HESI RN
HESI Exit Exam RN Capstone
1. The nurse is teaching a group of women about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity?
- A. Weight-bearing exercise
- B. Aerobic exercise
- C. Low-impact exercises such as swimming
- D. Stretching and flexibility exercises
Correct answer: A
Rationale: The correct answer is A: Weight-bearing exercise. Weight-bearing exercise helps build and maintain bone density, which is critical in preventing osteoporosis. Activities like aerobic exercises, stretching, and low-impact exercises such as swimming are beneficial for overall fitness but do not directly contribute to improving bone strength, making them less effective in preventing osteoporosis.
2. A client with a nasogastric tube in place following gastric surgery reports nausea. What is the most appropriate nursing action?
- A. Irrigate the NG tube with 30 ml of normal saline.
- B. Administer an antiemetic as prescribed.
- C. Assess the NG tube for patency and reposition if necessary.
- D. Provide sips of water and reassess the client's symptoms.
Correct answer: C
Rationale: Assessing the NG tube for patency and repositioning it if necessary is the most appropriate action to relieve the client's nausea. Nausea in a client with a nasogastric tube can be due to the tube's malposition or blockage. Irrigating the NG tube with normal saline (Choice A) without assessing for patency or repositioning may worsen the situation. Administering an antiemetic (Choice B) can help manage symptoms but does not address the potential issue with the NG tube. Providing sips of water and reassessing symptoms (Choice D) may be contraindicated if there is a problem with the NG tube and could exacerbate the nausea.
3. A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets about:
- A. Preparing the client for a perfusion scan
- B. Attaching the client to a cardiac monitor
- C. Administering oxygen via nasal cannula
- D. Ensuring that the intravenous (IV) line is patent
Correct answer: C
Rationale: When a client who has just undergone surgery experiences sudden chest pain, dyspnea, and tachypnea, indicating possible pulmonary embolism, the immediate priority for the nurse is to administer oxygen via nasal cannula. This intervention aims to improve oxygenation and alleviate respiratory distress, which is crucial in the setting of a potential pulmonary embolism. Preparing the client for a perfusion scan is not the immediate priority as stabilizing the client's respiratory status comes first. While attaching the client to a cardiac monitor is important for monitoring, administering oxygen takes precedence in this situation. Ensuring IV line patency is relevant for overall client care but is not the priority when a client is experiencing respiratory distress requiring immediate intervention.
4. Insulin glargine (Lantus) is prescribed for a client with diabetes mellitus. The nurse tells the client that it is best to take the insulin:
- A. 1 hour after each meal
- B. Once daily, at the same time each day
- C. 15 minutes before breakfast, lunch, and dinner
- D. Before each meal, based on the blood glucose level
Correct answer: B
Rationale: Insulin glargine (Lantus) is a long-acting insulin with a duration of action of approximately 24 hours, making it suitable for once-daily dosing at the same time each day. This regimen helps maintain consistent blood glucose levels and simplifies the client's treatment routine. Taking insulin glargine once daily provides basal insulin coverage throughout the day, reducing the risk of hypoglycemia compared to short-acting insulins that are taken before each meal.
5. The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is
- A. Heart rate
- B. Pedal pulses
- C. Lung sounds
- D. Pupil responses
Correct answer: D
Rationale: Assessing pupil responses is crucial in a client with hypertensive crisis to monitor for signs of increased intracranial pressure, which can indicate potential neurological complications. While heart rate, pedal pulses, and lung sounds are important assessments, they do not take precedence over neurological assessments in this critical situation.