HESI RN
HESI Exit Exam RN Capstone
1. A client with multiple sclerosis is admitted with an acute exacerbation. What is the nurse's priority action?
- A. Monitor the client’s vital signs every hour.
- B. Assess for changes in the client’s muscle strength.
- C. Administer prescribed corticosteroids to reduce inflammation.
- D. Educate the client on managing fatigue and preventing relapses.
Correct answer: C
Rationale: The correct answer is C. Administering prescribed corticosteroids to reduce inflammation is the priority action when a client with multiple sclerosis is admitted with an acute exacerbation. Corticosteroids help manage symptoms during exacerbations and reduce inflammation. Monitoring vital signs and assessing muscle strength are important aspects of care but not the priority during an acute exacerbation. Educating the client on managing fatigue and preventing relapses is essential but can be addressed after the acute exacerbation has been managed.
2. In a client with heart failure presenting bilateral +4 edema of the right ankle extending up to midcalf while sitting with legs dependent, what is the priority goal?
- A. Decrease venous congestion.
- B. Maintain normal respirations.
- C. Maintain body temperature.
- D. Prevent injury to lower extremities.
Correct answer: A
Rationale: The priority goal in this scenario is to decrease venous congestion. By elevating the legs above the heart level, venous return is improved, reducing congestion in the lower extremities. This intervention helps decrease swelling and prevents complications such as impaired tissue perfusion. Maintaining normal respirations and body temperature are important aspects of care but are secondary to addressing the immediate issue of venous congestion. Preventing injury to lower extremities is also essential but takes precedence after managing the venous congestion to prevent further complications.
3. A client with a postoperative wound that eviscerated yesterday has an elevated temperature. Which intervention is most important for the nurse to implement?
- A. Initiate contact isolation.
- B. Obtain a wound swab for culture and sensitivity.
- C. Assess temperature every 4 hours.
- D. Use alcohol-based solutions for hand hygiene.
Correct answer: B
Rationale: In this scenario, the most critical intervention is to obtain a wound swab for culture and sensitivity. This will help identify the causative organism present in the wound, enabling healthcare providers to prescribe the appropriate treatment. Initiating contact isolation (Choice A) may be necessary in certain situations but is not the priority in this case where infection is suspected. Assessing the temperature (Choice C) is important for monitoring the client's condition but does not address the underlying cause. Using alcohol-based solutions for hand hygiene (Choice D) is a standard practice for infection control but does not directly address the client's specific condition of a postoperative wound with evisceration and elevated temperature.
4. Several employees who have a 10-year or longer smoking history ask for assistance with smoking cessation. A nurse develops a 2-month program that includes weekly group sessions on lifestyle changes and use of over-the-counter nicotine substitute products. Which measurement provides the best indication of the program's effectiveness?
- A. survey employees to determine how many are smoking 2 months after the end of the program
- B. test the employees' knowledge of OTC nicotine substitute products at the end of the program
- C. ask employees to inform the group if they stop smoking and if they start smoking again
- D. design a questionnaire that identifies lifestyle changes contributing to smoking cessation
Correct answer: A
Rationale: Surveying employees to determine how many are smoking 2 months after the end of the program provides a direct assessment of the program's effectiveness. This measurement evaluates the actual behavior change related to smoking cessation. Choice B, testing knowledge of OTC nicotine substitute products, does not directly measure smoking cessation outcomes. Choice C relies on self-reporting, which may not be accurate or reliable. Choice D focuses on identifying lifestyle changes but does not directly assess the program's impact on smoking cessation.
5. A 2-year-old is admitted to the hospital with possible encephalitis, and a lumbar puncture is scheduled. Which information should the nurse provide this child concerning the procedure?
- A. Describe the side-lying, knees to chest position that must be assumed during the procedure.
- B. Tell the child to expect loud clicking noises during the procedure that may be slightly annoying.
- C. Reassure the child that there will be no restrictions on activity after the procedure is completed.
- D. Explain that fluids cannot be taken for 8 hours before the procedure and for 4 hours after the procedure.
Correct answer: A
Rationale: The correct answer is A. Describing the side-lying, knees to chest position that must be assumed during the lumbar puncture procedure is essential as it helps the child understand what to expect, promotes cooperation, and reduces anxiety. This position is necessary for the procedure to be performed safely and effectively. Choice B is incorrect because mentioning loud clicking noises may increase the child's anxiety. Choice C is incorrect because there may be restrictions on activity after the procedure, depending on individual cases. Choice D is also incorrect as it provides information about fluid intake restrictions that are not directly related to the procedure itself.