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. 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.
3. A client with chronic obstructive pulmonary disease (COPD) is admitted with increasing shortness of breath. What is the nurse's priority action?
- A. Administer oxygen via nasal cannula.
- B. Reposition the client to improve breathing.
- C. Perform chest physiotherapy.
- D. Encourage the client to cough and deep breathe.
Correct answer: A
Rationale: The correct answer is A: Administer oxygen via nasal cannula. Oxygen therapy is the priority intervention for a client with COPD experiencing increasing shortness of breath. It helps improve oxygenation and relieve respiratory distress. Choice B is not the priority as oxygenation needs to be addressed first. Choice C, chest physiotherapy, may be beneficial but is not the immediate priority in this situation. Choice D, encouraging the client to cough and deep breathe, is not the priority intervention when oxygenation is compromised.
4. A client with hypoglycemia is unresponsive. What is the nurse's priority action?
- A. Administer intravenous dextrose.
- B. Check the client's blood glucose level.
- C. Administer glucagon intramuscularly.
- D. Prepare to administer oral glucose.
Correct answer: C
Rationale: The correct answer is to administer glucagon intramuscularly. In an unresponsive hypoglycemic client, administering glucagon intramuscularly is the priority action as it helps raise blood glucose levels quickly. Intravenous dextrose may be challenging to administer in an unresponsive client. Checking the client's blood glucose level is important but not the priority when the client is unresponsive. Preparing to administer oral glucose is not ideal for an unresponsive client as they may not be able to swallow.
5. A client with Type 1 diabetes reports feeling shaky and lightheaded. The nurse checks the client's blood glucose level and it is 60 mg/dL. What action should the nurse take first?
- A. Give the client a glucagon injection
- B. Encourage the client to eat a high-protein snack
- C. Recheck the blood glucose level in 15 minutes
- D. Administer 15 grams of a fast-acting carbohydrate
Correct answer: D
Rationale: The correct answer is D: Administer 15 grams of a fast-acting carbohydrate. The first step in treating hypoglycemia is to quickly raise the client's blood sugar level. Fast-acting carbohydrates like glucose tablets or juice are essential for this purpose. Giving a glucagon injection is typically reserved for severe hypoglycemia when the client is unable to take anything by mouth. Encouraging the client to eat a high-protein snack is not appropriate for immediate treatment of hypoglycemia. Rechecking the blood glucose level in 15 minutes is important after administering the fast-acting carbohydrate to ensure that the blood sugar has returned to a safe level.
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