HESI RN
HESI RN Exit Exam 2023 Capstone
1. The nurse is performing a functional assessment for a client requiring nursing home care. Which action should the nurse implement?
- A. Question the client about the frequency of falls.
- B. Request the client to lie still during the assessment.
- C. Ask how often episodes of sundowning are experienced.
- D. Assist the client with values clarification about end-of-life care.
Correct answer: A
Rationale: The correct answer is A: Question the client about the frequency of falls. In the elderly population, falls are a significant risk factor that can impact their functional abilities and safety. By assessing the frequency of falls, the nurse can identify potential risks and implement interventions to prevent future falls. Choices B, C, and D are incorrect because they do not directly address the primary focus of a functional assessment for nursing home care, which is to evaluate the client's functional status and identify areas that may require assistance or intervention.
2. A policy requiring the removal of acrylic nails by all nursing personnel was implemented 6 months ago. Which assessment measure best determines if the intended outcome of the policy is being achieved?
- A. Number of staff-induced injuries
- B. Client satisfaction survey
- C. Healthcare-associated infection rate
- D. Rate of needle-stick injuries by nurses
Correct answer: C
Rationale: The correct answer is C - Healthcare-associated infection rate. Acrylic nails can harbor bacteria, increasing the risk of healthcare-associated infections. By implementing a policy to remove acrylic nails, the goal is to reduce the infection rate. Monitoring the healthcare-associated infection rate will provide a direct measure of the policy's effectiveness in achieving its intended outcome. This measure is more specific and directly related to the objective of reducing the risk of infections compared to the other choices.
3. The healthcare provider prescribes a sepsis protocol for a client with multi-organ failure caused by a ruptured appendix. Which intervention is most important for the nurse to include in the care plan?
- A. Ensure early ambulation
- B. Administer antibiotics as prescribed
- C. Maintain strict intake and output
- D. Monitor blood glucose levels
Correct answer: C
Rationale: In sepsis with multi-organ failure, monitoring intake and output is critical to assess renal function and fluid balance, as organ failure can cause fluid shifts and decreased kidney function. Antibiotics are essential to treat the infection, but monitoring intake and output provides real-time insight into the client's status, helping to detect early signs of worsening organ function. Early ambulation and blood glucose monitoring are important aspects of care but are not as crucial as maintaining strict intake and output in this situation.
4. Earlier this morning, an elderly Hispanic female was discharged to a LTC facility. The family members are now gathered in the hallway outside her room. What is the best action?
- A. Ask the family to wait in the cafeteria while the next of kin makes the necessary arrangements
- B. Provide space and privacy for the family to share their concerns about the client’s discharge
- C. Ask the social worker to encourage the family to clear the hallway
- D. Explain to the family the client’s need for privacy so that she can make independent decisions
Correct answer: B
Rationale: In this situation, providing space and privacy for the family allows them to openly discuss their concerns regarding the client’s discharge. It respects the family's need for support, communication, and involvement in the decision-making process, ultimately fostering a more effective and compassionate care environment.
5. A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend first?
- A. Plan low-carbohydrate and high-protein meals
- B. Engage in moderate physical activity for an hour daily
- C. Keep a record of food and drinks consumed daily
- D. Participate in a group exercise class 3 times a week
Correct answer: C
Rationale: A BMI of 30 indicates the patient is obese. The first step in a weight loss plan should be to keep a food journal to track calorie intake, which can help in meal planning and creating a workout routine. Choice (A) suggests a dietary approach, which is important but not the first step. Choice (B) recommends strenuous activity, which may not be suitable for everyone and is not the initial step. Choice (D) involves group exercise, which can be beneficial but is not the primary action to take at the beginning of a weight loss plan.