HESI RN
HESI RN Exit Exam 2024 Quizlet Capstone
1. The nurse is assessing a client 2 hours postoperatively following an appendectomy. The nurse should intervene for which abnormal finding?
- A. Heart rate of 88 beats per minute
- B. Blood pressure of 100/60
- C. Oxygen saturation of 94%
- D. Respiratory rate of 16
Correct answer: C
Rationale: The correct answer is C. Oxygen saturation levels below 95% indicate hypoxia and require immediate intervention. A heart rate of 88 beats per minute, a blood pressure of 100/60, and a respiratory rate of 16 are within normal ranges and do not require immediate intervention. Oxygen saturation is a critical parameter reflecting the client's oxygenation status.
2. A mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night. Which finding is most significant in planning care for this family?
- A. The mother is a single parent and lives with her parents
- B. The mother states the baby is irritable during feedings
- C. The infant’s formula has been changed twice
- D. The diaper area shows severe skin breakdown
Correct answer: D
Rationale: Severe skin breakdown in the diaper area is a significant finding indicating a potential health issue that needs immediate attention. It may be a sign of a skin condition, such as a diaper rash, which can cause discomfort and pain for the infant. Addressing this concern promptly is crucial to prevent further complications and ensure the baby's well-being. The other choices may also be important in assessing the overall situation of the family, but in terms of immediate care for the infant, the severe skin breakdown takes priority.
3. A female client who is admitted to the mental health unit for opiate dependency is receiving clonidine 0.1 mg PO for withdrawal symptoms. The client begins to complain of feeling nervous and tells the nurse that her bones are itching. Which finding should the nurse identify as a contraindication for administering the medication?
- A. Blood pressure 90/76 mm Hg.
- B. Heart rate of 85 bpm.
- C. Respiratory rate of 20 breaths/minute.
- D. Temperature of 99°F (37.2°C).
Correct answer: A
Rationale: Clonidine can lower blood pressure, so a BP of 90/76 mm Hg may indicate that it is unsafe to administer another dose. In this situation, the low blood pressure reading indicates that the client is already experiencing hypotension, which is a common side effect of clonidine. Administering more clonidine could further lower the blood pressure, leading to potential complications. The heart rate, respiratory rate, and temperature are within normal limits and do not serve as contraindications for administering clonidine in this scenario.
4. Which female reproductive organ is positioned directly posterior to the bladder?
- A. Uterine tube
- B. Vagina
- C. Uterus
- D. Ovaries
Correct answer: C
Rationale: The correct answer is the uterus. The uterus is positioned directly posterior to the bladder in the female reproductive system. The uterine tube (choice A) is also known as the fallopian tube, which is not positioned directly posterior to the bladder. The vagina (choice B) is located below the uterus and not directly posterior to the bladder. The ovaries (choice D) are located on either side of the uterus, but they are not positioned directly posterior to the bladder.
5. A male client with rheumatoid arthritis is scheduled for a procedure in the morning. The procedure cannot be completed because of early morning stiffness. Which intervention should the nurse implement?
- A. Assign a UAP to assist the client with a warm shower early in the morning.
- B. Provide the client with a warm blanket to reduce stiffness.
- C. Delay the procedure until the client is less stiff.
- D. Encourage the client to perform range-of-motion exercises.
Correct answer: A
Rationale: A warm shower can help reduce morning stiffness, making the procedure more comfortable for the client. This intervention promotes comfort and mobility, addressing the immediate issue of stiffness. Providing a warm blanket (choice B) may offer some comfort but will not address the stiffness as effectively as a warm shower. Delaying the procedure (choice C) may inconvenience the client and not address the underlying stiffness issue. Encouraging range-of-motion exercises (choice D) is important for long-term management but may not provide immediate relief from the stiffness that is hindering the procedure.