HESI RN
HESI RN Exit Exam 2024 Quizlet Capstone
1. A client with hyperthyroidism is admitted to the postoperative unit after a subtotal thyroidectomy. Which of the client's serum laboratory values requires intervention by the nurse?
- A. Blood glucose 90 mg/dL
- B. Sodium 138 mEq/L
- C. Total calcium 5.0 mg/dL
- D. Potassium 4.2 mEq/L
Correct answer: C
Rationale: A total calcium level of 5.0 mg/dL is critically low and indicates possible hypocalcemia, a common complication after thyroid surgery. This condition can lead to tetany and requires immediate intervention. Blood glucose within normal range, sodium, and potassium levels are not indicative of an immediate postoperative complication like hypocalcemia in this case.
2. The nurse is caring for a client with a history of congestive heart failure (CHF) who is receiving digoxin therapy. The client reports seeing halos around lights. Which action should the nurse take?
- A. Assess the client's digoxin level
- B. Increase the client's fluid intake
- C. Check the client's blood pressure
- D. Administer a dose of potassium
Correct answer: A
Rationale: Seeing halos around lights is a classic symptom of digoxin toxicity. The nurse should assess the client's digoxin level to determine if the dose needs to be adjusted or if the medication should be held. Increasing fluid intake or checking blood pressure would not directly address the symptom of halos around lights. Administering a dose of potassium is not indicated without knowing the digoxin level and could potentially worsen the toxicity.
3. Which self-care measure is most important for the nurse to include in the plan of care of a client recently diagnosed with type 2 diabetes mellitus?
- A. Maintaining a low-sugar diet
- B. Foot care
- C. Blood glucose monitoring
- D. Daily exercise
Correct answer: C
Rationale: Blood glucose monitoring is crucial for managing diabetes effectively. By monitoring blood sugar levels, individuals can understand how their lifestyle choices, medications, and diet affect their glucose levels. This information helps in making necessary adjustments to control blood sugar levels and prevent complications. While maintaining a low-sugar diet, foot care, and daily exercise are all important aspects of managing diabetes, blood glucose monitoring takes precedence as it provides real-time data for informed decision-making.
4. The nurse reviews the diagnostic tests prescribed for a client with a positive skin test. Which subjective findings reported by the client support the diagnosis of tuberculosis?
- A. Mucopurulent cough and night sweats
- B. Fatigue and headache
- C. Persistent cough and weight gain
- D. Weight loss and fever
Correct answer: A
Rationale: A mucopurulent cough and night sweats are hallmark signs of active tuberculosis. These symptoms are key indicators of TB as the combination of a productive cough with night sweats is highly suggestive of the disease. Fatigue and headache (choice B) are nonspecific symptoms that can occur in many conditions and are not specific to TB. Persistent cough and weight gain (choice C) are not typical findings in tuberculosis. Weight loss and fever (choice D) can be present in TB, but the specific combination of mucopurulent cough and night sweats is more specific to the diagnosis.
5. A client with emphysema reports shortness of breath. What is the nurse's priority action?
- A. Administer oxygen therapy.
- B. Assess the client’s respiratory rate and effort.
- C. Prepare the client for intubation.
- D. Increase the client's oxygen flow rate.
Correct answer: B
Rationale: Shortness of breath in a client with emphysema may indicate respiratory distress. Assessing the client’s respiratory rate and effort is the first priority to determine the severity of the distress and guide appropriate interventions. Administering oxygen therapy (Choice A) could be necessary, but assessing the client first is crucial to tailor the intervention. Intubation (Choice C) is an invasive procedure that is not the initial priority. Increasing oxygen flow rate (Choice D) should only be done after a thorough assessment to avoid potential harm.
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