HESI RN
HESI RN Exit Exam Capstone
1. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy. Which assessment finding indicates that the client's oxygenation is improving?
- A. Pulse oximetry reading of 94%
- B. Heart rate increases from 80 to 90 beats per minute
- C. Respiratory rate increases from 16 to 20 breaths per minute
- D. Client reports increased energy levels
Correct answer: A
Rationale: A pulse oximetry reading of 94% indicates adequate oxygenation. Monitoring oxygen saturation is the most objective way to assess the effectiveness of oxygen therapy. Choices B, C, and D do not directly reflect the client's oxygenation status. An increase in heart rate or respiratory rate may indicate increased work of breathing or stress on the body. The client reporting increased energy levels is subjective and may not directly correlate with improved oxygenation.
2. The nurse is caring for a client with a chest tube in place following a pneumothorax. Which assessment finding requires immediate intervention?
- A. Oxygen saturation of 94%
- B. Crepitus around the insertion site
- C. Subcutaneous emphysema
- D. Blood pressure of 110/70 mmHg
Correct answer: C
Rationale: Subcutaneous emphysema is the assessment finding that requires immediate intervention in a client with a chest tube following a pneumothorax. Subcutaneous emphysema can indicate a pneumothorax recurrence or air leak, which can compromise respiratory function and lead to serious complications. Oxygen saturation of 94% may be concerning but does not require immediate intervention as it is still within an acceptable range. Crepitus around the insertion site is common after chest tube placement and may not always indicate a problem. A blood pressure of 110/70 mmHg is within normal limits and does not require immediate intervention in this context.
3. A client who had a kidney transplant is receiving therapy with cyclosporine (Sandimmune). Which statement by the client indicates a need for further instruction?
- A. I need to obtain a yearly influenza vaccine.
- B. I need to have dental checkups every 3 months.
- C. I need to self-monitor my blood pressure at home.
- D. I need to call the health care provider (HCP) if my urine volume decreases or my urine becomes cloudy.
Correct answer: A
Rationale: The correct answer is A. Cyclosporine is an immunosuppressant that can reduce the effectiveness of vaccines. Clients should avoid vaccinations without consulting their health care provider to prevent potential complications or reduced efficacy of the vaccines.
4. Appropriate Technologies and Skills:
- A. Must be selected according to universal standards
- B. Involves ensuring the woman delivers at the hospital
- C. Requires specific qualifications such as being a nurse
- D. Necessitates the presence of a doctor at the service providing facility
Correct answer: A
Rationale: The correct answer is A because appropriate technologies must adhere to universal standards to ensure their effectiveness. Choice B is incorrect because the question is not specifically referring to childbirth. Choice C is incorrect as it limits the scope to only nurses. Choice D is incorrect as it implies the necessity of a doctor, which may not always be the case.
5. A nurse is caring for a new mother who is breastfeeding her term newborn. The newborn weighed 3.4 kg (7.5 lb) at birth and weighs 3.3 kg (7.3 lb) on the second day of life. The mother expresses concern about the weight loss and asks the nurse about the amount of her breast milk. Which of the following responses by the nurse is appropriate?
- A. Why don't you switch to formula to ensure your baby is eating enough?
- B. It is common for new mothers to worry that they are not producing enough milk for their baby.
- C. A healthy newborn can lose 6% of his birth weight before starting to gain weight.
- D. Your newborn will need to remain in the hospital so his weight can be monitored.
Correct answer: C
Rationale: The correct answer is C. A healthy newborn can lose up to 6% of their birth weight within the first few days of life, which is considered normal. This weight loss is usually due to fluid shifts and initial adjustments. Choices A, B, and D are incorrect. Choice A is inappropriate as switching to formula is not necessary at this point. Choice B, while acknowledging the mother's concerns, does not provide factual information about newborn weight loss. Choice D is unnecessary and may cause unnecessary stress to the mother and newborn since monitoring weight loss at home is sufficient unless there are other concerns.