finding requires immediate intervention to prevent further complications such as tissue damage or non-healing ulcers. Option A, decreased pain and increased redness, can be a sign of improving wound condition. Option B, increased serous drainage, may indicate a normal part of the healing process. Option D, pitting edema, is common in venous leg ulcers and may not require immediate intervention unless severe and accompanied by other concerning symptoms.
2. Which of the following best describes the nurse's responsibility in obtaining informed consent?
- A. The nurse is responsible for ensuring that the patient understands the procedure and has the opportunity to ask questions.
- B. The nurse should ensure that the patient signs the consent form before the procedure begins.
- C. The nurse is responsible for witnessing the patient sign the consent form and documenting the event.
- D. The nurse should delegate the task of obtaining informed consent to another healthcare provider.
Correct answer: A
Rationale: The correct answer is A. Informed consent is a process where the healthcare provider, in this case, the nurse, ensures that the patient understands the procedure, risks, benefits, and alternatives before they agree to it. The nurse plays a crucial role in facilitating this understanding by explaining the information in a clear and understandable manner and providing the patient with the opportunity to ask questions. Choice B is incorrect because merely obtaining the patient's signature on the consent form does not ensure that the patient truly understands what they are consenting to. Choice C is not fully accurate as the nurse's role goes beyond just witnessing the signature; it involves actively ensuring the patient's comprehension. Choice D is incorrect as the responsibility of obtaining informed consent should not be delegated to another healthcare provider, as it is the nurse's duty to ensure proper communication and understanding with the patient.
3. What does Integrated Reproductive Health entail?
- A. Women of childbearing age
- B. Women and under-five children only
- C. Men, women, adolescents, youth, and children
- D. Pregnant women only
Correct answer: C
Rationale: Integrated Reproductive Health involves providing services that cater to a wide range of demographics, including men, women, adolescents, youth, and children. This comprehensive approach ensures that reproductive health needs are addressed across different age groups and genders. Choices A, B, and D are too restrictive and do not encompass the full scope of Integrated Reproductive Health services.
4. The nurse is evaluating the health status of an older client. Which finding is most important for the nurse to report to the healthcare provider?
- A. Client reports decreased urine output
- B. Client reports loss of appetite
- C. Client reports pain in the lower back
- D. Client reports a persistent cough
Correct answer: C
Rationale: Pain in the lower back is a significant finding in an older client as it can indicate underlying issues such as kidney problems, spinal issues, or even aortic aneurysm. These conditions can be serious and require prompt medical attention. Decreased urine output (choice A) could indicate dehydration or kidney issues but is not as urgent as lower back pain. Loss of appetite (choice B) may be concerning but is not as critical as the potential life-threatening conditions associated with lower back pain. A persistent cough (choice D) is important to assess but is generally not as urgent as the potential serious implications of lower back pain in an older client.
5. The client is being taught about precautions with Coumadin therapy. The client should be instructed to avoid which over-the-counter medication?
- A. Non-steroidal anti-inflammatory drugs
- B. Cough medicines containing guaifenesin
- C. Histamine blockers
- D. Laxatives containing magnesium salts
Correct answer: A
Rationale: The correct answer is A: Non-steroidal anti-inflammatory drugs (NSAIDs). NSAIDs can increase the risk of bleeding in clients taking Coumadin, which is an anticoagulant medication. Avoiding NSAIDs helps prevent potentially dangerous interactions with Coumadin. Choices B, C, and D are incorrect. Cough medicines with guaifenesin, histamine blockers, and laxatives containing magnesium salts do not typically have significant interactions with Coumadin therapy. Therefore, they are not the over-the-counter medications that the client needs to avoid while on Coumadin.