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HESI RN COMPREHENSIVE EXAM A FOR CAPSTONE ACTUAL EXAM QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS)| ALREADY GRADED A+ $27.49
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HESI RN COMPREHENSIVE EXAM A FOR CAPSTONE 2023 -
2024 ACTUAL EXAM QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED ANSWERS)|
ALREADY GRADED A+
The nurse is assessing a client using the Snellen chart and determines that the
client's visual acuity is the same as in a previous examination, which was recorded
as 20/100. When the client asks the meaning of this, which information should the
nurse prov ide?
A.This visual acuity result is five times worse that of a normal finding.
B.This line should be seen clearly when the client wears corrective lenses.
C.A client with normal vision can read at 100 feet what this client reads at 20 feet.
D.This client can see at 100 feet what a client with normal vision can see at 20 feet.
- ANSWER - C
Rationale: The interpretation of the client's visual acuity is compared to the
Snellen scale of 20/20, which indicates that the letter size on the Snellen chart is
seen clearly and read by a client with normal vision at 20 feet. A finding of 20/100
means that this cl ient can read at 20 feet what a person with normal vision can read
at 100 feet (C). (A, B, and D) are inaccurate.
A client with small cell carcinoma of the lung has also developed syndrome of
inappropriate antidiuretic hormone (SIADH). Which outcome finding is the
priority for this client?
A.Reduced peripheral edema
B.Urinary output of at least 70 mL/hr
C.Decrease in urine osmolarity
D.Serum sodium level of 137 mEq/L - ANSWER - D
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Rationale: Syndrome of inappropriate antidiuretic hormone (SIADH) results from
an abnormal production or sustained secretion of antidiuretic hormone, causing
fluid retention, hyponatremia, and central nervous system (CNS) fluid shifts. The
client's normalization of t he serum sodium level (normal is 135 to 145 mEq/L) (D)
is the most important outcome because sudden and severe hyponatremia caused by
fluid overload can result in heart failure. Fluid retention of SIADH contributes to
daily weight gain, which can predispos e to peripheral edema (A), but the higher
priority outcome is the effect on serum electrolyte levels. Although (B and C) are
findings associated with resolving SIADH, they do not have the priority of (D).
50. Two days after swallowing 30 tablets of alprazolam (Xanax), a client with a
history of depression is hemodynamically stable but wants to leave the hospital
against medical advice. Which nursing action(s) is(are) most likely to maintain
client safety?
(Select all that apply.)
A.Direct the client to sign a liability release form.
B.Restrict the client's ability to leave the unit.
C.Explain the benefits of remaining in the hospital.
D.Instruct the client to take medications as prescribed.
E.Provide the client with names of local support groups.
F.Notify the health care provider of the client's intention. - ANSWER - CDF
Rationale : Correct responses are (C, D, and F). To maintain safety and to provide
information, the nurse should explain the potential benefits of continuing treatment
in the hospital (C) and the need to take prescribed medications (D). This client,
who is very likely self-destructive, should remain on the unit and the health care
provider should be notified (F). Signing a release form (A) before leaving the
hospital does not contribute to safety. The nurse may ask the client not to leave the
hospital (B), but pressuri ng clients is unethical behavior. (E) may be helpful at a
later time in this client's treatment program.
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Which assessment finding indicates that nystatin (Mycostatin) swish and swallow,
prescribed for a client with oral candidiasis, has been effective?
A.The client denies dysphagia.
B.The client is afebrile with warm and dry skin.
C.The oral mucosa is pink and intact.
D.There is no reflux following food intake. - ANSWER - C
Rationale : Mycostatin swish and swallow is prescribed for its local effect on the
oral mucosa, reducing the white curdlike lesions in the mouth and larynx (C). The
ability to swallow (A) does not indicate that the medication has been effective. (B
and D) do not refle ct effectiveness of the local medication.
Because of census overload, the charge nurse of an acute care medical unit must
select a client who can be transferred back to a residential facility. The client with
which symptomology is the most stable?
A.A stage 3 sacral pressure ulcer, with colonized methicillin -resistant
Staphylococcus aureus (MRSA)
B.Pneumonia, with a sputum culture of gram -negative bacteria
C.Urinary tract infection, with positive blood cultures
D.Culture of a diabetic foot ulcer shows gram -positive cocci - ANSWER - A
Rationale: The client with colonized MRSA (A) is the most stable client, because
colonization does not cause symptomatic disease. The gram -negative organisms
causing pneumonia are typically resistant to drug therapy (B), which makes
recovery very difficult. Positive blood cultures (C) indicate a systemic infection.
Poor circulation places the diabetic with an infected ulcer (D) at high risk for poor
healing and bone infection.
An older client who resides in a long -term care facility is hearing -impaired. How
should the nurse modify interventions for this client?
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A.Turn off the client's television and speak very loudly.
B.Communicate in writing whenever it is possible.
C.Speak very slowly while exaggerating each word.
D.Face the client and speak in a normal tone of voice. - ANSWER - D
Rationale: A hearing -impaired client frequently relies on lip reading and body
language to determine what is being said, so (D) should be implemented. (A and
C) may distort the sounds and facial expressions, which alters the client's ability to
interpret the verbal m essage. Communicating in writing is another option that
could be used if verbal or body language is ineffective (B).
The health care provider prescribes 1000 mL of Ringer's lactate solution with 30
units of oxytocin (Pitocin) to infuse over 4 hours for a client who has just delivered
a 10-lb infant by cesarean section. The tubing has been changed to a 20 gtt/mL
administr ation set. The nurse should set the flow rate at how many gtt/min?
A.42
B.83
C.125
D.250 - ANSWER - B
Rationale : Use the following calculation (B):
The RN is caring for a client who is in skeletal traction. Which activity should the
RN assign to the PN?
A.Assess skeletal pins for infection. Powered by TCPDF (www.tcpdf.org)
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