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 young woman with multiple sclerosis just received several immunizations in preparation for moving into a college dormitory. Two days later, she reports to the nurse that she is experiencing increasing fatigue and visual problems. What teaching should the nurse provide?
- A. Immunizations can trigger a relapse of the disease, so get plenty of extra rest
- B. Visual problems are unrelated to the recent immunizations
- C. Increase fluid intake to reduce symptoms of fatigue
- D. Consult the healthcare provider immediately for steroid therapy
Correct answer: A
Rationale: Immunizations can sometimes trigger relapses in multiple sclerosis due to the activation of the immune system. Extra rest can help manage these symptoms. Choice B is incorrect because visual problems can be associated with the immune response triggered by immunizations in individuals with multiple sclerosis. While increasing fluid intake is generally good advice, in this case, the nurse should focus on explaining the possible connection between the immunizations and the symptoms experienced. Choice D is not the immediate course of action; educating the patient on the potential link between immunizations and symptom exacerbation is more appropriate at this stage.
3. Prior to surgery, written consent must be obtained. What is the nurse's legal responsibility with regard to obtaining written consent?
- A. Witness the consent and sign the form as a witness
- B. Inform the client of alternatives to the procedure
- C. Explain the procedure in detail to the client
- D. Determine that the surgical consent form has been signed and is included in the client's record
Correct answer: D
Rationale: The nurse's legal responsibility is to ensure that informed consent has been obtained by verifying that the client has signed the form and that it is included in the record. Witnessing the consent and signing as a witness is not the nurse's role, as this is typically done by a neutral party. Informing the client of alternatives to the procedure and explaining the procedure in detail are responsibilities of the healthcare provider performing the surgery, not the nurse.
4. A client asks the nurse to call the police and states: 'I need to report that I am being abused by a nurse.' The nurse should first
- A. Focus on reality orientation to place and person
- B. Assist with the report of the client's complaint to the police
- C. Obtain more details of the client's claim of abuse
- D. Document the statement in the client's chart with a report to the manager
Correct answer: C
Rationale: The correct initial action for the nurse is to obtain more details about the client's claim of abuse. This will help the nurse better understand the situation before proceeding with any further actions. Option A is incorrect as reality orientation is not the priority in this situation. Option B is premature as more details are needed first. Option D is not the immediate step as gathering information should come before documentation and reporting.
5. The nurse is developing an educational program for older clients discharged with new antihypertensive medications. The nurse should ensure that the education materials include which characteristics?
- A. Uses pictures to help illustrate complex ideas
- B. Contains a list with definitions of unfamiliar terms
- C. Uses common words with few syllables
- D. All of the above
Correct answer: D
Rationale: The correct answer is D, 'All of the above.' When developing educational materials for older clients with new antihypertensive medications, it is essential to include characteristics such as using pictures to illustrate complex ideas, providing a list with definitions of unfamiliar terms, and using common words with few syllables. These features help enhance understanding and medication adherence, especially for older adults who may have challenges with health literacy. Choices A, B, and C collectively address the need for simplicity, visual support, and clarification of terms in educational materials, making them crucial for effective patient education.
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