HESI RN
HESI RN Exit Exam Capstone
1. A client is newly prescribed lithium for bipolar disorder. Which finding is most important to report to the healthcare provider?
- A. A serum lithium level of 1.2 mEq/L.
- B. Fine hand tremors noted after starting the medication.
- C. A blood pressure of 110/60 mmHg.
- D. A serum sodium level of 140 mEq/L.
Correct answer: B
Rationale: The correct answer is B. Fine hand tremors noted after starting lithium are an early sign of lithium toxicity. It is crucial to report this finding to the healthcare provider promptly. Adjusting the dose or monitoring serum levels more closely may be necessary to prevent further toxicity. Choice A, a serum lithium level of 1.2 mEq/L, is within the therapeutic range (0.6-1.2 mEq/L) for treating bipolar disorder. Choice C, a blood pressure of 110/60 mmHg, and Choice D, a serum sodium level of 140 mEq/L, are within normal limits and not directly related to lithium therapy or toxicity.
2. A client is receiving a blood transfusion and reports feeling chilled and short of breath. What is the nurse's priority action?
- A. Stop the transfusion and notify the healthcare provider.
- B. Administer an antihistamine as prescribed.
- C. Administer a dose of acetaminophen.
- D. Administer a PRN dose of diphenhydramine.
Correct answer: A
Rationale: The correct action for the nurse to take when a client receiving a blood transfusion reports feeling chilled and short of breath is to stop the transfusion immediately and notify the healthcare provider. These symptoms could indicate a transfusion reaction, which can be serious and even life-threatening. Stopping the transfusion is crucial to prevent further adverse reactions, and notifying the healthcare provider ensures timely intervention and appropriate management. Administering antihistamines, acetaminophen, or diphenhydramine is not the priority in this situation and may delay necessary actions to address the potential transfusion reaction.
3. A client with heart failure is prescribed spironolactone. What is the nurse's priority intervention?
- A. Monitor the client's potassium levels closely.
- B. Assess for signs of hyperkalemia.
- C. Instruct the client to increase intake of potassium-rich foods.
- D. Increase the client’s fluid intake to prevent dehydration.
Correct answer: B
Rationale: The correct answer is B: Assess for signs of hyperkalemia. Spironolactone is a potassium-sparing diuretic, which can cause hyperkalemia (high potassium levels). Therefore, the nurse's priority intervention should be to assess the client for signs of hyperkalemia, such as muscle weakness, fatigue, and potentially dangerous cardiac arrhythmias. Monitoring potassium levels closely (choice A) is important but assessing for signs of hyperkalemia takes precedence. Instructing the client to increase intake of potassium-rich foods (choice C) can exacerbate hyperkalemia in this case. Increasing the client’s fluid intake to prevent dehydration (choice D) is not directly related to the potential side effect of spironolactone.
4. Where should the healthcare provider consider starting a screening program for hypothyroidism?
- A. A business and professional women’s group.
- B. An African-American senior citizens' center.
- C. A daycare center in a Hispanic neighborhood.
- D. An after-school center for Native American teens.
Correct answer: B
Rationale: An African-American senior citizens' center is the most appropriate location to start a screening program for hypothyroidism. Older adults are at an increased risk of hypothyroidism, and African-Americans are more likely to be underserved in healthcare. Therefore, targeting this group can help in early detection and management of hypothyroidism. The other options, such as a business and professional women’s group, a daycare center in a Hispanic neighborhood, and an after-school center for Native American teens, do not align as closely with the demographic at higher risk for hypothyroidism.
5. 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.
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