HESI RN
HESI RN Exit Exam 2023 Capstone
1. The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to lead poisoning?
- A. An 8-year-old who lives in a housing project.
- B. A 2-year-old who plays on aging playground equipment.
- C. An adolescent who works in a paint factory.
- D. A 10-year-old with Type 1 diabetes.
Correct answer: B
Rationale: The correct answer is B. Young children, like the 2-year-old playing on aging playground equipment, are at higher risk of lead poisoning due to their hand-to-mouth behavior and exploration of their environment. Aging playground equipment may have lead-based paint that can be ingested by the child. While children living in housing projects are also at risk due to lead-based paint in older buildings, the 2-year-old child playing on potentially lead-contaminated playground equipment is the most susceptible in this scenario. The adolescent working in a paint factory may face occupational hazards related to lead exposure, but the immediate risk from environmental sources is higher for the 2-year-old. Type 1 diabetes in a 10-year-old is not directly linked to an increased susceptibility to lead poisoning.
2. A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during the first 12 hours after admission?
- A. Side-lying on the left with the head elevated 10 degrees
- B. Side-lying on the left with the head elevated 35 degrees
- C. Side-lying on the right with the head elevated 10 degrees
- D. Side-lying on the right with the head elevated 35 degrees
Correct answer: A
Rationale: The correct answer is side-lying on the left with the head elevated 10 degrees. This position maximizes ventilation and promotes better perfusion to the unaffected lung. Placing the client in this position helps to optimize oxygenation and reduce pressure on the affected lung. Choices B, C, and D are incorrect because lying on the left side with the head elevated is essential to facilitate better lung expansion and gas exchange in the unaffected lung, while lying on the right side could further compromise the affected lung by increasing pressure on it.
3. A client with COPD and a history of emphysema presents with increasing shortness of breath. What action should the nurse implement first?
- A. Notify the healthcare provider of the client's distress.
- B. Auscultate the client's lung sounds and oxygen saturation.
- C. Determine if the client is experiencing anxiety.
- D. Assess the oxygen delivery system.
Correct answer: B
Rationale: The correct action for the nurse to implement first is to auscultate the client's lung sounds and oxygen saturation. This helps in assessing the respiratory status of the client, which is crucial in managing COPD and emphysema exacerbations. Checking for any abnormalities in lung sounds and monitoring oxygen saturation levels can provide important information for immediate intervention. Option A is not the first action to take in this situation as directly assessing the client's respiratory status is more immediate. Option C, determining if the client is experiencing anxiety, is important but should come after assessing the physical respiratory status. Option D, assessing the oxygen delivery system, is also essential but should follow the direct assessment of the client's respiratory status.
4. A male client with HIV receiving saquinavir PO in combination with other antiretrovirals reports constant hunger and thirst but is losing weight. What action should the nurse implement?
- A. Use a glucometer to check glucose level.
- B. Teach client to measure weight accurately.
- C. Explain that medication dose may need to be increased.
- D. Reassure client weight will increase as viral load decreases.
Correct answer: A
Rationale: The correct action for the nurse to implement is to use a glucometer to check the client's glucose level. Saquinavir, an HIV medication, can lead to hyperglycemia, which may cause symptoms like constant hunger and thirst while losing weight. Checking the glucose level will help assess for hyperglycemia. Choice B is not the priority in this situation as the client's weight loss is a concerning symptom that needs immediate attention. Choice C is incorrect because increasing the medication dose without assessing the glucose level first could exacerbate hyperglycemia. Choice D is incorrect as it does not address the symptoms of constant hunger, thirst, and weight loss, which may indicate a more urgent issue like hyperglycemia.
5. When conducting diet teaching for a client on a postoperative full liquid diet, which foods should the nurse encourage the client to eat?
- A. Yogurt, milk, and pudding
- B. Tea, lentils, and potato soup
- C. Ice cream, broth, and fruit smoothies
- D. Orange juice, mashed potatoes, and soft cheese
Correct answer: A
Rationale: A full liquid diet includes foods that are liquid or will turn liquid at room temperature. Yogurt, milk, and pudding are appropriate choices as they align with the consistency requirements of a full liquid diet. Choices B, C, and D are incorrect. Tea, lentils, potato soup, ice cream, fruit smoothies, orange juice, mashed potatoes, and soft cheese are not typically part of a full liquid diet. These options either contain solid elements or are not in liquid form, which makes them unsuitable for a postoperative full liquid diet.
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