HESI RN
HESI RN Exit Exam Capstone
1. 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.
2. 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.
3. A child has a nosebleed (epistaxis) while playing soccer. In what position should the nurse place the child?
- A. Position the child lying flat and apply pressure to the bridge of the nose.
- B. Position the child sitting up and leaning forward.
- C. Have the child tilt the head back and pinch the nose.
- D. Position the child lying on their side and apply ice to the nose.
Correct answer: B
Rationale: The correct answer is to position the child sitting up and leaning forward. This position helps prevent blood from flowing down the throat, reducing the risk of choking or vomiting. Choice A is incorrect because lying flat can cause blood to flow down the throat. Choice C is wrong as tilting the head back may lead to blood entering the throat. Choice D is also incorrect as applying ice is not recommended for nosebleeds and lying on the side may not prevent blood from flowing down the throat.
4. Prior to administering warfarin to a client with a history of atrial fibrillation, what lab result should the nurse review?
- A. White blood cell count.
- B. Prothrombin time (PT) and International Normalized Ratio (INR).
- C. Hemoglobin and hematocrit.
- D. Blood urea nitrogen (BUN) and creatinine.
Correct answer: B
Rationale: The correct answer is B: Prothrombin time (PT) and International Normalized Ratio (INR). These lab values are crucial for monitoring the effectiveness of warfarin, an anticoagulant medication. PT measures the time it takes for blood to clot, while INR standardizes these results. Ensuring the client's PT/INR levels are within the therapeutic range is essential to prevent clotting or excessive bleeding. Choices A, C, and D are incorrect as they are not directly related to monitoring warfarin therapy in a client with atrial fibrillation.
5. The nurse is providing care for a client with suspected deep vein thrombosis (DVT) in the left leg. Which action should the nurse take first?
- A. Encourage the client to ambulate
- B. Apply a warm compress to the left leg
- C. Elevate the client's left leg
- D. Administer a prescribed anticoagulant
Correct answer: C
Rationale: Elevating the affected leg promotes venous return and reduces swelling, which is a priority intervention for a client with suspected DVT. This action helps prevent the thrombus from dislodging and causing further complications. Encouraging ambulation may dislodge the clot, leading to a pulmonary embolism. Applying a warm compress can increase blood flow to the area, potentially dislodging the clot. Administering anticoagulants is essential but should not be the first action as elevation helps to reduce the risk of complications associated with DVT.
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