HESI RN Exit Exam 2024 Capstone

HESI RN Exit Exam 2024 Capstone Related

Review HESI RN Exit Exam 2024 Capstone related questions and content

A female client experiences a sudden loss of consciousness and is taken to the emergency department. Initial assessment indicates her blood glucose level is critically low. Once stabilized, she reports being treated for anorexia nervosa. What intervention is most important for the nurse to include in the client's discharge plan?

  • A. Encourage a high-protein, low-carbohydrate diet.
  • B. Encourage her to join a group focusing on self-esteem.
  • C. Schedule an outpatient psychosocial assessment.
  • D. Teach relaxation techniques to manage stress.
Correct Answer: B

Rationale: Joining a group that focuses on self-esteem is the most important intervention for the nurse to include in the client's discharge plan. This can help the client address underlying emotional issues related to her anorexia nervosa and improve her mental health. Choice A is incorrect because a high-protein, low-carbohydrate diet may not address the psychological factors contributing to anorexia nervosa. Choice C is incorrect as scheduling an outpatient psychosocial assessment is important but not the most crucial intervention for discharge planning in this case. Choice D is also not the priority as teaching relaxation techniques, although beneficial, may not directly address the self-esteem and emotional issues that need to be tackled in this situation.

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The nurse is caring for a client with a nasogastric tube. Which of the following interventions is a priority to maintain client safety?

  • A. Flush the tube with water every 4 hours
  • B. Check the tube placement before each feeding
  • C. Secure the tube to the client's nose with tape
  • D. Keep the head of the bed elevated at 30 degrees
Correct Answer: B

Rationale: Verifying the correct placement of a nasogastric tube before each feeding is essential to prevent aspiration and ensure that the tube is properly positioned in the stomach or intestine. This action is a priority to maintain client safety. Flushing the tube with water every 4 hours is important for tube patency but is not the priority over verifying placement. Securing the tube with tape and keeping the head of the bed elevated are crucial but are considered secondary measures compared to confirming the correct tube placement.

A client with Addison's disease becomes confused and weak. What is the nurse's first action?

  • A. Administer a dose of hydrocortisone immediately.
  • B. Check the client's electrolyte levels.
  • C. Administer a dose of normal saline.
  • D. Measure the client's blood pressure in both arms.
Correct Answer: A

Rationale: The correct answer is to administer a dose of hydrocortisone immediately. In Addison's disease, confusion and weakness can be signs of an adrenal crisis. Administering hydrocortisone promptly is crucial to prevent further deterioration. Checking electrolyte levels (Choice B) is important but not the first action in managing an acute adrenal crisis. Administering normal saline (Choice C) is not the priority in this situation. Measuring blood pressure in both arms (Choice D) is not the initial action needed to address the client's confusion and weakness in Addison's disease.

An older client with a long history of coronary artery disease, HTN, and HF arrives in the ED in respiratory distress. The healthcare provider prescribes furosemide IV. Which therapeutic response to furosemide should the nurse expect in the client with acute HF?

  • A. Decreased heart rate
  • B. Improved blood pressure
  • C. Increased urine output
  • D. Reduced preload
Correct Answer: D

Rationale: The correct answer is D: Reduced preload. Furosemide is a diuretic that reduces fluid overload in heart failure, which lowers the preload (the volume of blood in the ventricles before contraction). By reducing this volume, furosemide improves symptoms of heart failure. While furosemide may lead to increased urine output and lower blood pressure, these effects are secondary to the reduction in preload. Decreased heart rate is not a direct effect of furosemide in heart failure.

Which documentation indicates that activities to prevent postoperative venous stasis were performed correctly?

  • A. Antiembolism stockings on, leg exercises performed hourly.
  • B. Antiembolism stockings removed hourly during leg exercises.
  • C. Leg exercises not performed due to antiembolism hose.
  • D. Client demonstrates ability to move extremities well.
Correct Answer: A

Rationale: The correct answer is A: 'Antiembolism stockings on, leg exercises performed hourly.' This documentation indicates the correct performance of activities to prevent postoperative venous stasis, as both components are crucial for prevention. Choice B is incorrect because removing stockings hourly is not recommended. Choice C is incorrect as leg exercises should be performed despite wearing antiembolism stockings. Choice D is incorrect as demonstrating the ability to move extremities well does not specifically address the prevention of venous stasis.

The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high-protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?

  • A. A tuna fish sandwich with chips and ice cream
  • B. A vegetable salad with croutons and ranch dressing
  • C. A grilled chicken breast with steamed vegetables
  • D. A peanut butter and jelly sandwich with soda
Correct Answer: C

Rationale: The correct answer is C. Grilled chicken is an excellent source of protein, which is important for wound healing. Choices A, B, and D are less ideal for wound healing. Choice A contains high-fat and high-sugar components like chips and ice cream, which may not support wound healing effectively. Choice B includes croutons and ranch dressing, which may not provide as much protein as needed for wound healing. Choice D with a peanut butter and jelly sandwich and soda lacks a balanced meal with adequate protein to promote wound healing.

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