HESI RN
HESI RN Exit Exam 2024 Capstone
1. Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)?
- A. Accompanying a client who self-administers insulin
- B. Cleansing and dressing a small decubitus ulcer
- C. Monitoring a client's response to passive range of motion exercises
- D. Applying and caring for a client's rectal pouch
Correct answer: D
Rationale: The correct answer is D because tasks like applying and caring for a client's rectal pouch are within the UAP's scope of practice, as they do not require clinical judgment. Choices A, B, and C involve more complex assessments or interventions that require clinical judgment and should be performed by licensed nursing staff.
2. In conducting a health assessment for a family with a history of diabetes, which family member should be prioritized for further evaluation and intervention?
- A. a 50-year-old mother with a history of hypertension
- B. a 45-year-old father who is overweight and has high cholesterol
- C. a 17-year-old daughter who is inactive
- D. a 12-year-old son who has a normal weight and is active
Correct answer: B
Rationale: The correct answer is the 45-year-old father who is overweight and has high cholesterol. He possesses multiple risk factors for diabetes, indicating a need for prioritized evaluation and intervention. The mother's hypertension, the daughter's inactivity, and the son's normal weight and activity level are important factors to consider but do not present as immediate red flags for diabetes risk compared to the father's combination of being overweight and having high cholesterol.
3. The nurse is monitoring a client who has just had a thyroidectomy. The client complains of tingling in the fingers and around the mouth. Which of these findings should the nurse assess first?
- A. Calcium level
- B. Chvostek's sign
- C. Trousseau's sign
- D. Serum potassium level
Correct answer: B
Rationale: The correct answer is B, Chvostek's sign. This is a classic sign of hypocalcemia, which can occur after a thyroidectomy due to injury or removal of the parathyroid glands. Hypocalcemia can lead to serious complications like tetany and laryngospasm, necessitating immediate attention. Assessing Chvostek's sign helps in early identification and management of hypocalcemia. Choices A, C, and D are not the priority in this situation. While assessing the calcium level is important for diagnosing hypocalcemia, the immediate concern is to identify clinical signs like Chvostek's sign, which indicate acute hypocalcemia. Trousseau's sign is also related to hypocalcemia but is not the most critical sign to assess first. Serum potassium level, although important for overall electrolyte balance, is not directly related to the client's current symptoms of tingling in the fingers and around the mouth.
4. How should the nurse prepare the body of a deceased adult for transfer to the mortuary?
- A. Leave the body as is, no preparation needed
- B. Bathe the body and place ID tags on it
- C. Remove dentures before bathing the body
- D. Position the body with its head down and arms folded on its chest
Correct answer: B
Rationale: When preparing the body of a deceased adult for transfer to the mortuary, it is essential to bathe the body and place identification tags on it. This process ensures proper identification and respectful care of the deceased individual.
5. A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication ____________.
- A. Can predispose to dysrhythmias
- B. May lead to oliguria
- C. May cause irritability and anxiety
- D. Sometimes alters consciousness
Correct answer: A
Rationale: The correct answer is A: Can predispose to dysrhythmias. Hypokalemia combined with digoxin increases the risk of dysrhythmias due to the potentiation of digoxin's effects on cardiac conduction. Choice B, May lead to oliguria, is incorrect because hypokalemia is not typically associated with oliguria. Choice C, May cause irritability and anxiety, is incorrect as these symptoms are more commonly associated with hypocalcemia. Choice D, Sometimes alters consciousness, is incorrect as altered consciousness is not a typical effect of hypokalemia combined with digoxin.