HESI RN
HESI RN Exit Exam Capstone
1. 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.
2. A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take priority in planning care?
- A. Esophagitis
- B. Leukopenia
- C. Fatigue
- D. Skin irritation
Correct answer: B
Rationale: The correct answer is B: Leukopenia. Leukopenia, or a low white blood cell count, is a critical concern in clients undergoing radiation therapy due to the increased risk of infection. While esophagitis, fatigue, and skin irritation are also potential side effects of radiation therapy, leukopenia poses a higher risk as it compromises the body's ability to fight infections effectively.
3. The nurse is caring for a client with pancreatitis who is receiving total parenteral nutrition (TPN). Which assessment finding requires immediate intervention by the nurse?
- A. Blood glucose level of 200 mg/dL
- B. The client reports feeling weak and shaky
- C. The TPN bag is 5% dextrose
- D. The client reports feeling thirsty
Correct answer: B
Rationale: The correct answer is B. Weakness and shakiness can indicate hypoglycemia, a potential complication of TPN. Immediate intervention is necessary to assess blood glucose levels and provide treatment as needed. Choice A is incorrect because a blood glucose level of 200 mg/dL is within an acceptable range and does not require immediate intervention. Choice C is incorrect as a 5% dextrose TPN bag is a standard concentration. Choice D is also incorrect as feeling thirsty is not a critical assessment finding requiring immediate intervention in this context.
4. While changing a client's chest tube dressing, the nurse notes a cracking sensation when gentle pressure is applied to the skin at the insertion site. What should the nurse do next?
- A. Apply a pressure dressing at the chest tube site.
- B. Administer an oral antihistamine per PRN order.
- C. Assess the client for allergies to topical cleaning agents.
- D. Measure the area of crackling and swelling.
Correct answer: D
Rationale: Measuring the area of crackling and swelling is essential in monitoring the progression of subcutaneous emphysema, which can result from air leaking into the tissues around the chest tube insertion site. This technique helps evaluate the extent of the issue and guides further interventions. Applying a pressure dressing (choice A) might exacerbate the condition by trapping more air. Administering an oral antihistamine (choice B) is not indicated for subcutaneous emphysema. Assessing for allergies to topical cleaning agents (choice C) is not the priority in this situation compared to evaluating and managing the subcutaneous emphysema.
5. A client with a recent myocardial infarction is prescribed a beta-blocker. What side effect should the nurse monitor for?
- A. Monitor the client for bradycardia.
- B. Check the client’s blood pressure for signs of hypotension.
- C. Monitor the client for signs of hyperglycemia.
- D. Monitor for signs of fluid retention.
Correct answer: B
Rationale: The correct answer is B: 'Check the client’s blood pressure for signs of hypotension.' Beta-blockers can lead to decreased heart rate, but bradycardia is not the primary side effect to monitor. Monitoring for bradycardia is more relevant when administering medications like digoxin. Hyperglycemia is associated with medications like corticosteroids, not beta-blockers. Fluid retention is a side effect seen with medications like corticosteroids or calcium channel blockers, not beta-blockers. Therefore, in a client taking a beta-blocker after a myocardial infarction, monitoring for hypotension is crucial due to the medication's mechanism of action.
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