HESI RN
HESI RN Exit Exam 2023 Capstone
1. A male client reports that he took tadalafil 10 mg two hours ago and now feels flushed. What action should the nurse take?
- A. Instruct the client to increase oral fluid intake.
- B. Reassure the client that flushing is a common side effect.
- C. Advise the client to take nitroglycerin as a precaution.
- D. Ask the client to come to the emergency room.
Correct answer: B
Rationale: The correct answer is B: Reassure the client that flushing is a common side effect. Tadalafil, a medication used for erectile dysfunction, can cause flushing as a common side effect. In this situation, the nurse should provide reassurance to the client that the flushing is expected and not necessarily a cause for concern. Increasing oral fluid intake (choice A) may be beneficial for other conditions but is not directly related to tadalafil-induced flushing. Advising the client to take nitroglycerin (choice C) is incorrect, as nitroglycerin is not indicated for flushing. Asking the client to come to the emergency room (choice D) is unnecessary at this point since flushing is a known side effect and does not typically require urgent medical attention.
2. To prevent unnecessary hypoxia during suctioning of a tracheostomy, what must the nurse do?
- A. Apply suction for no more than 10 seconds
- B. Maintain sterile technique
- C. Lubricate 3 to 4 inches of the catheter tip
- D. Withdraw catheter in a circular motion
Correct answer: A
Rationale: The correct answer is to apply suction for no more than 10 seconds. Prolonged suctioning can lead to hypoxia, so it is essential to limit the suctioning time. Maintaining sterile technique (choice B) is important to prevent infections but is not directly related to preventing hypoxia during suctioning. Lubricating the catheter tip (choice C) helps with insertion but does not specifically address hypoxia prevention. Withdrawing the catheter in a circular motion (choice D) is not a standard practice during tracheostomy suctioning and does not help prevent hypoxia.
3. How can the need to respect clients' rights to informed consent be attained in quality of care?
- A. by providing adequate information and counseling
- B. by forcing all patients scheduled for surgery to sign the consent form
- C. by engaging the Senior medical superintendent of the hospital to sign consent forms for the patients
- D. by simply telling the patient to sign the consent form
Correct answer: A
Rationale: The correct answer is A: 'by providing adequate information and counseling.' Respecting clients' rights to informed consent involves ensuring that patients are adequately informed about the procedures they will undergo. This includes providing them with all necessary information and counseling to make an informed decision. Choice B is incorrect because forcing patients to sign consent forms does not ensure that they are fully informed or that their rights are respected. Choice C is incorrect as involving a senior medical superintendent to sign consent forms does not guarantee that patients are adequately informed. Choice D is incorrect because simply telling the patient to sign the consent form does not fulfill the requirement of providing adequate information for informed consent.
4. A client with chronic kidney disease is receiving erythropoietin therapy. Which finding indicates that the therapy is effective?
- A. Hemoglobin of 12 g/dL.
- B. Reticulocyte count of 1%.
- C. Blood pressure of 130/80 mm Hg.
- D. Serum ferritin level of 100 ng/mL.
Correct answer: A
Rationale: The correct answer is A: Hemoglobin of 12 g/dL. Erythropoietin therapy stimulates red blood cell production, leading to an increase in hemoglobin levels. A hemoglobin level of 12 g/dL indicates that the therapy is effective in managing anemia associated with chronic kidney disease. Choice B, a reticulocyte count of 1%, is not a direct indicator of the effectiveness of erythropoietin therapy. Choice C, a blood pressure of 130/80 mm Hg, is important to monitor in clients with chronic kidney disease but does not specifically indicate the effectiveness of erythropoietin therapy. Choice D, a serum ferritin level of 100 ng/mL, is related to iron stores in the body and may be monitored during erythropoietin therapy but does not directly reflect the therapy's effectiveness in increasing red blood cell production.
5. What percentage of the offspring of the parents is predicted to have a cleft chin?
- A. 25%
- B. 50%
- C. 0%
- D. 75%
Correct answer: A
Rationale: When one parent carries the recessive gene for a cleft chin and the other does not, there is a 25% chance of the offspring inheriting the cleft chin. This is due to the fact that the trait follows a simple Mendelian inheritance pattern, where the offspring would need to inherit the recessive gene from both parents to express the trait. Therefore, 25% of the offspring are predicted to have a cleft chin. Choices B, C, and D are incorrect because the likelihood of inheriting a cleft chin in this specific scenario is 25%, not 50%, 0%, or 75%.