HESI RN
RN HESI Exit Exam Capstone
1. The nurse is caring for a group of clients with the help of a PN. Which nursing actions should the nurse assign to the PN?
- A. All of the above
- B. Administer a dose of insulin per sliding scale for a client with Type 2 DM
- C. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty
- D. Perform daily surgical dressing change for a client who had an abdominal hysterectomy
Correct answer: A
Rationale: All of these tasks fall within the PN's scope of practice, which includes performing surgical dressing changes, taking postoperative vital signs, and administering insulin under supervision. The RN can delegate these tasks to the PN safely. Choice A is the correct answer because all the tasks mentioned are appropriate for delegation to a PN. Choice B should not be assigned to a PN as only RNs should administer insulin. Choice C is suitable for delegation to a PN as obtaining vital signs falls within their scope of practice. Choice D is also appropriate for delegation to a PN as performing surgical dressing changes is within their scope of practice.
2. The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high-protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?
- A. A tuna fish sandwich with chips and ice cream
- B. A vegetable salad with croutons and ranch dressing
- C. A grilled chicken breast with steamed vegetables
- D. A peanut butter and jelly sandwich with soda
Correct answer: C
Rationale: The correct answer is C. Grilled chicken is an excellent source of protein, which is important for wound healing. Choices A, B, and D are less ideal for wound healing. Choice A contains high-fat and high-sugar components like chips and ice cream, which may not support wound healing effectively. Choice B includes croutons and ranch dressing, which may not provide as much protein as needed for wound healing. Choice D with a peanut butter and jelly sandwich and soda lacks a balanced meal with adequate protein to promote wound healing.
3. The nurse is providing care for a client with severe peripheral arterial disease (PAD). The client reports a history of rest ischemia, with leg pain that occurs during the night. Which action should the nurse take in response to this finding?
- A. Elevate the legs on pillows
- B. Encourage ambulation and leg exercises
- C. Provide a heating pad for warmth
- D. Offer cold packs when the pain occurs
Correct answer: C
Rationale: Providing warmth can help dilate peripheral vessels and increase blood flow, relieving ischemic pain. In PAD, where there is already compromised blood flow, elevating the legs or applying cold therapy could worsen ischemic pain by further reducing blood flow to the extremities. Encouraging ambulation and leg exercises may be beneficial in other conditions but not suitable for clients with severe PAD experiencing rest ischemia.
4. A client receiving chemotherapy for cancer treatment is experiencing nausea and vomiting. What is the nurse's best intervention to manage these symptoms?
- A. Offer frequent, small meals
- B. Administer antiemetics before meals
- C. Encourage the client to eat a high-fat diet
- D. Provide the client with cold, carbonated beverages
Correct answer: B
Rationale: Administering antiemetics before meals is the best intervention to manage nausea and vomiting in clients receiving chemotherapy. This proactive approach helps control symptoms by preventing nausea from occurring, rather than waiting to treat it once symptoms have already started. Offering frequent, small meals (choice A) may worsen symptoms in some cases due to increased stomach activity. Encouraging a high-fat diet (choice C) can be difficult for nauseated clients and may not alleviate symptoms. Providing cold, carbonated beverages (choice D) could exacerbate nausea further due to the temperature and carbonation.
5. A client with Crohn's disease reports diarrhea. What intervention should the nurse implement?
- A. Instruct the client to drink clear fluids and avoid solid foods.
- B. Administer antidiarrheal medication as prescribed.
- C. Encourage a high-fiber diet and regular physical activity.
- D. Restrict fluid intake and monitor electrolytes.
Correct answer: C
Rationale: The correct intervention for a client with Crohn's disease reporting diarrhea is to encourage a high-fiber diet and regular physical activity. A high-fiber diet helps manage diarrhea in Crohn's disease by adding bulk to the stool and promoting more regular bowel movements. Instructing the client to drink clear fluids and avoid solid foods (Choice A) may not be appropriate as it can further exacerbate diarrhea. Administering antidiarrheal medication (Choice B) without addressing the underlying cause may not be the best initial approach. Encouraging a high-fiber diet and physical activity (Choice C) is beneficial for managing symptoms. Restricting fluid intake and monitoring electrolytes (Choice D) is not recommended as it can lead to dehydration, which is a concern in clients with diarrhea.
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