HESI RN
HESI 799 RN Exit Exam Capstone
1. An antibiotic IM injection for a 2-year-old child is ordered. The total volume of the injection equals 2.0 ml. The correct action is to
- A. Administer the medication in 2 separate injections
- B. Give the medication in the dorsal gluteal site
- C. Call to get a smaller volume ordered
- D. Check with the pharmacy for a liquid form of the medication
Correct answer: A
Rationale: Injections over 1 mL should be split into two separate injections for young children. This helps in preventing discomfort, ensuring proper absorption, and reducing the risk of tissue damage. Giving the medication in one injection of 2.0 ml might be too much for a 2-year-old child. Choices B and D are incorrect because the dorsal gluteal site is not recommended for children due to potential injury, and changing the form of medication might not be necessary if the volume can be adjusted. Choice C is unnecessary as splitting the dose into two injections is the appropriate action.
2. The nurse is caring for a client with an indwelling urinary catheter. Which of the following actions should the nurse prioritize to prevent infection?
- A. Maintain a closed drainage system
- B. Cleanse the catheter insertion site daily
- C. Increase the client's fluid intake
- D. Empty the collection bag every 4 hours
Correct answer: A
Rationale: The correct answer is to maintain a closed drainage system. This action is crucial in preventing infection as it helps prevent bacteria from entering the urinary tract. While cleansing the catheter insertion site and ensuring adequate hydration are important aspects of catheter care, the top priority is maintaining the integrity of the closed system to prevent infection. Emptying the collection bag regularly is also important but not as critical as ensuring a closed drainage system to minimize infection risk.
3. The nurse is planning care for a client with a venous leg ulcer. Which intervention should the nurse include in the plan of care to promote healing?
- A. Apply compression therapy to the affected leg
- B. Keep the affected leg in a dependent position
- C. Massage the area surrounding the ulcer
- D. Encourage the client to elevate the leg for 2 hours daily
Correct answer: A
Rationale: Compression therapy is essential for managing venous leg ulcers as it helps improve venous return, reduces edema, and promotes healing. By applying compression therapy to the affected leg, the nurse can assist in enhancing circulation, reducing swelling, and aiding in the healing process. Keeping the affected leg in a dependent position can worsen venous insufficiency. Massaging the area surrounding the ulcer is contraindicated as it can cause further damage and delay healing. While encouraging the client to elevate the leg is beneficial, it is not as effective as compression therapy for promoting healing in venous leg ulcers.
4. A client with type 2 diabetes mellitus arrives at the clinic reporting episodes of weakness and palpitations. Which finding should the nurse identify may indicate an emerging situation?
- A. History of hypertension
- B. Fingertips feel numb
- C. Reduced deep tendon reflexes
- D. Elevated fasting blood glucose level
Correct answer: B
Rationale: Numb fingertips may suggest neuropathy, a common complication of diabetes that may indicate a worsening condition. Episodes of weakness and palpitations, combined with neuropathy symptoms, could also suggest hypoglycemia or poor glycemic control, requiring further investigation. The other choices are less likely to be directly related to the client's current symptoms. While a history of hypertension is a common comorbidity in clients with diabetes, it may not directly explain the reported weakness and palpitations. Reduced deep tendon reflexes are more indicative of certain neurological conditions rather than acute emerging situations related to the client's current symptoms. An elevated fasting blood glucose level is expected in a client with type 2 diabetes and may not be the primary indicator of an emerging situation in this context.
5. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up?
- A. Increased appetite
- B. Describes life without purpose
- C. Exhibits mood swings
- D. Complains of insomnia
Correct answer: B
Rationale: An adolescent expressing 'life without purpose' after taking duloxetine (Cymbalta) may be indicating suicidal ideation, which requires immediate attention. The initial period of antidepressant treatment can increase the risk of suicidal thoughts, especially in younger populations. Increased appetite (Choice A) is a common side effect of duloxetine and may not require immediate follow-up. Mood swings (Choice C) and insomnia (Choice D) are also possible side effects of the medication but are not as urgent as addressing suicidal ideation.
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