HESI RN Exit Exam 2024 Capstone

HESI RN Exit Exam 2024 Capstone Related

Review HESI RN Exit Exam 2024 Capstone related questions and content

The father of a 4-year-old has been battling metastatic lung cancer for the past 2 years. After discussing the remaining options with his healthcare provider, the client requests that all treatment stop and that no heroic measures be taken to save his life. When the client is transferred to the palliative care unit, which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care?

  • A. Ensure the client's family is aware of the client's wishes
  • B. Begin comfort measures immediately
  • C. Obtain a detailed report from the nurse transferring the client
  • D. Confirm that the client understands the treatment plan
Correct Answer: C

Rationale: Obtaining a detailed report from the previous nurse ensures continuity of care and that all relevant information is passed on. This is critical in palliative care, where comfort measures and symptom management are key components of care. Choice A is not the most important action in this scenario, as the question focuses on continuity of care within the healthcare team. Beginning comfort measures immediately, as in choice B, is essential but obtaining a detailed report takes precedence to ensure a smooth transition of care. Confirming that the client understands the treatment plan, as in choice D, is important but does not directly address the need for continuity of care through a detailed report.

You may also like to solve these questions

When caring for a client with acute respiratory distress syndrome (ARDS), why does the nurse elevate the head of the bed 30 degrees?

  • A. To reduce abdominal pressure on the diaphragm
  • B. To promote oxygenation by improving lung expansion
  • C. To encourage use of accessory muscles for breathing
  • D. To drain secretions and prevent aspiration
Correct Answer: D

Rationale: Elevating the head of the bed in a client with acute respiratory distress syndrome (ARDS) is essential to drain secretions and prevent aspiration. This position helps facilitate the removal of secretions from the airways, reducing the risk of aspiration pneumonia. Choices A, B, and C are incorrect as the primary reason for elevating the head of the bed in ARDS is to assist with secretion drainage and prevent complications associated with aspiration.

A client with pneumonia is receiving oxygen via nasal cannula at 2 L/min. What assessment finding indicates the need for further intervention?

  • A. The client reports feeling short of breath.
  • B. The client's oxygen saturation is 92%.
  • C. The client's respiratory rate is 20 breaths per minute.
  • D. The client is unable to complete sentences without pausing.
Correct Answer: D

Rationale: The correct answer is D because the inability to complete sentences without pausing indicates respiratory distress and the need for immediate intervention. This finding suggests an increased work of breathing and inadequate oxygenation. Choices A, B, and C are not as urgent as choice D. Feeling short of breath (choice A) is expected in pneumonia but does not necessarily indicate the need for immediate intervention. An oxygen saturation of 92% (choice B) is slightly below the normal range but may not require immediate intervention. A respiratory rate of 20 breaths per minute (choice C) is within the normal range and does not signify an urgent need for intervention.

A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106, and he admits that he has not been taking the prescribed medication because the drugs make him feel bad. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?

  • A. Stroke secondary to hemorrhage
  • B. Myocardial infarction
  • C. Heart failure
  • D. Renal failure
Correct Answer: A

Rationale: Stroke is a major complication of uncontrolled hypertension. Elevated BP, especially at levels like 158/106, can cause damage to blood vessels in the brain, leading to a hemorrhagic stroke. Controlling BP is essential to prevent such life-threatening events. Myocardial infarction (choice B) is more commonly associated with coronary artery disease, while heart failure (choice C) and renal failure (choice D) can be complications of uncontrolled hypertension but are not directly related to the elevated BP leading to a hemorrhagic stroke.

A client with deep vein thrombosis (DVT) is prescribed warfarin. What teaching should the nurse provide?

  • A. Avoid foods high in vitamin K, such as spinach.
  • B. Report any signs of bleeding, such as bruising or nosebleeds.
  • C. Take the medication on an empty stomach.
  • D. Monitor for changes in blood pressure.
Correct Answer: B

Rationale: The correct teaching for a client prescribed warfarin is to report any signs of bleeding, such as unusual bruising, nosebleeds, or blood in the urine or stool. Warfarin is an anticoagulant that increases the risk of bleeding, so it is crucial for the client to promptly report any bleeding-related symptoms for evaluation by a healthcare provider. Choices A, C, and D are incorrect. Avoiding foods high in vitamin K, such as spinach, is more relevant for clients taking warfarin to maintain consistent vitamin K intake. Warfarin should be taken with food to avoid gastrointestinal upset, so taking it on an empty stomach is not recommended. Monitoring for changes in blood pressure is not directly related to warfarin therapy; instead, the focus should be on monitoring for signs of bleeding.

A child is brought to the emergency department after ingesting an unknown quantity of acetaminophen. What is the most important action for the nurse to take?

  • A. Assess the child's level of consciousness.
  • B. Prepare to administer activated charcoal.
  • C. Notify the poison control center.
  • D. Obtain an order for serum acetaminophen levels.
Correct Answer: D

Rationale: Obtaining serum acetaminophen levels is critical in determining the level of toxicity and guiding treatment. It helps to assess the risk of hepatotoxicity and determine the need for antidotal therapy with N-acetylcysteine. Assessing the child's level of consciousness (Choice A) is important but obtaining serum acetaminophen levels takes precedence as it directly guides the specific treatment required. Activated charcoal (Choice B) is not routinely used in acetaminophen poisoning. While notifying the poison control center (Choice C) is important, obtaining serum acetaminophen levels should be the immediate action to assess the child's condition and guide treatment.

Copyright © 2025 Nokea. All rights reserved.