HESI RN
HESI RN Exit Exam Capstone
1. A client asks the nurse for information about reducing risk factors for BPH. Which information should the nurse provide?
- A. Increase physical activity
- B. Decrease alcohol consumption
- C. Reduce intake of dairy products
- D. Avoid caffeine and spicy foods
Correct answer: A
Rationale: The correct answer is A: Increase physical activity. Physical activity can help reduce the risk of benign prostatic hyperplasia (BPH) by improving overall circulation and reducing inflammation. While decreasing alcohol consumption and avoiding caffeine and spicy foods may help with symptom management, increasing physical activity is more strongly linked to the prevention of BPH.
2. What are the primary pathophysiological mechanisms responsible for ascites in liver failure?
- A. Decreased liver enzymes.
- B. Increased hydrostatic pressure in portal circulation.
- C. High bilirubin levels.
- D. Fluid shifts due to decreased serum proteins.
Correct answer: B
Rationale: The correct answer is B: Increased hydrostatic pressure in portal circulation. Ascites in liver failure is primarily caused by fluid shifts from the intravascular space to the interstitial space due to increased hydrostatic pressure in the portal circulation. Choice A is incorrect as ascites is not caused by decreased liver enzymes. Choice C is incorrect as high bilirubin levels are not the primary mechanism for ascites in liver failure. Choice D is incorrect as fluid shifts in ascites are due to decreased serum proteins, not increased serum proteins.
3. A young male client is admitted to rehabilitation following a right above-knee amputation (AKA) and reports aching in his right foot. Which intervention is most important for the nurse to implement?
- A. Encourage discussion about feelings of limb loss.
- B. Administer a prescription for gabapentin.
- C. Teach the client how to wrap the stump with an elastic bandage.
- D. Offer assistance to move to a quiet room to relax.
Correct answer: B
Rationale: The correct answer is B: Administer a prescription for gabapentin. Gabapentin is used to treat phantom limb pain, which is common after amputations. Encouraging discussion about feelings of limb loss (choice A) is important for emotional support but does not address the physical pain. Teaching the client how to wrap the stump with an elastic bandage (choice C) is not indicated for aching in the 'right foot' as described. Offering assistance to move to a quiet room to relax (choice D) may provide comfort but does not address the underlying issue of phantom limb pain.
4. The nurse reviews the diagnostic tests prescribed for a client with a positive skin test. Which subjective findings reported by the client support the diagnosis of tuberculosis?
- A. Mucopurulent cough and night sweats
- B. Fatigue and headache
- C. Persistent cough and weight gain
- D. Weight loss and fever
Correct answer: A
Rationale: A mucopurulent cough and night sweats are hallmark signs of active tuberculosis. These symptoms are key indicators of TB as the combination of a productive cough with night sweats is highly suggestive of the disease. Fatigue and headache (choice B) are nonspecific symptoms that can occur in many conditions and are not specific to TB. Persistent cough and weight gain (choice C) are not typical findings in tuberculosis. Weight loss and fever (choice D) can be present in TB, but the specific combination of mucopurulent cough and night sweats is more specific to the diagnosis.
5. A client is admitted to isolation with active tuberculosis. What infection control measures should the nurse implement?
- A. Initiate protective environment precautions.
- B. Use droplet precautions only.
- C. Ensure a positive pressure environment in the room.
- D. Implement negative pressure and contact precautions.
Correct answer: D
Rationale: When caring for a client with active tuberculosis, it is crucial to implement negative pressure rooms and contact precautions to prevent the spread of infection. Choice A, initiating protective environment precautions, is incorrect as this is not the recommended approach for tuberculosis. Choice B, using droplet precautions only, is insufficient as tuberculosis requires additional precautions. Choice C, ensuring a positive pressure environment in the room, is incorrect because negative pressure rooms are necessary to contain airborne pathogens like tuberculosis. Therefore, the most appropriate measures include implementing negative pressure rooms and contact precautions.
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