HESI RN
HESI 799 RN Exit Exam Capstone
1. A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse?
- A. A client with a Dopamine drip IV with vital signs monitored every 5 minutes
- B. A client with a myocardial infarction that is free from pain and dysrhythmias
- C. A client with a tracheotomy of 24 hours in some respiratory distress
- D. A client with a pacemaker inserted this morning with intermittent capture
Correct answer: B
Rationale: In this scenario, it is more appropriate to assign a stable client, such as the one with a myocardial infarction who is free from pain and dysrhythmias, to a nurse who lacks specialized critical care experience. This client's condition is relatively stable and does not require immediate critical interventions. Choices A, C, and D involve clients with more complex and critical conditions that would be better managed by a nurse with specialized critical care training. Choice A involves a client on a Dopamine drip with frequent vital sign monitoring, Choice C has a client with a tracheotomy in respiratory distress, and Choice D describes a client with a pacemaker experiencing intermittent capture, all of which require a higher level of critical care expertise.
2. What is the composition of the cellular membrane?
- A. A bilayer of phospholipid molecules
- B. A single layer of phospholipid molecules
- C. Proteins that act as transport highways
- D. Carbohydrates
Correct answer: A
Rationale: The cellular membrane is primarily composed of a phospholipid bilayer, which consists of two layers of phospholipid molecules. These molecules have a hydrophilic (water-attracting) head and hydrophobic (water-repelling) tail, creating a barrier that separates the internal cellular environment from the external surroundings. While proteins are embedded within this bilayer and act as transport channels, receptors, and structural support, carbohydrates are found on the outer surface of the membrane for cell recognition and signaling purposes. Therefore, the correct answer is a bilayer of phospholipid molecules.
3. While assessing an older client's fall risk, the client reports living at home alone and never falling. Which action should the nurse take?
- A. Suggest moving to an assisted living facility
- B. Continue to obtain client data needed to complete the fall risk survey
- C. Reduce the frequency of fall risk assessments for this client
- D. Confirm that the client is safe living alone
Correct answer: B
Rationale: The correct action for the nurse to take is to continue obtaining client data to complete the fall risk survey. Even though the client reports never falling, it is essential to assess all fall risk factors comprehensively. Fall risk surveys provide valuable information on mobility, vision, medications, and other factors that can impact safety. Option A is incorrect because suggesting moving to an assisted living facility is premature without completing the fall risk assessment. Option C is incorrect as reducing the frequency of fall risk assessments could overlook potential risk factors. Option D is incorrect as the client's statement alone is not enough to confirm their safety living alone; a thorough assessment is necessary.
4. When taking a client's blood pressure, the healthcare professional is unable to distinguish the point at which the first sound was heard. What is the best action for the healthcare professional to take?
- A. Deflate the cuff completely and immediately reattempt the reading.
- B. Reinflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading.
- C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading.
- D. Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen.
Correct answer: C
Rationale: The correct action when unable to distinguish the point of the first sound during blood pressure measurement is to deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. This allows blood flow to return to the extremity, ensuring a more accurate reading the second time. It is important to ensure that the cuff is fully deflated and the appropriate wait time is given to obtain an accurate blood pressure measurement.
5. In order to provide services effectively and in the best interests of the whole family:
- A. The wife's relatives need to be contacted
- B. It's important to seek the services of a traditional healer
- C. Health providers need to be aware of the roles and decision-making process within the family
- D. Health providers need to conduct door-to-door sensitization on health matters
Correct answer: C
Rationale: The correct answer is C: 'Health providers need to be aware of the roles and decision-making process within the family.' To provide services effectively, health providers must understand the dynamics within a family, including who makes decisions and how roles are distributed. This knowledge helps them tailor their services to meet the needs and preferences of the whole family. Choices A and B are incorrect because contacting the wife's relatives or seeking the services of a traditional healer may not necessarily align with providing effective services based on family dynamics. Choice D is also incorrect as door-to-door sensitization may not directly address the internal dynamics of a family.