HESI RN
HESI RN Exit Exam 2024 Quizlet Capstone
1. What safety measure should the nurse take for a client with a seizure disorder who has an IV line?
- A. Ensure that the IV site is padded and protected.
- B. Limit the client's mobility to prevent dislodging the IV.
- C. Place the IV site on the same side as the seizure activity.
- D. Ensure the client is positioned on the opposite side of the IV line.
Correct answer: D
Rationale: The correct answer is D: Ensure the client is positioned on the opposite side of the IV line. Placing the IV line on the opposite side of any seizure activity is essential to prevent injury. It helps to ensure that the IV line is not dislodged during a seizure. Choices A, B, and C are incorrect. While padding and protecting the IV site is important, the priority is to position the client on the side opposite to the IV line to prevent dislodgement and injury during a seizure.
2. The healthcare provider is developing standards of care for a client with gastroesophageal reflux disease and wants to review current evidence for practice. Which one of the following resources will provide the most helpful information?
- A. A review in the Cochrane Library.
- B. A literature search in a database, such as the Cumulative Index to Nursing and Allied Health Literature (CINAHL).
- C. An online nursing textbook.
- D. The policy and procedure manual at the healthcare agency.
Correct answer: A
Rationale: The Cochrane Library provides systematic reviews of primary research in healthcare, making it a reliable resource for evidence-based practice. Choice B, a literature search in a database like CINAHL, may also be useful but does not guarantee the same level of systematic review and reliability as the Cochrane Library. Choice C, an online nursing textbook, may offer information but might not provide the most current or evidence-based practices. Choice D, the policy and procedure manual at the healthcare agency, is unlikely to offer the comprehensive evidence-based information needed for developing standards of care.
3. A nurse is contributing to the plan of care of a client who has had a stroke. The client is experiencing severe dysphagia with choking and coughing while eating. Which of the following nutritional therapies should the nurse expect to include in the plan of care?
- A. NPO until dysphagia subsides
- B. Supplements via NG tube
- C. Initiation of total parenteral nutrition
- D. Mechanical soft diet
Correct answer: D
Rationale: The correct answer is D: Mechanical soft diet. A mechanical soft diet is appropriate for clients with severe dysphagia as it helps reduce the risk of choking and aspiration by providing food that is easier to swallow. Choice A, NPO until dysphagia subsides, may be necessary initially but is not a long-term solution. Choice B, supplements via NG tube, may be considered if the client is unable to meet their nutritional needs orally, but it does not address the texture modification needed for dysphagia. Choice C, initiation of total parenteral nutrition, is typically reserved for clients who cannot tolerate any oral intake and is not the first-line option for dysphagia management.
4. A client with cholelithiasis is admitted with jaundice due to obstruction of the common bile duct. Which finding is most important for the nurse to report to the healthcare provider?
- A. Distended, hard, and rigid abdomen
- B. Clay-colored stool
- C. Radiating sharp pain in the right shoulder
- D. Bile-stained emesis
Correct answer: A
Rationale: The most important finding for the nurse to report to the healthcare provider in a client with cholelithiasis and jaundice due to common bile duct obstruction is a distended, hard, and rigid abdomen. These signs may indicate a possible surgical emergency, such as a complication like gallbladder perforation or peritonitis, which require immediate intervention. Clay-colored stool is associated with obstructive jaundice but does not indicate an acute surgical emergency. Radiating sharp pain in the right shoulder (referred pain from the diaphragm) and bile-stained emesis may also be seen in cholelithiasis but are not as urgent as a distended, hard, and rigid abdomen.
5. A client with hypertension is prescribed a beta-blocker. What teaching should the nurse provide about this medication?
- A. Instruct the client to avoid high-potassium foods.
- B. Monitor the client’s heart rate and report any bradycardia.
- C. Advise the client to rise slowly from a sitting or lying position.
- D. Instruct the client to avoid sudden position changes.
Correct answer: C
Rationale: The correct answer is to advise the client to rise slowly from a sitting or lying position. Beta-blockers can cause bradycardia and hypotension, so clients should be advised to rise slowly to prevent dizziness and falls. Monitoring the client's heart rate and blood pressure regularly is essential. Instructing the client to avoid high-potassium foods (Choice A) is not directly related to beta-blockers. While monitoring the client's heart rate (Choice B) is important, advising the client to rise slowly (Choice C) is more directly related to potential side effects of beta-blockers. Instructing the client to avoid sudden position changes (Choice D) is not as specific or essential as advising them to rise slowly to prevent adverse effects.