HESI RN
HESI RN Exit Exam 2024 Quizlet Capstone
1. A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. What action should the nurse take when finding the radiation implant in the bed?
- A. Call radiation therapy for assistance
- B. Place the implant in a lead container using long-handled forceps
- C. Leave the implant in the bed and notify the provider
- D. Dispose of the implant in the nearest sharps container
Correct answer: B
Rationale: The correct action for the nurse to take when finding the radiation implant in the bed is to use long-handled forceps to place the implant in a lead container. This procedure is crucial in reducing radiation exposure to both the patient and healthcare providers. Calling radiation therapy for assistance (Choice A) may delay the immediate need for safe handling of the implant. Leaving the implant in the bed and notifying the provider (Choice C) is unsafe and can lead to increased radiation exposure. Disposing of the implant in a sharps container (Choice D) is incorrect as the implant should be placed in a lead container, not a sharps container, to contain the radiation.
2. A client in the oliguric phase of acute renal failure (ARF) has a 24-hour urine output of 400 ml. How much oral intake should the nurse allow this client to have during the next 24 hours?
- A. Encourage oral fluids as tolerated
- B. Decrease oral intake to 200 ml
- C. Allow the client to have exactly 400 ml oral intake
- D. Limit oral intake to 900 to 1,000 ml
Correct answer: D
Rationale: In the oliguric phase of acute renal failure (ARF), the goal is to prevent fluid overload. Since the client has a low urine output of 400 ml in 24 hours, limiting oral intake to 900 to 1,000 ml is appropriate. Encouraging unrestricted oral fluids (Choice A) can exacerbate fluid overload. Decreasing oral intake to 200 ml (Choice B) would be too restrictive and may lead to dehydration. Allowing the client to have exactly 400 ml oral intake (Choice C) would not account for other sources of fluid intake and output, potentially resulting in fluid imbalance.
3. Which instruction should be included in the discharge teaching plan for a client who underwent cataract extraction today?
- A. Use a metal eye shield on the operative eye during the day.
- B. Administer eye ointment before applying eye drops.
- C. Sexual activities may be resumed after returning home.
- D. Light housekeeping is safe to do, but avoid heavy lifting.
Correct answer: D
Rationale: The correct instruction to include in the discharge teaching plan for a client who underwent cataract extraction is to advise them that light housekeeping is safe to do, but they should avoid heavy lifting. Heavy lifting can strain the surgical site and potentially lead to complications. Choice A is incorrect as a metal eye shield is usually recommended during sleep, not during the day. Choice B is incorrect because eye ointment should typically be administered after applying eye drops to prevent dilution of the medication. Choice C is incorrect as sexual activities should usually be avoided for a specific period post-surgery as advised by the healthcare provider.
4. A client is receiving a blood transfusion and develops a fever. What is the nurse's first action?
- A. Administer an antipyretic as prescribed.
- B. Stop the transfusion and notify the healthcare provider.
- C. Slow the rate of the transfusion.
- D. Continue the transfusion and reassess in 15 minutes.
Correct answer: B
Rationale: The correct first action when a client receiving a blood transfusion develops a fever is to stop the transfusion and notify the healthcare provider. This is crucial to prevent further reactions and ensure prompt intervention. Administering an antipyretic (Choice A) may mask symptoms and delay appropriate treatment. Slowing the rate of the transfusion (Choice C) might not address the underlying cause of the fever. Continuing the transfusion and reassessing in 15 minutes (Choice D) could worsen the client's condition if there is a severe reaction occurring.
5. To auscultate for a carotid bruit, where should the nurse place the stethoscope?
- A. Base of the neck on the right side
- B. Above the clavicle
- C. Over the sternum
- D. Over the trachea
Correct answer: A
Rationale: To auscultate for a carotid bruit, the nurse should place the stethoscope at the base of the neck, near the carotid artery. A carotid bruit is an abnormal sound that indicates turbulent blood flow in the carotid artery, potentially due to arterial narrowing or atherosclerosis. Placing the stethoscope above the clavicle, over the sternum, or over the trachea would not provide the nurse with the optimal location to assess for carotid artery abnormalities.