HESI RN
HESI RN Exit Exam 2024 Capstone Questions
Question 1 of 5
The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high-protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?
Correct Answer: C
Rationale: The correct answer is C. Grilled chicken is an excellent source of protein, which is important for wound healing. Choices A, B, and D are less ideal for wound healing. Choice A contains high-fat and high-sugar components like chips and ice cream, which may not support wound healing effectively. Choice B includes croutons and ranch dressing, which may not provide as much protein as needed for wound healing. Choice D with a peanut butter and jelly sandwich and soda lacks a balanced meal with adequate protein to promote wound healing.
Question 2 of 5
A nurse is planning discharge teaching for a client with congestive heart failure (CHF). Which dietary instruction should the nurse provide?
Correct Answer: A
Rationale: The correct answer is A: Limit sodium intake to reduce fluid retention. Limiting sodium intake is crucial for managing congestive heart failure (CHF) as it helps reduce fluid retention. Excess fluid retention can worsen CHF by increasing the workload on the heart. Choice B is incorrect because while protein is essential for overall health, it is not directly related to managing CHF. Choice C is incorrect because potassium, although important, is not the primary focus in managing CHF. Choice D is incorrect because increasing fluid intake can exacerbate fluid retention in CHF patients.
Question 3 of 5
A client with chronic kidney disease is prescribed a low-potassium diet. Which food should the nurse instruct the client to avoid?
Correct Answer: C
Rationale: The correct answer is C: Bananas. Bananas are high in potassium and should be avoided in clients who are on a low-potassium diet due to chronic kidney disease. Foods like apples and white bread are low in potassium and are safer choices. Carrots are also low in potassium and do not need to be avoided in this case.
Question 4 of 5
The nurse is caring for a client with deep vein thrombosis (DVT) who is receiving heparin therapy. Which assessment finding requires immediate intervention by the nurse?
Correct Answer: D
Rationale: Hematuria is a sign of bleeding, which is a potential complication of heparin therapy. Immediate intervention is required to manage the bleeding and adjust the heparin dosage if necessary. Localized warmth, calf pain, and swelling in the affected leg are common findings in clients with DVT and receiving heparin therapy. While these symptoms should be monitored, hematuria indicates a more serious issue requiring immediate attention.
Question 5 of 5
The nurse is caring for a client with a traumatic brain injury who is receiving mechanical ventilation. Which assessment finding indicates that the client may be experiencing increased intracranial pressure (ICP)?
Correct Answer: A
Rationale: Increased lethargy is a sign of worsening intracranial pressure, which can be life-threatening in clients with brain injuries. As ICP rises, it can lead to decreased level of consciousness, such as lethargy or even coma. Choices B, C, and D are not indicative of increased ICP. A normal respiratory rate, response to verbal stimuli, and equal reactive pupils do not specifically point towards increased intracranial pressure.