HESI RN
HESI RN Exit Exam Capstone
1. Which activity is most important for a client recovering from a hip replacement to avoid during the first few weeks of recovery?
- A. Sitting in a chair for short periods
- B. Crossing the legs while sitting
- C. Walking with assistance
- D. Performing light stretching exercises
Correct answer: B
Rationale: The correct answer is B: Crossing the legs while sitting. Cross-leg position after a hip replacement can significantly increase the risk of hip dislocation. During the first few weeks of recovery, it is crucial for clients to avoid crossing their legs to protect the new joint. Choices A, C, and D are not as critical during the initial recovery phase. Sitting in a chair for short periods, walking with assistance, and performing light stretching exercises are generally encouraged activities that can help in the recovery process without posing a significant risk of complications like hip dislocation.
2. A client with cirrhosis is admitted with jaundice and ascites. Which assessment finding is most concerning?
- A. Peripheral edema
- B. Confusion and altered mental status
- C. Yellowing of the skin
- D. Increased abdominal girth
Correct answer: C
Rationale: In a client with cirrhosis presenting with jaundice and ascites, yellowing of the skin (icterus) is the most concerning assessment finding. This indicates significant liver dysfunction and a high level of bilirubin in the blood. Yellowing of the skin suggests a severe impairment of the liver's ability to process bilirubin, which can lead to serious complications. Peripheral edema and increased abdominal girth are common manifestations of cirrhosis but are not as acutely concerning as skin yellowing. Confusion and altered mental status are also critical findings in cirrhosis, indicating hepatic encephalopathy, but skin yellowing is more closely associated with the severity of liver dysfunction in this scenario.
3. A nurse receives a report on a client who is four hours post-total abdominal hysterectomy. The previous nurse reported that it was necessary to change the client's perineal pad hourly and that it is again saturated. The previous nurse also reports that the client's urinary output has decreased. Which action should the nurse implement first?
- A. Measure urinary output
- B. Assess for weakness or dizziness
- C. Increase IV fluids
- D. Check for vaginal bleeding
Correct answer: D
Rationale: Saturation of the perineal pad after a hysterectomy suggests excessive vaginal bleeding, which must be addressed immediately. Assessing for vaginal bleeding is the priority in this situation as it can lead to hypovolemic shock. Measuring urinary output, assessing for weakness or dizziness, and increasing IV fluids are important interventions but checking for vaginal bleeding takes precedence due to the risk of hemorrhage post-hysterectomy.
4. Which of the following is a characteristic symptom of multiple sclerosis (MS)?
- A. Muscle atrophy.
- B. Severe pain.
- C. Vision problems.
- D. Hearing loss.
Correct answer: C
Rationale: Vision problems are a characteristic symptom of multiple sclerosis (MS) due to demyelination of the optic nerve. This can lead to issues such as optic neuritis, blurred vision, double vision, or even total vision loss. Muscle atrophy (Choice A) is not a primary symptom of MS but can occur as a secondary effect of decreased mobility. Severe pain (Choice B) is not a typical symptom of MS, though some individuals may experience pain related to muscle spasms or other factors. Hearing loss (Choice D) is not commonly associated with MS unless there is an unrelated concurrent condition affecting the auditory system.
5. A client has just returned to the nursing unit after computerized tomography (CT) with contrast medium. Which of the following actions should the nurse plan to take as part of routine after-care for this client?
- A. Administering a laxative
- B. Encouraging fluid intake
- C. Maintaining the client on strict bed rest
- D. Holding all medications for at least 2 hours
Correct answer: B
Rationale: After CT scanning with contrast medium, the client does not require special restrictions or interventions. Encouraging fluid intake is important to help flush out the contrast dye and prevent dehydration. Administering a laxative (Choice A) is unnecessary and not indicated after CT with contrast. Maintaining the client on strict bed rest (Choice C) is not necessary unless specified by the healthcare provider. Holding all medications for at least 2 hours (Choice D) is not a standard practice after CT with contrast.