HESI RN
HESI RN Exit Exam 2024 Capstone
1. A client with type 1 diabetes reports blurry vision. What is the most important assessment the nurse should perform?
- A. Assess the client’s most recent blood glucose levels.
- B. Check the client’s hemoglobin A1C level.
- C. Check the client’s blood pressure for signs of hypertension.
- D. Examine the client’s feet for signs of neuropathy.
Correct answer: A
Rationale: Blurry vision in clients with type 1 diabetes may indicate hyperglycemia, which requires prompt assessment of recent blood glucose levels to determine the cause and appropriate intervention. Checking the client’s hemoglobin A1C level (Choice B) is useful for assessing long-term glucose control, not for immediate management of blurry vision. Monitoring blood pressure (Choice C) is important in diabetes care but is not the most crucial assessment when blurry vision is reported. Examining the client’s feet for signs of neuropathy (Choice D) is important in diabetic foot care but is not the priority when dealing with blurry vision.
2. A client is being educated by a healthcare professional about initiating a prescribed abstinence therapy using Disulfiram (Antabuse). What information should the client acknowledge understanding?
- A. Admit to others that they are a substance abuser.
- B. Remain alcohol-free for 12 hours before taking the first dose.
- C. Attend monthly Alcoholics Anonymous meetings.
- D. Completely abstain from heroin or cocaine use.
Correct answer: B
Rationale: B: Before starting Disulfiram therapy, it is crucial for clients to be alcohol-free for a minimum of 12 hours to prevent adverse reactions. A: Admitting substance abuse is important, but it is not directly linked to the initiation of Disulfiram therapy. C: Attending Alcoholics Anonymous meetings is beneficial for support but not a specific requirement for starting Disulfiram. D: The focus of Disulfiram therapy is on alcohol abstinence, so abstaining from heroin or cocaine is not directly related to this medication.
3. During the admission assessment, a female client requests that her husband be allowed to stay in the room. When the RN notes a discrepancy between the client’s verbal and nonverbal communication, what action should the RN take?
- A. Pay close attention to and document the nonverbal messages.
- B. Ask the client’s husband to interpret the discrepancy.
- C. Ignore the nonverbal behavior and focus solely on the client’s verbal messages.
- D. Integrate the verbal and nonverbal messages and interpret them together.
Correct answer: A
Rationale: During a client assessment, noting and documenting nonverbal messages is important as it captures the full context of the client’s communication. Nonverbal cues can often reveal underlying emotions or issues that may not be expressed verbally. Asking the client’s husband to interpret the discrepancy (Choice B) may not be appropriate as it could potentially breach the client's privacy and trust. Ignoring nonverbal behavior (Choice C) can result in missing important cues that could impact the care provided. Integrating verbal and nonverbal messages (Choice D) is beneficial, but the initial step should be to pay close attention and document the nonverbal messages to fully understand the client's communication.
4. The letter 'T' in the Acronym 'GATHER' denotes:
- A. Ask the client about themselves - particular needs, obstetric and medical history
- B. Tell the client about modern FP methods available, and discuss each in detail
- C. Help the client choose a method and repeat information regarding the chosen method if necessary
- D. Explain how to use the method - what, where, when, and how
Correct answer: B
Rationale: The correct answer is B: 'Tell the client about modern FP methods available, and discuss each in detail.' In the GATHER acronym, 'T' stands for providing information about modern family planning methods to the client and having a detailed discussion. Choices A, C, and D are incorrect because they do not accurately represent the 'T' component in the GATHER approach. Choice A focuses more on gathering information from the client, choice C is about helping the client choose a method, and choice D is about explaining how to use the method, none of which align with the 'T' in GATHER.
5. The nurse is caring for a client with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which intervention is most important for the nurse to implement?
- A. Encourage oral hydration
- B. Monitor for signs of dehydration
- C. Restrict fluid intake
- D. Administer IV fluids as prescribed
Correct answer: C
Rationale: In SIADH, there is excessive ADH secretion leading to water retention and dilutional hyponatremia. The most crucial intervention is to restrict fluid intake to prevent further fluid overload and worsening of hyponatremia. Encouraging oral hydration (choice A) would exacerbate the condition by adding more fluids. Monitoring for signs of dehydration (choice B) is not appropriate as the client is at risk of fluid overload. Administering IV fluids (choice D) would worsen the hyponatremia and should be avoided.