HESI RN
HESI RN Exit Exam Capstone
1. While palpating the gallbladder of a mildly obese client, what finding does the nurse expect if the gallbladder is inflamed?
- A. Severe tenderness and guarding
- B. Slight discomfort upon palpation
- C. A sensation of fullness
- D. No symptoms unless the gallbladder is extremely inflamed
Correct answer: A
Rationale: Correct. If the gallbladder is inflamed, the nurse would expect to find severe tenderness and guarding, which are typical signs of acute cholecystitis. This indicates an inflammatory process in the gallbladder. Choices B, C, and D are incorrect because slight discomfort, a sensation of fullness, or no symptoms unless extremely inflamed are not typical findings associated with gallbladder inflammation.
2. A client with chronic kidney disease is prescribed erythropoietin. What is the nurse's priority action?
- A. Monitor the client's hemoglobin and hematocrit.
- B. Monitor the client's blood pressure.
- C. Assess the client for signs of infection.
- D. Monitor the client for signs of bleeding.
Correct answer: A
Rationale: The correct answer is A: 'Monitor the client's hemoglobin and hematocrit.' When a client with chronic kidney disease is prescribed erythropoietin, the nurse's priority action is to monitor the client's hemoglobin and hematocrit. Erythropoietin stimulates red blood cell production, so monitoring these lab values helps evaluate the effectiveness of erythropoietin in treating anemia. Monitoring the client's blood pressure (choice B) is important but not the priority in this scenario. Assessing the client for signs of infection (choice C) is important but not the priority related to the prescription of erythropoietin. Monitoring the client for signs of bleeding (choice D) is relevant but not the priority action when erythropoietin is prescribed.
3. The healthcare worker is wearing PPE while caring for a client. When exiting the room, which PPE should be removed first?
- A. Gloves
- B. Face shield
- C. Mask
- D. Gown
Correct answer: A
Rationale: Gloves should be removed first as they are most likely to be contaminated. This is followed by the gown, then face shield, and mask. Correct removal sequence helps prevent contamination. Removing gloves first reduces the risk of transferring pathogens from the gloves to other PPE or surfaces. Face shield and mask should be removed last as they protect mucous membranes from exposure to contaminants. Removing PPE in the correct sequence is crucial in preventing the spread of infections.
4. The nurse is teaching a client about lifestyle changes to manage hypertension. Which of the following should be emphasized?
- A. Increase daily intake of sodium.
- B. Exercise regularly and maintain a healthy weight.
- C. Reduce intake of potassium-rich foods.
- D. Drink alcohol in moderation.
Correct answer: B
Rationale: The correct answer is B. Regular exercise and maintaining a healthy weight are crucial lifestyle changes in managing hypertension. Exercise helps lower blood pressure and improves heart health, while maintaining a healthy weight reduces the risk of hypertension. Choices A, C, and D are incorrect. Increasing daily intake of sodium can elevate blood pressure, reducing intake of potassium-rich foods is not recommended as potassium helps lower blood pressure, and drinking alcohol should be limited or avoided as it can raise blood pressure.
5. A client with chronic obstructive pulmonary disease (COPD) is receiving supplemental oxygen. The client reports feeling short of breath and has a respiratory rate of 28 breaths per minute. What should the nurse do first?
- A. Increase the oxygen flow rate
- B. Notify the healthcare provider
- C. Administer a bronchodilator
- D. Elevate the head of the bed
Correct answer: D
Rationale: Elevating the head of the bed promotes lung expansion and improves oxygenation, making it the priority intervention for a client with shortness of breath. This position helps in maximizing lung expansion and aiding ventilation-perfusion matching in patients with COPD. Increasing the oxygen flow rate may be necessary but should come after optimizing the client's positioning. Notifying the healthcare provider and administering a bronchodilator are not the initial interventions for addressing shortness of breath in a client with COPD.
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