RN HESI Exit Exam Capstone

RN HESI Exit Exam Capstone Related

Review RN HESI Exit Exam Capstone related questions and content

A client in the third trimester of pregnancy reports that she feels some 'lumpy places' in her breasts and that her nipples sometimes leak a yellowish fluid. She has an appointment with her healthcare provider in two weeks. What action should the nurse take?

  • A. Instruct the client to immediately see her provider for an evaluation
  • B. Assess the fluid for signs of infection
  • C. Explain that this normal secretion can be assessed at the next visit
  • D. Recommend breast ultrasound to rule out abnormalities
Correct Answer: C

Rationale: The yellowish fluid is likely colostrum, a normal finding in late pregnancy as the breasts prepare for lactation. It is common for women in the third trimester to experience 'lumpy places' in the breasts due to increased milk duct development. In this situation, the nurse should educate the client that these findings are normal physiological changes associated with pregnancy. Since the client has an upcoming appointment with her healthcare provider in two weeks, it is appropriate to reassure her that this can be further assessed during that visit. Instructing the client to immediately see her provider (Choice A) is unnecessary as this is a common finding in late pregnancy. Assessing the fluid for signs of infection (Choice B) is not warranted as colostrum leakage is a normal occurrence. Recommending a breast ultrasound (Choice D) is premature without further assessment by the healthcare provider.

You may also like to solve these questions

A client with a history of chronic kidney disease presents with increased swelling and shortness of breath. What is the nurse's priority action?

  • A. Administer oxygen at 2 liters per nasal cannula.
  • B. Administer a diuretic as prescribed.
  • C. Monitor the client's vital signs.
  • D. Reposition the client to improve lung expansion.
Correct Answer: B

Rationale: The correct answer is to administer a diuretic as prescribed. In a client with chronic kidney disease experiencing increased swelling and shortness of breath, the priority action is to address fluid retention. Administering a diuretic helps reduce fluid overload, alleviate symptoms, and prevent complications associated with fluid buildup. Option A is not the priority in this situation as addressing fluid retention takes precedence over providing oxygen. While monitoring vital signs is important, it is secondary to addressing the underlying cause of symptoms. Repositioning the client may help with comfort but does not directly address the fluid overload seen in chronic kidney disease.

The nurse is caring for a client with fluid overload. The most reliable indicator of fluid volume status is

  • A. Body weight
  • B. Intake and output
  • C. Daily weight
  • D. Skin turgor
Correct Answer: C

Rationale: Daily weight is the most reliable indicator of fluid volume status as it reflects changes in body fluid balance accurately. Body weight alone can fluctuate due to various factors, including food intake and bowel movements, which may not accurately represent fluid status. Intake and output provide information on fluid balance over time but may not reflect immediate changes. Skin turgor is a physical assessment finding that indicates hydration status, not overall fluid volume status.

In monitoring tissue perfusion in a client following an above the knee amputation (AKA), which action should the nurse include in the plan of care?

  • A. Evaluate closest proximal pulse.
  • B. Note amount and color of wound drainage.
  • C. Observe for swelling around the stump.
  • D. Assess skin elasticity of the stump.
Correct Answer: A

Rationale: After an amputation, monitoring the pulse closest to the stump is crucial in evaluating tissue perfusion and the overall health of the limb. Swelling and changes in perfusion can indicate complications such as blood clots or infection. Assessing the proximal pulse helps the nurse ensure adequate blood flow to the remaining limb, thereby preventing further complications. Choices B, C, and D are less directly related to monitoring tissue perfusion in this scenario and are more focused on wound healing and stump care.

A client with pneumonia is receiving oxygen therapy. What assessment finding requires immediate intervention?

  • A. Increased oxygen saturation of 96%.
  • B. Oxygen saturation of 89%.
  • C. Respiratory rate of 20 breaths per minute.
  • D. Decreased heart rate of 70 beats per minute.
Correct Answer: B

Rationale: The correct answer is B. An oxygen saturation of 89% indicates hypoxemia, which is below the normal range (usually 95-100%). This finding requires immediate intervention as it signifies inadequate oxygenation. Options A, C, and D are within normal limits and do not indicate an urgent need for intervention. Option A indicates a good oxygen saturation level, option C denotes a normal respiratory rate, and option D suggests a normal heart rate. Therefore, these options do not require immediate intervention compared to the critically low oxygen saturation level of 89% in option B.

A client with hypertension is prescribed a low-sodium diet. What is the most important instruction for the nurse to provide?

  • A. Limit sodium intake to 2 grams per day.
  • B. Choose fresh fruits and vegetables.
  • C. Drink at least 8 glasses of water daily.
  • D. Avoid processed foods and canned soups.
Correct Answer: D

Rationale: The correct answer is D. Avoiding processed foods and canned soups is crucial for a client with hypertension on a low-sodium diet because these foods are typically high in sodium content. Fresh fruits and vegetables are generally healthy choices but may still contain some natural sodium. While limiting sodium intake to 2 grams per day is important, specifically avoiding processed foods and canned soups is more critical in this situation. Drinking water is essential for overall health but is not the most important instruction when focusing on reducing sodium intake.

Copyright © 2025 Nokea. All rights reserved.