HESI RN
HESI RN Exit Exam 2023 Capstone
1. Which strategy should the nurse implement when teaching a client with low literacy about a new diagnosis of hypertension?
- A. Provide a detailed handout with complex terms
- B. Use simple language and visual aids
- C. Encourage the client to research the diagnosis online
- D. Incorporate medical jargon to explain the condition
Correct answer: B
Rationale: The correct strategy for teaching a client with low literacy about a new diagnosis of hypertension is to use simple language and visual aids. This approach helps ensure better understanding of the diagnosis and treatment plan by making the information clear and accessible. Providing a detailed handout with complex terms (Choice A) would not be suitable as it may confuse the client further. Encouraging the client to research the diagnosis online (Choice C) could lead to misinformation and overwhelm the client with information they may not understand. Incorporating medical jargon to explain the condition (Choice D) would not be helpful for a client with low literacy as it may complicate rather than clarify the information.
2. After working with a very demanding client, an unlicensed assistive personnel (UAP) tells the nurse, 'I have had it with that client. I just can't do anything that pleases him. I'm not going in there again.' The nurse should respond by saying
- A. He has a lot of problems. You need to have patience with him.
- B. I will talk with him and try to figure out what to do.
- C. He is scared and taking it out on you. Let's talk to figure out what to do.
- D. Ignore him and get the rest of your work done. Someone else can take care of him for the rest of the day.
Correct answer: C
Rationale: The correct response is to acknowledge the UAP's feelings while exploring the client's behavior. By stating, 'He is scared and taking it out on you. Let's talk to figure out what to do,' the nurse shows empathy and readiness to address the situation collaboratively. This approach helps maintain a therapeutic environment for both the UAP and the client. Choices A and D are dismissive and do not address the underlying issue or provide support. Choice B, while showing willingness to intervene, lacks the understanding of the client's potential fear and does not address the UAP's feelings.
3. A client reports unilateral leg swelling after a long flight. What complication is the nurse most concerned about?
- A. Monitor for signs of a pulmonary embolism.
- B. Assess for signs of dehydration.
- C. Monitor for signs of compartment syndrome.
- D. Check the client’s oxygen saturation levels.
Correct answer: A
Rationale: The correct answer is A. Unilateral leg swelling following a long flight may indicate a pulmonary embolism, which is a life-threatening complication requiring immediate attention. Pulmonary embolism occurs when a blood clot travels to the lungs, potentially blocking blood flow and leading to serious complications. Choices B, C, and D are incorrect because dehydration, compartment syndrome, and oxygen saturation levels are not typically associated with unilateral leg swelling after a long flight. While dehydration can cause leg cramps, compartment syndrome is more commonly associated with trauma or injury, and oxygen saturation levels are not the primary concern in this scenario.
4. A client with heart failure receiving furosemide develops muscle weakness. What is the nurse's priority action?
- A. Administer potassium supplements as prescribed.
- B. Monitor the client’s potassium levels.
- C. Instruct the client to increase their salt intake.
- D. Discontinue the furosemide.
Correct answer: B
Rationale: Muscle weakness in a client receiving furosemide (a diuretic) is often a sign of hypokalemia, as furosemide increases potassium loss. Monitoring potassium levels is essential to identify and address any imbalances and prevent complications such as arrhythmias. Administering potassium supplements without monitoring the levels can lead to hyperkalemia, which has its own set of serious complications. Instructing the client to increase salt intake is not appropriate in this situation as it does not address the underlying electrolyte imbalance. Discontinuing furosemide abruptly can worsen heart failure symptoms; therefore, monitoring potassium levels and adjusting the treatment accordingly is the most appropriate action.
5. A client is being prepared for surgery and has been placed on NPO status. Which of the following is the nurse's priority assessment?
- A. Assess the client's understanding of the procedure
- B. Monitor the client's compliance with NPO status
- C. Check the client's vital signs
- D. Ensure the client's consent form is signed
Correct answer: B
Rationale: The correct answer is B. Monitoring the client's compliance with NPO status is the priority assessment. Ensuring the client remains NPO (nothing by mouth) is crucial to reduce the risk of aspiration during surgery. Assessing the client's understanding of the procedure is important but not the priority at this moment. Checking vital signs is also essential but ensuring NPO status takes precedence for patient safety. Ensuring the client's consent form is signed is necessary but not the priority assessment compared to maintaining NPO status.
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