HESI RN
HESI 799 RN Exit Exam Capstone
1. A client with chronic obstructive pulmonary disease (COPD) is admitted with increasing shortness of breath. What is the nurse's priority action?
- A. Administer oxygen via nasal cannula.
- B. Reposition the client to improve breathing.
- C. Perform chest physiotherapy.
- D. Encourage the client to cough and deep breathe.
Correct answer: A
Rationale: The correct answer is A: Administer oxygen via nasal cannula. Oxygen therapy is the priority intervention for a client with COPD experiencing increasing shortness of breath. It helps improve oxygenation and relieve respiratory distress. Choice B is not the priority as oxygenation needs to be addressed first. Choice C, chest physiotherapy, may be beneficial but is not the immediate priority in this situation. Choice D, encouraging the client to cough and deep breathe, is not the priority intervention when oxygenation is compromised.
2. Prolonged exposure to high concentrations of supplemental oxygen over several days can cause which pathophysiological effect?
- A. Reduced cardiac output
- B. Disrupted surfactant production
- C. Hyperactivity of alveoli
- D. Increased oxygen carrying capacity
Correct answer: B
Rationale: Corrected Rationale: Prolonged exposure to high oxygen concentrations can disrupt the production of surfactant in the lungs, leading to atelectasis and other lung complications. Surfactant is essential for maintaining lung compliance and preventing alveolar collapse. Reduced cardiac output (Choice A) is not directly associated with prolonged oxygen exposure. Hyperactivity of alveoli (Choice C) is not a recognized consequence of high oxygen levels. Increased oxygen carrying capacity (Choice D) is not a pathophysiological effect of prolonged high oxygen exposure.
3. The home care nurse visits a client who has cancer. The client reports having a good appetite but experiencing nausea when smelling food cooking. Which action should the nurse implement?
- A. Encourage family members to cook meals outdoors and bring the cooked food inside
- B. Provide anti-nausea medication prior to meals
- C. Suggest drinking cold water with meals to reduce nausea
- D. Recommend smaller, frequent meals
Correct answer: A
Rationale: In some cases, the smell of food cooking can trigger nausea in cancer patients. Cooking food outside reduces the intensity of odors that could trigger nausea, helping the client maintain adequate nutrition. Providing anti-nausea medication (Choice B) may not address the root cause of the nausea triggered by the smell of cooking food. Suggesting cold water (Choice C) or smaller, frequent meals (Choice D) may not directly address the issue of cooking odors triggering nausea, which is specific to this client's situation.
4. A client with a history of hypertension and hyperlipidemia is admitted with chest pain. What is the nurse's priority action?
- A. Administer prescribed nitroglycerin.
- B. Obtain a 12-lead electrocardiogram (ECG).
- C. Check the client's vital signs.
- D. Place the client on continuous telemetry.
Correct answer: B
Rationale: The correct answer is to obtain a 12-lead electrocardiogram (ECG). This action is crucial in assessing the heart's electrical activity and helps in the evaluation of chest pain. Administering nitroglycerin (Choice A) may be necessary but should come after obtaining the ECG to confirm the diagnosis. Checking vital signs (Choice C) is important but does not provide direct information about the heart's electrical status. Placing the client on continuous telemetry (Choice D) may be appropriate later but does not provide immediate information on the heart's electrical activity as an ECG does.
5. A client with Alzheimer's disease is prescribed donepezil. What is the most important teaching point?
- A. Take the medication as directed for best results.
- B. Report any unusual changes in behavior.
- C. This medication helps improve cognitive function.
- D. This medication is not a cure for Alzheimer's disease.
Correct answer: C
Rationale: The most important teaching point for a client prescribed donepezil is that it helps improve cognitive function. While it is important to take the medication as directed for best results (choice A) and report any unusual changes in behavior (choice B), the key point is that donepezil is not a cure for Alzheimer's disease (choice D). Therefore, the correct answer is C.
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