HESI RN
HESI RN Exit Exam Capstone
1. The nurse is caring for a client with a chest tube following surgery. The nurse should intervene if which of the following is observed?
- A. The chest tube is securely taped at the insertion site.
- B. The water seal chamber is filled to the correct level.
- C. The chest drainage system is below chest level.
- D. There are no air leaks in the system.
Correct answer: C
Rationale: The correct answer is C. The chest drainage system should always be kept below chest level to ensure proper drainage. Having the system above chest level can result in ineffective drainage. Choices A, B, and D are all correct actions to maintain the integrity and functionality of the chest tube system. Securing the chest tube at the insertion site, maintaining the water seal chamber at the correct level, and ensuring there are no air leaks are all essential components of caring for a client with a chest tube post-surgery.
2. Which assessment finding requires immediate intervention for a client receiving enteral feedings via a nasogastric tube?
- A. Auscultate the client's lungs for breath sounds
- B. Check the client's blood glucose level
- C. Monitor the client's bowel sounds
- D. Elevate the head of the bed to 45 degrees
Correct answer: D
Rationale: Elevating the head of the bed to 45 degrees is crucial for clients receiving enteral feedings via a nasogastric tube to prevent aspiration. Aspiration can lead to serious complications such as pneumonia. Auscultating the client's lungs for breath sounds (choice A) is important but not as urgent as preventing aspiration. Checking the client's blood glucose level (choice B) and monitoring bowel sounds (choice C) are also essential aspects of care for a client receiving enteral feedings, but they do not take precedence over preventing aspiration.
3. The nurse is caring for a patient who has recurrent urinary tract infections. The patient’s current infection is not responding to an antibiotic that has been used successfully several times in the past. The nurse understands that this is most likely due to
- A. acquired bacterial resistance.
- B. cross-resistance.
- C. inherent bacterial resistance.
- D. transferred resistance.
Correct answer: A
Rationale: The correct answer is A: acquired bacterial resistance. Acquired resistance happens when an organism has been exposed to the antibacterial drug, making it less effective over time. Cross-resistance (B) occurs when resistance to one drug leads to resistance to another. Inherent resistance (C) happens without prior exposure to the drug, meaning the bacteria are naturally resistant. Transferred resistance (D) involves the transfer of resistant genes from one organism to another, contributing to resistance development.
4. A client with cirrhosis is taking lactulose (Cephulac). Which finding indicates that the lactulose is having the desired effect?
- A. Two to three soft bowel movements per day
- B. Increased serum ammonia levels
- C. Decreased white blood cell count
- D. Soft, formed stool twice a day
Correct answer: A
Rationale: The correct answer is A: 'Two to three soft bowel movements per day.' Lactulose is prescribed to produce soft, regular bowel movements to reduce ammonia levels in clients with cirrhosis. This helps in preventing hepatic encephalopathy. Option B is incorrect because increased serum ammonia levels would indicate that lactulose is not effectively reducing ammonia levels. Option C is incorrect because lactulose does not directly affect white blood cell counts. Option D is incorrect because soft, formed stools twice a day may not be frequent enough to effectively reduce ammonia levels in clients with cirrhosis.
5. To minimize unsafe abortions, IRH has strengthened:
- A. The termination of pregnancy act
- B. The post-abortion care and counseling services
- C. The gender and violence unit of the police services
- D. The empowerment of all women who want to abort
Correct answer: B
Rationale: Post-abortion care and counseling services are crucial in reducing unsafe abortions by providing support, medical care, and guidance to individuals who have undergone abortions, ensuring their physical and emotional well-being. Strengthening the termination of pregnancy act (Choice A) might focus more on the legal aspects rather than the healthcare services needed post-abortion. The gender and violence unit of the police services (Choice C) is important for addressing gender-based violence but not directly related to reducing unsafe abortions. Empowering all women who want to abort (Choice D) is a broad concept that may not specifically address the need for comprehensive post-abortion care and counseling services.