HESI RN
HESI RN Exit Exam 2024 Capstone
1. The father of a 4-year-old has been battling metastatic lung cancer for the past 2 years. After discussing the remaining options with his healthcare provider, the client requests that all treatment stop and that no heroic measures be taken to save his life. When the client is transferred to the palliative care unit, which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care?
- A. Ensure the client's family is aware of the client's wishes
- B. Begin comfort measures immediately
- C. Obtain a detailed report from the nurse transferring the client
- D. Confirm that the client understands the treatment plan
Correct answer: C
Rationale: Obtaining a detailed report from the previous nurse ensures continuity of care and that all relevant information is passed on. This is critical in palliative care, where comfort measures and symptom management are key components of care. Choice A is not the most important action in this scenario, as the question focuses on continuity of care within the healthcare team. Beginning comfort measures immediately, as in choice B, is essential but obtaining a detailed report takes precedence to ensure a smooth transition of care. Confirming that the client understands the treatment plan, as in choice D, is important but does not directly address the need for continuity of care through a detailed report.
2. A client with cirrhosis is receiving spironolactone. What electrolyte level should the nurse monitor closely?
- A. Monitor potassium levels.
- B. Monitor sodium levels.
- C. Monitor calcium levels.
- D. Monitor magnesium levels.
Correct answer: A
Rationale: The correct answer is to monitor potassium levels. Spironolactone is a potassium-sparing diuretic, which means it helps the body retain potassium and excrete sodium. Monitoring potassium levels closely is essential because spironolactone can cause hyperkalemia (high potassium levels). Sodium levels are not typically affected by spironolactone. Calcium and magnesium levels are also not directly impacted by spironolactone, making choices B, C, and D incorrect.
3. The nurse has received funding to design a health promotion project for African American women who are at risk for developing breast cancer. Which resource is most important in designing this program?
- A. Participation of community leaders in planning the program
- B. Latest research on breast cancer risk factors
- C. Partnership with local healthcare providers
- D. Health surveys of African American women in the community
Correct answer: A
Rationale: The most important resource in designing a health promotion project for African American women at risk for breast cancer is the participation of community leaders in planning the program. Involving community leaders helps ensure that the program is culturally relevant, addresses the specific needs of the target population, and fosters trust and engagement. While the latest research on breast cancer risk factors, partnership with local healthcare providers, and health surveys of African American women are valuable resources, they are not as crucial as community involvement for tailoring the program effectively.
4. The healthcare provider is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the healthcare provider?
- A. Breath sounds are audible bilaterally
- B. Mist is visible in the T-piece
- C. Pulse oximetry of 88
- D. Client is unable to verbalize
Correct answer: C
Rationale: A pulse oximetry reading of 88 indicates hypoxia, which is a serious condition requiring immediate intervention. Adequate oxygenation is crucial for the client's well-being. Choices A and B are normal findings after endotracheal intubation. Hearing bilateral breath sounds and seeing mist in the T-piece indicate proper functioning of the endotracheal tube. While choice D may indicate an issue with speaking due to the endotracheal tube, it is not as critical as the hypoxia indicated by the low pulse oximetry reading.
5. A client with pheochromocytoma is admitted to the hospital. Which intervention has the highest priority?
- A. Monitor blood pressure frequently
- B. Start intravenous fluids at a fast rate
- C. Administer pain medication to reduce discomfort
- D. Give antihypertensive medications as prescribed
Correct answer: B
Rationale: The correct answer is B: Start intravenous fluids at a fast rate. In a client with pheochromocytoma, the highest priority intervention is to ensure adequate intravascular volume before initiating any other treatment. This helps prevent a sudden drop in blood pressure that can occur due to the release of catecholamines during tumor manipulation. While monitoring blood pressure frequently is essential, ensuring adequate intravascular volume takes precedence. Administering pain medication and antihypertensive medications are important but are not the highest priority in the initial management of pheochromocytoma.
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