HESI RN
HESI RN Exit Exam 2024 Capstone
1. The nursing student is discussing with a preceptor the delegation of tasks to an unlicensed assistive personnel (UAP). Which tasks, delegated to a UAP, indicates the student needs further teaching about the delegation process?
- A. Assist a client post cerebral vascular accident to ambulate
- B. Feed a 2-year-old in balanced skeletal traction
- C. Care for a client with discharge orders
- D. Collect a sputum specimen for acid-fast bacillus
Correct answer: C
Rationale: Caring for a client with discharge orders involves tasks that require critical thinking and clinical judgment, which are beyond the scope of a UAP. Delegating this task to a UAP can compromise patient safety and outcomes. The correct answer is C. Choices A, B, and D are appropriate tasks to delegate to a UAP based on their training and scope of practice. Assisting a client to ambulate, feeding a pediatric patient in traction, and collecting a sputum specimen are tasks that can be safely performed by a UAP under appropriate supervision.
2. A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. What action should the nurse take when finding the radiation implant in the bed?
- A. Call radiation therapy for assistance
- B. Place the implant in a lead container using long-handled forceps
- C. Leave the implant in the bed and notify the provider
- D. Dispose of the implant in the nearest sharps container
Correct answer: B
Rationale: The correct action for the nurse to take when finding the radiation implant in the bed is to use long-handled forceps to place the implant in a lead container. This procedure is crucial in reducing radiation exposure to both the patient and healthcare providers. Calling radiation therapy for assistance (Choice A) may delay the immediate need for safe handling of the implant. Leaving the implant in the bed and notifying the provider (Choice C) is unsafe and can lead to increased radiation exposure. Disposing of the implant in a sharps container (Choice D) is incorrect as the implant should be placed in a lead container, not a sharps container, to contain the radiation.
3. A client with schizophrenia is experiencing auditory hallucinations. What is the nurse's best response?
- A. Encourage the client to ignore the voices and stay focused on reality.
- B. Acknowledge the client's feelings and ask what the voices are saying.
- C. Redirect the conversation to help distract the client from the hallucinations.
- D. Offer reassurance that the voices cannot harm the client.
Correct answer: B
Rationale: The best response for a client with schizophrenia experiencing auditory hallucinations is to acknowledge the client's feelings and ask what the voices are saying. This approach helps build rapport with the client, demonstrates empathy, and allows the nurse to assess the content of the hallucinations. Understanding the content is crucial to determine whether the client is at risk of harm. Encouraging the client to ignore the voices (Choice A) may invalidate their experience. Redirecting the conversation (Choice C) may not address the underlying issue of the hallucinations. Offering reassurance (Choice D) without understanding the content may overlook potential risks.
4. The nurse is providing education to a client who experiences recurrent levels of moderate anxiety in response to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?
- A. Practice using muscle relaxation techniques
- B. Take medication only when anxiety is at its worst
- C. Avoid interactions that trigger stress
- D. Engage in exercise during anxious periods
Correct answer: A
Rationale: Teaching relaxation techniques, such as muscle relaxation, helps the client manage anxiety more effectively. These techniques can be practiced regularly to reduce overall anxiety and can complement prescribed medications. Choice B is incorrect because medication should be taken as prescribed, not only when anxiety is at its worst. Choice C is incorrect as avoiding interactions that trigger stress may not always be feasible and does not teach the client coping mechanisms. Choice D is incorrect as engaging in exercise during anxious periods may not be the most effective strategy for managing moderate anxiety levels.
5. A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking in hot baths at night with no relief of his discomfort. Which action should the nurse take?
- A. Instruct the client to use a moisturizer immediately after the bath
- B. Advise the client to take shorter baths with less water
- C. Suggest taking antihistamines for the pruritus
- D. Encourage the client to use cooler water and apply calamine lotion after soaking
Correct answer: D
Rationale: In this situation, the client's pruritus (itching) is likely exacerbated by hot baths, which can worsen the itching sensation. Using cooler water will help soothe the skin and reduce pruritus. Additionally, applying calamine lotion after soaking can provide further relief. Instructing the client to use a moisturizer immediately after the bath (Choice A) may not address the root cause of pruritus aggravated by hot baths. Advising the client to take shorter baths with less water (Choice B) might not be as effective in relieving the itching sensation caused by cirrhosis. Suggesting antihistamines for the pruritus (Choice C) may not directly address the impact of hot baths on the client's discomfort.
Similar Questions
Access More Features
HESI RN Basic
$69.99/ 30 days
- 5,000 Questions with answers
- All HESI courses Coverage
- 30 days access
HESI RN Premium
$149.99/ 90 days
- 5,000 Questions with answers
- All HESI courses Coverage
- 30 days access