HESI RN
HESI RN Exit Exam 2023 Capstone
1. A client is diagnosed with tuberculosis and is placed on isoniazid (INH) and rifampin (Rifadin). The nurse should emphasize the importance of
- A. Daily use of a bronchodilator
- B. The importance of taking medication as prescribed
- C. Decreasing salt intake
- D. Avoidance of direct sunlight
Correct answer: B
Rationale: The correct answer is B: The importance of taking medication as prescribed. In the treatment of tuberculosis, adherence to the prescribed medication regimen is crucial to effectively manage the infection and prevent the development of drug resistance. Choices A, C, and D are incorrect because bronchodilators, salt intake, and sunlight exposure are not directly related to the treatment of tuberculosis with isoniazid and rifampin.
2. The nurse is providing discharge teaching to a client with newly diagnosed hypertension. Which lifestyle modification should the nurse emphasize to the client?
- A. Increase sodium intake to improve fluid balance
- B. Engage in regular physical activity
- C. Increase caffeine intake to improve energy
- D. Reduce potassium intake to lower blood pressure
Correct answer: B
Rationale: Engaging in regular physical activity is a crucial lifestyle modification for managing hypertension. Regular exercise helps improve cardiovascular health, lower blood pressure, and contribute to overall well-being. Choices A, C, and D are incorrect. Increasing sodium intake is not recommended for hypertension as it can worsen fluid retention and elevate blood pressure. Increasing caffeine intake is also not advised as it may lead to increased heart rate and blood pressure. Reducing potassium intake is not beneficial as potassium is essential for maintaining healthy blood pressure levels.
3. When assessing a client, why is it important for the nurse to be informed about cultural issues related to the client's background?
- A. Normal patterns of behavior may be labeled as deviant, immoral, or insane
- B. The meaning of the client's behavior can be derived from conventional wisdom
- C. Personal values will guide the interaction between individuals from different cultures
- D. The nurse should rely on her knowledge of different developmental mental stages
Correct answer: A
Rationale: Being aware of cultural differences is crucial because normal behaviors in one culture may be perceived as deviant, immoral, or insane in another. This awareness helps the nurse avoid misunderstandings or misinterpretations of behaviors that are considered acceptable in the client's cultural context but may be viewed differently in another. Choices B, C, and D are incorrect because understanding cultural issues goes beyond deriving meanings from conventional wisdom, personal values guiding interactions, or relying solely on knowledge of developmental mental stages.
4. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy. Which assessment finding indicates that the client's oxygenation is improving?
- A. Pulse oximetry reading of 94%
- B. Heart rate increases from 80 to 90 beats per minute
- C. Respiratory rate increases from 16 to 20 breaths per minute
- D. Client reports increased energy levels
Correct answer: A
Rationale: A pulse oximetry reading of 94% indicates adequate oxygenation. Monitoring oxygen saturation is the most objective way to assess the effectiveness of oxygen therapy. Choices B, C, and D do not directly reflect the client's oxygenation status. An increase in heart rate or respiratory rate may indicate increased work of breathing or stress on the body. The client reporting increased energy levels is subjective and may not directly correlate with improved oxygenation.
5. A client in labor who received epidural anesthesia experiences a sudden drop in blood pressure. What action should the nurse take first?
- A. Administer oxygen via nasal cannula.
- B. Administer an intravenous fluid bolus.
- C. Prepare the client for an emergency cesarean section.
- D. Place the client in a lateral position.
Correct answer: D
Rationale: In a client experiencing a sudden drop in blood pressure after epidural anesthesia, the first action the nurse should take is to place the client in a lateral position. This position helps improve venous return and cardiac output by relieving aortocaval compression. Administering oxygen via nasal cannula may be necessary if the client shows signs of respiratory distress, but it is not the first priority in this situation. Administering an intravenous fluid bolus can help stabilize blood pressure, but repositioning the client takes precedence. Preparing the client for an emergency cesarean section is not indicated solely based on a sudden drop in blood pressure after epidural anesthesia; this step would be considered if other complications arise.
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