HESI RN
HESI RN Exit Exam Capstone
1. A client with type 1 diabetes mellitus is admitted to the emergency department with confusion, sweating, and a blood sugar level of 45 mg/dL. What is the nurse's priority action?
- A. Administer 50% dextrose IV push
- B. Provide a carbohydrate snack
- C. Check the client's urine for ketones
- D. Start an insulin drip
Correct answer: A
Rationale: A blood sugar level of 45 mg/dL indicates severe hypoglycemia, which can lead to life-threatening complications if not treated immediately. The priority is to administer IV dextrose to rapidly increase the blood sugar level. Administering 50% dextrose IV push will provide a quick source of glucose to raise the blood sugar. Providing a carbohydrate snack is not the immediate priority in this critical situation. Checking the client's urine for ketones is important in diabetic ketoacidosis, not for hypoglycemia. Starting an insulin drip would further lower the blood sugar and worsen the client's condition.
2. A client with hyperthyroidism is admitted for total thyroidectomy. What is the nurse's priority post-operative intervention?
- A. Monitor the client's calcium levels for hypocalcemia.
- B. Monitor for signs of respiratory distress.
- C. Administer oral calcium supplements.
- D. Elevate the head of the bed to 45 degrees.
Correct answer: A
Rationale: The correct answer is to monitor the client's calcium levels for hypocalcemia. After a total thyroidectomy, there is a risk of accidental removal or damage to the parathyroid glands, leading to hypocalcemia. This complication can manifest within the first 24-48 hours post-op. Monitoring calcium levels is crucial to prevent serious complications such as tetany or seizures. While monitoring for respiratory distress is important, it is not the priority in this case. Administering oral calcium supplements should only be done based on the healthcare provider's prescription and after assessing the client's calcium levels. Elevating the head of the bed to 45 degrees is beneficial for respiratory function but is not the priority intervention for a client at risk for hypocalcemia post-thyroidectomy.
3. The nurse is caring for a preterm newborn with nasal flaring, grunting, and sternal retractions. After administering surfactant, which assessment is most important for the nurse to monitor?
- A. Bowel sounds
- B. Heart rate
- C. Arterial blood gases
- D. Apnea episodes
Correct answer: C
Rationale: Corrected Rationale: Surfactant therapy is used to improve lung function and gas exchange in premature infants with respiratory distress. Monitoring arterial blood gases is essential to assess the effectiveness of the treatment and ensure adequate oxygenation. While monitoring heart rate is important in neonatal care, assessing arterial blood gases will provide direct information regarding the infant's oxygenation status post-surfactant administration. Bowel sounds are not directly related to the respiratory distress symptoms described, and monitoring apnea episodes, although important in preterm infants, is not the most crucial assessment immediately following surfactant administration.
4. A postoperative client with a history of diabetes mellitus is showing signs of hyperglycemia. What should the nurse assess first?
- A. Assess for signs of infection.
- B. Monitor the client’s fluid intake and output.
- C. Check the client’s capillary blood glucose level.
- D. Assess the client’s serum potassium level.
Correct answer: C
Rationale: The correct answer is to check the client’s capillary blood glucose level first. In a postoperative client with a history of diabetes mellitus showing signs of hyperglycemia, assessing blood glucose levels is crucial to confirm hyperglycemia and initiate appropriate interventions. While signs of infection are important to assess due to the client's postoperative status and diabetic history, checking the blood glucose level takes precedence to address the immediate concern of hyperglycemia. Monitoring fluid intake and output is essential but not the priority in this scenario. Assessing the client’s serum potassium level is important for overall assessment but not the initial step when hyperglycemia is suspected.
5. A 5-week-old infant who developed projectile vomiting over the last two weeks is diagnosed with hypertrophic pyloric stenosis. Which intervention should the nurse plan to implement?
- A. Instruct the mother to give the child sugar water only.
- B. Offer oral rehydration solution every 2 hours.
- C. Provide Pedialyte feedings via nasogastric tube.
- D. Maintain intravenous fluid therapy per prescription.
Correct answer: D
Rationale: The correct intervention for a 5-week-old infant diagnosed with hypertrophic pyloric stenosis and experiencing projectile vomiting is to maintain intravenous fluid therapy. Intravenous fluids are crucial for rehydrating an infant suffering from dehydration due to rapid fluid loss from vomiting. Instructing the mother to provide sugar water only (choice A) is inappropriate and insufficient for rehydration. Offering oral rehydration solution every 2 hours (choice B) may not be effective if the infant continues to vomit. Providing Pedialyte feedings via nasogastric tube (choice C) may also not be as effective as intravenous fluid therapy in rapidly replenishing fluids and stabilizing the child's condition.
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