HESI RN
HESI Exit Exam RN Capstone
1. The healthcare provider is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the healthcare provider?
- A. Breath sounds are audible bilaterally
- B. Mist is visible in the T-piece
- C. Pulse oximetry of 88
- D. Client is unable to verbalize
Correct answer: C
Rationale: A pulse oximetry reading of 88 indicates hypoxia, which is a serious condition requiring immediate intervention. Adequate oxygenation is crucial for the client's well-being. Choices A and B are normal findings after endotracheal intubation. Hearing bilateral breath sounds and seeing mist in the T-piece indicate proper functioning of the endotracheal tube. While choice D may indicate an issue with speaking due to the endotracheal tube, it is not as critical as the hypoxia indicated by the low pulse oximetry reading.
2. A client with end-stage pulmonary disease requests 'no heroic measures' if she stops breathing. What should the nurse do next?
- A. Document the client's request in the medical record.
- B. Ask the client to discuss a DNR order with her healthcare provider.
- C. Consult the ethics committee for guidance.
- D. Discharge the client with no further discussion.
Correct answer: B
Rationale: The correct next step for the nurse is to ask the client to discuss a 'do not resuscitate' (DNR) order with her healthcare provider. While the client's wishes should be respected, it is essential to ensure proper documentation and legal protection by involving the healthcare provider in this decision-making process. Documenting the request in the medical record (Choice A) is important but should follow the discussion with the healthcare provider. Consulting the ethics committee (Choice C) may not be necessary at this stage and could delay the necessary actions. Discharging the client (Choice D) without further discussion is not appropriate and disregards the importance of addressing the client's wishes in a respectful and professional manner.
3. A client with cirrhosis is prescribed spironolactone to manage ascites. Which serum laboratory value is most important for the nurse to monitor?
- A. Sodium
- B. Calcium
- C. Magnesium
- D. Potassium
Correct answer: D
Rationale: The correct answer is D: Potassium. Spironolactone is a potassium-sparing diuretic, which can lead to hyperkalemia. Monitoring potassium levels is crucial to prevent complications like cardiac arrhythmias. Choices A, B, and C are incorrect because sodium, calcium, and magnesium levels are not directly affected by spironolactone use for managing ascites in cirrhosis.
4. A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents?
- A. Regression in toileting may indicate a neurological complication
- B. The hospital staff can assist with toilet training efforts
- C. It is common for children to regress in toileting during hospital stays
- D. A potty chair should be brought from home so he can maintain his toileting skills
Correct answer: C
Rationale: When children are hospitalized, it is common for them to regress in toileting behaviors due to the unfamiliar environment and stress. It is important for the nurse to provide reassurance to the parents in such situations. Option A is incorrect because suggesting neurological complications without evidence could cause unnecessary alarm. Option B is not the most appropriate response as the focus should be on explaining the common regression in toileting. Option D may not address the underlying reasons for the regression and may not be practical during the hospital stay.
5. The nurse is providing care for a client receiving total parenteral nutrition (TPN). Which action should the nurse include in the client's plan of care?
- A. Increase the TPN infusion rate if the client is hungry
- B. Administer TPN via a peripheral IV line
- C. Monitor blood glucose levels regularly
- D. Ensure the TPN solution is refrigerated at all times
Correct answer: C
Rationale: The correct action the nurse should include in the client's plan of care is to monitor blood glucose levels regularly. Clients receiving TPN are at risk for hyperglycemia due to the high glucose content of the solution. Regular monitoring of blood glucose levels is essential to ensure appropriate management of blood sugar. Choice A is incorrect because increasing the TPN infusion rate based on hunger is not a valid parameter for adjusting TPN. Choice B is incorrect because TPN should be administered through a central line, not a peripheral IV line, to prevent complications. Choice D is incorrect because TPN solutions should be stored at room temperature, not refrigerated.
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