HESI RN
HESI Exit Exam RN Capstone
1. An unlicensed assistive personnel (UAP) reports a weak pulse of 44 beats per minute in a client. What action should the charge nurse implement?
- A. Have the UAP recheck the pulse and report back.
- B. Have a licensed practical nurse (LPN) assess the client for apical-radial pulse deficit.
- C. Call the healthcare provider for further instructions.
- D. Immediately call the healthcare provider and prepare for transfer to critical care.
Correct answer: B
Rationale: The correct action is to have a licensed practical nurse (LPN) assess the client for an apical-radial pulse deficit. This assessment can provide further information about the client’s cardiovascular status and help determine if further intervention is necessary. Having the UAP recheck the pulse may delay appropriate assessment and intervention. Calling the healthcare provider for further instructions may not be necessary at this point unless the LPN assessment indicates a need for it. Immediately transferring the client to critical care without further assessment is not warranted based solely on the initial report of a weak pulse.
2. During a routine assessment of a 3-year-old at a community health center, the healthcare professional should be alert for signs of autism spectrum disorder. Which behavior by the child should prompt further evaluation for a possible autistic spectrum disorder?
- A. Engages in odd repetitive behaviors
- B. Shows indifference to verbal stimulation
- C. Strokes the hair of a hand-held doll
- D. Has a history of temper tantrums
Correct answer: A
Rationale: Engaging in odd repetitive behaviors is a hallmark sign of autism spectrum disorder in children. These behaviors can include repetitive movements, insistence on sameness, or specific routines. Recognizing and addressing these behaviors early can help in providing appropriate interventions and support for the child.
3. Which of the following is a characteristic symptom of hypothyroidism?
- A. Fatigue.
- B. Weight gain.
- C. Cold intolerance.
- D. Heat intolerance.
Correct answer: C
Rationale: The correct answer is 'Cold intolerance.' Hypothyroidism is associated with a decreased metabolic rate, leading to a decreased ability to regulate body temperature and a feeling of being cold. Fatigue (Choice A) and weight gain (Choice B) are also common symptoms of hypothyroidism due to the overall slowing down of bodily functions. Heat intolerance (Choice D) is more commonly associated with hyperthyroidism, where the body's metabolism is overactive, leading to increased heat production.
4. A mother brings her 2-year-old son to the clinic because he has been crying and pulling on his earlobe for the past 12 hours. The child's oral temperature is 101.2°F. Which intervention should the nurse implement?
- A. Ask the mother if the child has had a runny nose
- B. Cleanse purulent exudate from the affected ear canal
- C. Apply a topical antibiotic to the periauricular area
- D. Provide parent education to prevent recurrence
Correct answer: A
Rationale: In a child presenting with ear pain and fever, asking if the child has had a runny nose is crucial in assessing possible causes of an ear infection. Respiratory infections can lead to secondary ear infections, so exploring symptoms related to upper respiratory tract infections, like a runny nose, can help in the evaluation and management of the child's condition. Choice B is incorrect because cleansing purulent exudate should be done by a healthcare provider, not a nurse, and only if necessary. Choice C is incorrect because applying a topical antibiotic without proper evaluation and prescription is not within the nurse's scope of practice. Choice D is incorrect because while parent education may be necessary, addressing the immediate concern of evaluating possible causes of the ear pain and fever takes priority.
5. The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by the client indicates a need for further teaching?
- A. I use a sliding scale to adjust regular insulin to my sugar level.
- B. Since my eyesight is so bad, I ask the nurse to fill several syringes.
- C. I keep my regular insulin bottle in the refrigerator.
- D. I always make sure to shake the NPH bottle hard to mix it well.
Correct answer: D
Rationale: Shaking the NPH insulin bottle hard can cause air bubbles and affect dosing accuracy; it should be rolled gently instead.