HESI RN
HESI RN Exit Exam 2024 Capstone
1. What is the most important assessment for a nurse to conduct on a child diagnosed with intussusception?
- A. Monitor for signs of infection.
- B. Measure abdominal girth and monitor for pain.
- C. Check for bowel movement and changes in stool.
- D. Assess hydration status and monitor urine output.
Correct answer: C
Rationale: The correct answer is C: 'Check for bowel movement and changes in stool.' Intussusception can cause obstruction in the bowel, leading to symptoms like abdominal pain, vomiting, and 'currant jelly' stools. Monitoring for changes in bowel movement, especially the passage of 'currant jelly' stools, is crucial for early detection of worsening conditions. Choices A, B, and D are important assessments in pediatric care but are not as specific or crucial as checking for changes in bowel movement in a child diagnosed with intussusception.
2. A client with liver cirrhosis and severe ascites has a serum sodium level of 115 mEq/L and is receiving 3% saline IV. Which assessment finding indicates that the nurse should notify the healthcare provider?
- A. The client's serum sodium level is now 130 mEq/L
- B. The client reports a headache and has a BP of 140/90
- C. The client reports shortness of breath and has an O2 saturation of 92%
- D. The client has crackles in both lung bases and an increased respiratory rate.
Correct answer: D
Rationale: The presence of crackles in both lung bases and an increased respiratory rate indicates fluid overload, which can be exacerbated by hypertonic saline. This condition can worsen the client's respiratory status and lead to further complications. The other options do not directly relate to the fluid overload caused by the hypertonic saline. A serum sodium level of 130 mEq/L is within a normal range for treatment. A headache and a blood pressure of 140/90 are not specific indicators of worsening condition related to hypertonic saline. Shortness of breath and an O2 saturation of 92% could be related to other factors in a client with liver cirrhosis and ascites.
3. To reduce the risk of pulmonary complications for a client with ALS, which intervention should the nurse implement?
- A. Perform chest physiotherapy
- B. Teach the client breathing exercises
- C. Initiate passive range of motion exercises
- D. Establish a regular bladder routine
Correct answer: A
Rationale: Performing chest physiotherapy is the most appropriate intervention to reduce the risk of pulmonary complications in clients with ALS. Chest physiotherapy helps mobilize and clear respiratory secretions, improving lung function and reducing the risk of complications such as pneumonia. Teaching breathing exercises (Choice B) may be beneficial for some clients, but chest physiotherapy is more specifically targeted at managing pulmonary issues in ALS. Initiating passive range of motion exercises (Choice C) and establishing a regular bladder routine (Choice D) are important interventions in ALS care but are not directly related to reducing the risk of pulmonary complications.
4. A woman has been scheduled for a routine mammogram. What should the nurse tell the client?
- A. That mammography takes about 1 hour
- B. Not to eat or drink on the morning of the test
- C. That there is no discomfort associated with the procedure
- D. That deodorants, powders, or creams used in the axillary or breast area must be washed off before the test
Correct answer: D
Rationale: The correct answer is D. The nurse should instruct the client to avoid using deodorants, powders, or creams on the day of the mammogram. These products used in the axillary or breast area can interfere with the mammogram results and must be washed off before the test. Choices A, B, and C are incorrect because mammography typically takes less than 30 minutes, there is no need for fasting before the test, and some discomfort may be experienced during the procedure.
5. The nurse is caring for a patient who is receiving isotonic intravenous (IV) fluids at an infusion rate of 125 mL/hour. The nurse performs an assessment and notes a heart rate of 102 beats per minute, a blood pressure of 160/85 mm Hg, and crackles auscultated in both lungs. Which action will the nurse take?
- A. Decrease the IV fluid rate and notify the provider.
- B. Increase the IV fluid rate and notify the provider.
- C. Request an order for a colloidal IV solution.
- D. Request an order for a hypertonic IV solution.
Correct answer: A
Rationale: The patient is showing signs of fluid volume excess, indicated by crackles in both lungs, increased heart rate, and elevated blood pressure. To address this, the nurse should decrease the IV fluid rate and notify the provider. Increasing the IV fluid rate would worsen fluid overload. Requesting colloidal or hypertonic IV solutions would exacerbate the issue by pulling more fluids into the intravascular space, leading to further volume overload.