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. 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.
3. A client with schizophrenia is experiencing paranoia. What is the nurse's priority intervention?
- A. Reassure the client that their fears are unfounded.
- B. Place the client in a private room to reduce stimuli.
- C. Provide the client with a distraction to redirect their attention.
- D. Encourage the client to express their concerns and validate their feelings.
Correct answer: D
Rationale: Encouraging clients with paranoia to express their concerns and validating their feelings is crucial as it helps establish trust and reduce anxiety. This approach also aids in building a therapeutic relationship. Reassuring the client that their fears are unfounded (Choice A) may invalidate their feelings and worsen trust. Placing the client in a private room to reduce stimuli (Choice B) may be helpful in some situations but does not address the underlying issue of paranoia. Providing a distraction (Choice C) may temporarily shift the client's focus but does not address the root cause of the paranoia. Therefore, the priority intervention is to encourage the client to express their concerns and validate their feelings.
4. A client with bipolar disorder is prescribed lithium. What should the nurse teach the client about lithium toxicity?
- A. Take the medication with meals to prevent gastrointestinal upset.
- B. Report any symptoms of nausea, vomiting, or diarrhea.
- C. Monitor lithium levels regularly and maintain hydration.
- D. Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs) while on lithium.
Correct answer: D
Rationale: The correct answer is D. Clients taking lithium should avoid NSAIDs as they can increase lithium levels leading to toxicity. It is essential to monitor lithium levels regularly and maintain hydration to prevent toxicity. Reporting symptoms like nausea, vomiting, or diarrhea is important, but the key teaching point regarding lithium toxicity is to avoid NSAIDs.
5. A middle-aged woman talks to the nurse in the healthcare provider's office about uterine fibroids, also called leiomyomas or myomas. What statement by the woman indicates more education is needed?
- A. I am one out of every 4 women that get fibroids, and among women my age, between the 30s or 40s, fibroids occur more frequently.
- B. My fibroids are noncancerous tumors that grow slowly.
- C. The associated problems I have had are pelvic pressure and pain, urinary incontinence, frequent urination or urine retention, and constipation.
- D. Fibroids that cause no problems still need to be taken out.
Correct answer: D
Rationale: The correct answer is D because fibroids that do not cause symptoms do not necessarily need to be removed unless they pose other health risks. Choice A provides accurate information about the prevalence of fibroids among women of the woman's age group. Choice B correctly describes fibroids as noncancerous tumors. Choice C lists common symptoms associated with fibroids, which is relevant information. However, choice D is incorrect as fibroids that are asymptomatic or not causing problems usually do not require treatment, unless they lead to complications or health risks.
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