HESI RN
RN HESI Exit Exam Capstone
1. A client with cirrhosis is admitted with jaundice, fatigue, and a distended abdomen. Which laboratory result is most important for the nurse to monitor?
- A. Ammonia level
- B. White blood cell count
- C. Albumin level
- D. Hemoglobin level
Correct answer: A
Rationale: Corrected Rationale: In clients with cirrhosis, elevated ammonia levels can lead to hepatic encephalopathy, which is a serious complication. Monitoring ammonia levels is crucial to assess for changes in mental status and initiate treatment if needed. White blood cell count (choice B) is not the most important parameter to monitor in this scenario as it does not directly relate to the complications of cirrhosis. Albumin level (choice C) and hemoglobin level (choice D) are also important in cirrhosis, but in this case, monitoring ammonia level takes precedence due to its direct association with hepatic encephalopathy.
2. A client is being discharged following a cystectomy and urinary diversion. What is the most important instruction for the nurse to provide?
- A. Avoid lifting heavy objects for six weeks.
- B. Report any signs of cloudy urine output.
- C. Drink 8 glasses of water a day.
- D. Monitor for signs of infection at the surgical site.
Correct answer: B
Rationale: The most important instruction for the nurse to provide to a client following a cystectomy and urinary diversion is to report any signs of cloudy urine output. Cloudy urine may indicate infection, which is a serious concern in clients with a urinary diversion. Instructing the client to report any signs of infection immediately is crucial to prevent complications. Avoiding heavy lifting is important for postoperative recovery but not as critical as identifying a potential infection. Drinking an adequate amount of water is generally beneficial for health but not the most crucial instruction in this scenario. While monitoring for signs of infection at the surgical site is essential, cloudy urine is a more specific and immediate indicator of a potential problem in clients with urinary diversions.
3. Following a lumbar puncture, a client complains of worsening headache when sitting up. What complication is the client likely experiencing?
- A. A migraine headache
- B. An infection from the puncture site
- C. Low blood sugar
- D. Spinal fluid leakage (post-lumbar puncture headache)
Correct answer: D
Rationale: The client is likely experiencing spinal fluid leakage (post-lumbar puncture headache), a common complication of a lumbar puncture. This leakage results in a reduction of cerebrospinal fluid volume around the brain and spinal cord, leading to a headache that worsens when in an upright position due to reduced buoyancy. A migraine headache (Choice A) is not typically associated with a lumbar puncture. Infection from the puncture site (Choice B) would present with localized signs of inflammation, such as redness, swelling, and warmth, rather than worsening headache. Low blood sugar (Choice C) is not a common complication of lumbar puncture and would not typically manifest as a worsening headache when sitting up.
4. A client admitted to the ICU with Syndrome of Inappropriate Antidiuretic Hormone (SIADH) has developed osmotic demyelination. What is the first intervention the nurse should implement?
- A. Evaluate the client's swallowing ability.
- B. Reorient the client frequently.
- C. Patch one eye to minimize confusion.
- D. Perform range of motion exercises.
Correct answer: A
Rationale: The correct answer is to evaluate the client's swallowing ability. Osmotic demyelination can cause dysphagia, putting the client at risk for aspiration. Assessing swallowing function is crucial to prevent complications such as aspiration pneumonia. Reorienting the client frequently (Choice B) is more suitable for confusion related to conditions like delirium. Patching one eye (Choice C) is a technique used for diplopia or double vision, not specifically indicated for osmotic demyelination. Performing range of motion exercises (Choice D) may be beneficial for preventing complications of immobility but is not the priority intervention for osmotic demyelination.
5. The nurse is assessing a client with a new diagnosis of hyperthyroidism. Which assessment finding should the nurse expect?
- A. Decreased heart rate
- B. Increased appetite
- C. Cold intolerance
- D. Weight gain
Correct answer: B
Rationale: In hyperthyroidism, there is an increase in metabolism, leading to symptoms such as increased appetite, weight loss, and heat intolerance. Therefore, the nurse should expect an increased appetite in a client with hyperthyroidism. Choices A, C, and D are incorrect because decreased heart rate and cold intolerance are more commonly associated with hypothyroidism, while weight gain is not typically seen in hyperthyroidism.
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