HESI RN
HESI Exit Exam RN Capstone
1. A male client with a history of deep vein thrombosis (DVT) is admitted with new onset shortness of breath and a productive cough. What is the nurse's priority action?
- A. Administer prescribed anticoagulant.
- B. Notify the healthcare provider.
- C. Auscultate lung sounds.
- D. Prepare for chest physiotherapy.
Correct answer: A
Rationale: Administering an anticoagulant is the nurse's priority action in this situation. Given the client's history of DVT and the presentation of new onset shortness of breath and a productive cough, there is a concern for a pulmonary embolism, which is a life-threatening complication of DVT. Administering an anticoagulant promptly is crucial to prevent further clot formation and to manage the existing clot, reducing the risk of pulmonary embolism. While auscultating lung sounds and preparing for chest physiotherapy are important actions in respiratory assessment and management, the priority in this case is to address the potential complication of a pulmonary embolism by administering the anticoagulant. Notifying the healthcare provider can be done after initiating the immediate intervention of anticoagulant therapy.
2. 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.
3. Where does the ovum receive the sperm?
- A. Animal pole
- B. Vegetal pole
- C. Zona pellucida
- D. None of the above
Correct answer: C
Rationale: The correct answer is C, 'Zona pellucida.' The ovum receives the sperm at the zona pellucida, which is the glycoprotein layer surrounding the plasma membrane of the oocyte. This layer plays a crucial role in preventing polyspermy. Choices A and B, 'Animal pole' and 'Vegetal pole,' are incorrect as they refer to different regions of the egg and are not where the sperm fertilizes the ovum. Choice D, 'None of the above,' is incorrect as the sperm indeed interacts with the zona pellucida during fertilization.
4. Angiotensin-converting enzyme (ACE) inhibitors may be prescribed for the client with diabetes mellitus to reduce vascular changes and possibly prevent or delay the development of:
- A. Chronic obstructive pulmonary disease (COPD).
- B. Pancreatic cancer.
- C. Renal failure.
- D. Cerebrovascular accident.
Correct answer: C
Rationale: The correct answer is C: Renal failure. ACE inhibitors are commonly used in clients with diabetes mellitus to help reduce the progression of diabetic nephropathy by improving renal blood flow. This medication class can help prevent or delay the development of renal failure in these clients. Choices A, B, and D are incorrect because ACE inhibitors do not have a direct impact on preventing or delaying the development of chronic obstructive pulmonary disease, pancreatic cancer, or cerebrovascular accidents in clients with diabetes mellitus.
5. In the newborn nursery, the nurse admits a baby from labor and delivery who is suspected of having a congenital heart disease. Which finding helps to confirm this diagnosis?
- A. Pink lips and tongue with cyanotic hands and feet
- B. Respiration rate of 40 and heart rate of 144
- C. Centralized cyanosis and tachycardia when crying
- D. Desquamation from areas of cracked, parchment-like skin
Correct answer: C
Rationale: Centralized cyanosis and tachycardia are classic signs of congenital heart disease. Choice A is incorrect because cyanosis in the hands and feet is not specific to congenital heart disease. Choice B is incorrect as the vital signs provided are not specific indicators of congenital heart disease. Choice D is unrelated to the typical signs of congenital heart disease.