Capstone HESI Exit 1
1. 1. Following discharge teaching, a male client with duodenal ulcer tells the nurse
the he will drink plenty of dairy products, such as milk, to help coat and protect his
ulcer. What is the best follow-up action by the nurse Ans: Review with the client the
need to avoid foods that are rich in milk and cream
2. 2. A male client with hypertension, who received new antihypertensive
prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood
pressure (BP). His BP is 158/106 and he admits that he has not been taking the
prescribed medication because the drugs make him "feel bad". In explaining the need
for hypertension control, the nurse should stress that an elevated BP places the client
at risk for which pathophysiological condition Ans: Stroke secondary to hemorrhage
3. 3. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly
admitted client who has a seizure disorder. The client is supine and the UAP is
placing soft pillows along the side rails. What action should the nurse implement Ans:
Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.
4. 4. An adolescent with major depressive disorder has been taking duloxetine
(Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-
up Ans: Describes life without purpose
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, 5. 5. A 60-year-old female client with a positive family history of ovarian cancer has
developed an abdominal mass and is being evaluated for possible ovarian cancer. Her
Papanicolau (Pap) smear results are negative. What information should the nurse
include in the client's teaching plan Ans: Further evaluation involving surgery may be
needed
6. 6. A client who recently underwear a tracheostomy is being prepared for
discharge to home. Which instructions is most important for the nurse to include
in the discharge plan Ans: Teach tracheal suctioning techniques
7. 7. In assessing an adult client with a partial rebreather mask, the nurse notes that the
oxygen reservoir bag does not deflate completely during inspiration and the client's
respiratory rate is 14 breaths / minute. What action should the nurse implement Ans:
Document the assessment data
8. 8. During shift report, the central electrocardiogram (EKG) monitoring sys- tem
alarms. Which client alarm should the nurse investigate firs Ans: Respiratory apnea of
30 seconds
9. 9. During a home visit, the nurse observed an elderly client with diabetes slip and fall.
What action should the nurse take first Ans: Check the client for lacerations or fractures
10. 10. At 0600 while admitting a woman for a schedule repeat cesarean section (C-
Section), the client tells the nurse that she drank a cup a coffee at
2/
10
1. 1. Following discharge teaching, a male client with duodenal ulcer tells the nurse
the he will drink plenty of dairy products, such as milk, to help coat and protect his
ulcer. What is the best follow-up action by the nurse Ans: Review with the client the
need to avoid foods that are rich in milk and cream
2. 2. A male client with hypertension, who received new antihypertensive
prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood
pressure (BP). His BP is 158/106 and he admits that he has not been taking the
prescribed medication because the drugs make him "feel bad". In explaining the need
for hypertension control, the nurse should stress that an elevated BP places the client
at risk for which pathophysiological condition Ans: Stroke secondary to hemorrhage
3. 3. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly
admitted client who has a seizure disorder. The client is supine and the UAP is
placing soft pillows along the side rails. What action should the nurse implement Ans:
Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.
4. 4. An adolescent with major depressive disorder has been taking duloxetine
(Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-
up Ans: Describes life without purpose
1/
10
, 5. 5. A 60-year-old female client with a positive family history of ovarian cancer has
developed an abdominal mass and is being evaluated for possible ovarian cancer. Her
Papanicolau (Pap) smear results are negative. What information should the nurse
include in the client's teaching plan Ans: Further evaluation involving surgery may be
needed
6. 6. A client who recently underwear a tracheostomy is being prepared for
discharge to home. Which instructions is most important for the nurse to include
in the discharge plan Ans: Teach tracheal suctioning techniques
7. 7. In assessing an adult client with a partial rebreather mask, the nurse notes that the
oxygen reservoir bag does not deflate completely during inspiration and the client's
respiratory rate is 14 breaths / minute. What action should the nurse implement Ans:
Document the assessment data
8. 8. During shift report, the central electrocardiogram (EKG) monitoring sys- tem
alarms. Which client alarm should the nurse investigate firs Ans: Respiratory apnea of
30 seconds
9. 9. During a home visit, the nurse observed an elderly client with diabetes slip and fall.
What action should the nurse take first Ans: Check the client for lacerations or fractures
10. 10. At 0600 while admitting a woman for a schedule repeat cesarean section (C-
Section), the client tells the nurse that she drank a cup a coffee at
2/
10
