HESI RN
HESI 799 RN Exit Exam Capstone
1. An unresponsive male victim of a diving accident is brought to the emergency department where immediate surgery is required to save his life. No family members are available. What action should the nurse take first?
- A. Ask the friend to sign an informed consent.
- B. Notify the unit manager that a court order is needed.
- C. Continue providing life support until a guardian is found.
- D. Proceed with surgery preparation without consent.
Correct answer: D
Rationale: In emergency situations where immediate surgery is required to save a patient's life and no family members are available, consent can be waived to proceed with necessary interventions. The priority in this scenario is to proceed with surgery preparation without waiting for consent, as any delay could jeopardize the patient's life. Asking the friend to sign informed consent or notifying the unit manager for a court order would cause unnecessary delays, which are not advisable in this critical situation. Continuing life support until a guardian is found is not the most appropriate action when immediate surgical intervention is necessary.
2. A client with multiple sclerosis is receiving intravenous methylprednisolone. What is the nurse's priority action?
- A. Monitor blood glucose levels every 6 hours.
- B. Monitor for signs of infection.
- C. Encourage increased oral fluid intake.
- D. Check the client's temperature every 4 hours.
Correct answer: B
Rationale: When a client with multiple sclerosis is receiving intravenous methylprednisolone, the nurse's priority action is to monitor for signs of infection. Corticosteroids like methylprednisolone can suppress the immune system, increasing the risk of infection. Monitoring for signs of infection allows for early detection and prompt intervention. Monitoring blood glucose levels may be important in clients receiving corticosteroids for prolonged periods, but it is not the priority in this case. Encouraging increased oral fluid intake is generally beneficial but not the priority over monitoring for infection. Checking the client's temperature is important but not the priority action compared to monitoring for signs of infection.
3. Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel, a platelet inhibitor, to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's care plan?
- A. Check platelet count
- B. Observe the color of urine
- C. Review liver function tests
- D. Monitor for bleeding
Correct answer: D
Rationale: Prasugrel is a platelet inhibitor, which increases the risk of bleeding. Monitoring for bleeding, particularly at the catheterization site and in other areas, is the most important assessment following administration of the drug. Checking platelet count and observing urine color are relevant but not as immediate. Reviewing liver function tests is not directly related to the adverse effects of prasugrel.
4. A client with myasthenia gravis (MG) is receiving immunosuppressive therapy. Recent lab tests show decreased serum magnesium. What nursing action is most important?
- A. Observe rhythm on telemetry monitor.
- B. Check for visual difficulties.
- C. Assess for hip and hand joint pain.
- D. Note the most recent hemoglobin level.
Correct answer: A
Rationale: Magnesium plays a crucial role in maintaining normal cardiac rhythms, particularly in patients with cardiac conditions. Abnormal levels can lead to arrhythmias, which is why continuous monitoring of the heart's electrical activity is important. Magnesium's effect on neuromuscular and cardiac function makes it essential to monitor its levels, and any discrepancies can impact treatment decisions. Checking for visual difficulties (choice B) may be important in MG but is not the priority in the context of decreased serum magnesium. Assessing for hip and hand joint pain (choice C) is not directly related to the issue of decreased serum magnesium. Noting the most recent hemoglobin level (choice D) is not the priority in this situation compared to monitoring the cardiac rhythm due to low magnesium levels.
5. A client with anxiety disorder is experiencing increased anxiety prior to vaginal delivery. What should the nurse’s initial action be?
- A. Increase the client's sedative dose
- B. Encourage the client to express her feelings and provide emotional support
- C. Initiate breathing techniques to manage anxiety
- D. Administer anxiolytic medication to calm the client
Correct answer: B
Rationale: The correct initial action for a client with anxiety disorder experiencing increased anxiety prior to vaginal delivery is to encourage the client to express her feelings and provide emotional support. Emotional support is crucial in reducing anxiety during childbirth. Initiating breathing techniques or administering medications should come after emotional support has been provided. Increasing sedative doses may not address the underlying emotional needs of the client and can have potential risks.
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