HESI RN
HESI RN Exit Exam Capstone
1. The nurse is caring for a client with an exacerbation of chronic obstructive pulmonary disease (COPD). Which intervention is most important to promote effective breathing?
- A. Encourage diaphragmatic breathing
- B. Increase the client's oxygen flow rate
- C. Have the client perform range of motion exercises
- D. Place the client in a supine position
Correct answer: A
Rationale: Encouraging diaphragmatic breathing is crucial in clients with COPD as it helps improve lung expansion and oxygen exchange, promoting more effective breathing. This intervention aids in reducing dyspnea and enhancing ventilation. Increasing the client's oxygen flow rate may not be appropriate and can potentially worsen hypercapnia in individuals with COPD. Performing range of motion exercises and placing the client in a supine position do not directly address the breathing difficulties associated with COPD exacerbation.
2. Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)?
- A. Accompanying a client who self-administers insulin
- B. Cleansing and dressing a small decubitus ulcer
- C. Monitoring a client's response to passive range of motion exercises
- D. Applying and caring for a client's rectal pouch
Correct answer: D
Rationale: The correct answer is D because tasks like applying and caring for a client's rectal pouch are within the UAP's scope of practice, as they do not require clinical judgment. Choices A, B, and C involve more complex assessments or interventions that require clinical judgment and should be performed by licensed nursing staff.
3. The nurse is teaching a group of women about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity?
- A. Weight-bearing exercise
- B. Aerobic exercise
- C. Low-impact exercises such as swimming
- D. Stretching and flexibility exercises
Correct answer: A
Rationale: The correct answer is A: Weight-bearing exercise. Weight-bearing exercise helps build and maintain bone density, which is critical in preventing osteoporosis. Activities like aerobic exercises, stretching, and low-impact exercises such as swimming are beneficial for overall fitness but do not directly contribute to improving bone strength, making them less effective in preventing osteoporosis.
4. A client has been given a prescription for tetracycline HCL (Sumycin). The nurse should emphasize the client to
- A. Take the medication with food or milk
- B. Avoid prolonged sun exposure
- C. Monitor for signs of yellowing skin or eyes
- D. Expect a yellow-brown discoloration of the teeth
Correct answer: C
Rationale: The correct answer is C: 'Monitor for signs of yellowing skin or eyes.' Tetracycline can cause hepatotoxicity, leading to jaundice which may present as yellowing of the skin or eyes. This is a serious side effect that the nurse should emphasize to the client. Choice A is incorrect because tetracycline should generally be taken on an empty stomach, not with food or milk. Choice B is also incorrect as tetracycline can cause photosensitivity, but it is not directly related to yellowing skin or eyes. Choice D is incorrect because tetracycline can cause yellow-brown discoloration of the teeth, but this is usually seen in children under 8 years of age, not a common concern for adult clients.
5. The nurse is conducting diet teaching for a client diagnosed with hypertension. Which foods should the nurse encourage the client to eat?
- A. Pickled olives
- B. Canned soup
- C. Fresh or frozen vegetables without sauce
- D. Fruits without sauce
Correct answer: C
Rationale: The correct answer is C: Fresh or frozen vegetables without sauce. These foods are low in sodium, which is crucial for managing hypertension. Pickled olives (choice A) and canned soup (choice B) are high in sodium, which can exacerbate hypertension. While fruits without sauce (choice D) are generally healthy, emphasizing vegetables is more beneficial for hypertension due to their lower sodium content.
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