HESI RN
HESI RN Exit Exam Capstone
1. The nurse is teaching a client about postoperative care following a total knee arthroplasty. What instruction should the nurse prioritize?
- A. Begin ambulation as soon as possible.
- B. Use continuous passive motion therapy to maintain joint mobility.
- C. Avoid putting weight on the affected leg.
- D. Apply ice packs to reduce pain and swelling.
Correct answer: B
Rationale: The correct answer is B: 'Use continuous passive motion therapy to maintain joint mobility.' Continuous passive motion therapy is crucial in postoperative care following a total knee arthroplasty as it helps prevent stiffness and maintain joint mobility. Ambulation is important but should be guided and not immediate. Avoiding putting weight on the affected leg is also essential initially to prevent complications. Applying ice packs can help reduce pain and swelling, but it is not the priority instruction for maintaining joint mobility and preventing stiffness.
2. While changing a client's chest tube dressing, the nurse notes a cracking sensation when gentle pressure is applied to the skin at the insertion site. What should the nurse do next?
- A. Apply a pressure dressing at the chest tube site.
- B. Administer an oral antihistamine per PRN order.
- C. Assess the client for allergies to topical cleaning agents.
- D. Measure the area of crackling and swelling.
Correct answer: D
Rationale: Measuring the area of crackling and swelling is essential in monitoring the progression of subcutaneous emphysema, which can result from air leaking into the tissues around the chest tube insertion site. This technique helps evaluate the extent of the issue and guides further interventions. Applying a pressure dressing (choice A) might exacerbate the condition by trapping more air. Administering an oral antihistamine (choice B) is not indicated for subcutaneous emphysema. Assessing for allergies to topical cleaning agents (choice C) is not the priority in this situation compared to evaluating and managing the subcutaneous emphysema.
3. A client with a head injury is being monitored for increased intracranial pressure. Which of these findings should be reported to the healthcare provider immediately?
- A. A heart rate of 72 beats per minute
- B. A blood pressure of 110/70 mm Hg
- C. Pupils equal and reactive to light
- D. Client reports headache
Correct answer: C
Rationale: The correct answer is C. Pupils that are equal and reactive to light are a crucial neurological assessment finding. Changes in pupil size and reactivity can indicate increased intracranial pressure, which requires immediate medical attention. Reporting this finding promptly allows for timely intervention to prevent further complications. Choices A, B, and D are within normal ranges and are not indicative of increased intracranial pressure. A heart rate of 72 beats per minute, blood pressure of 110/70 mm Hg, and a client reporting a headache are common findings and may not necessitate immediate intervention in this context.
4. The nurse is planning a health fair for young adults. Which action is most important for the nurse to implement?
- A. Provide educational materials on smoking cessation
- B. Offer blood pressure screening and monitoring
- C. Provide information on safe sex practices
- D. Discuss the importance of a healthy diet and exercise
Correct answer: B
Rationale: Offering blood pressure screening and monitoring is crucial for young adults as it helps in the early detection and management of hypertension, a condition that often goes unnoticed. High blood pressure can lead to serious health issues if left untreated. While education on smoking cessation, safe sex practices, healthy diet, and exercise are important aspects of overall health promotion, blood pressure screening takes precedence due to its immediate impact on health and the prevention of potential complications.
5. What is the most common symptom in all clinical types of abortion EXCEPT:
- A. Lower abdominal pain
- B. Per vaginal bleeding
- C. Show
- D. Backache
Correct answer: C
Rationale: The correct answer is C. 'Show' is not a common symptom in all types of abortion. Lower abdominal pain, per vaginal bleeding, and backache are common symptoms associated with abortion. Lower abdominal pain may result from uterine contractions, per vaginal bleeding is a typical presentation, and backache can be a symptom due to the process of abortion. 'Show' refers to the mucus plug that blocks the cervix during pregnancy and is not a typical symptom of abortion.