HESI RN
HESI RN Exit Exam 2024 Capstone
1. A child is admitted with bacterial meningitis. What assessment finding should the nurse monitor most closely?
- A. Monitor the client’s skin for rash and lesions.
- B. Monitor for signs of increased intracranial pressure.
- C. Monitor the client’s blood pressure closely.
- D. Monitor for changes in heart rate and rhythm.
Correct answer: B
Rationale: Correct Answer: B. Signs of increased intracranial pressure, such as changes in consciousness or pupil reactivity, are critical to monitor in children with bacterial meningitis to prevent complications. Monitoring the client’s skin for rash and lesions (Choice A) is not the priority in bacterial meningitis. While monitoring blood pressure (Choice C) is important, signs of increased intracranial pressure take precedence. Monitoring for changes in heart rate and rhythm (Choice D) is less specific to the condition and may not indicate worsening neurological status.
2. The RN is admitting a male client who takes lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately?
- A. Short-term memory loss.
- B. Five-pound weight gain.
- C. Decreased affect.
- D. Nausea and vomiting.
Correct answer: D
Rationale: Nausea and vomiting are signs of potential lithium toxicity, which is a serious condition requiring immediate attention. These symptoms can indicate a dangerous level of lithium in the body that can lead to severe complications. Short-term memory loss (A), five-pound weight gain (B), and decreased affect (C) are important to monitor but are not as immediately concerning as symptoms of potential toxicity like nausea and vomiting.
3. A client with renal calculi is being assessed by a nurse. Which question should the nurse ask?
- A. Is there a family history of this problem?
- B. Do you consume cranberry juice?
- C. Do you urinate after sexual intercourse?
- D. Do you have burning sensation during urination?
Correct answer: A
Rationale: When assessing a client with renal calculi, it is important for the nurse to inquire about a family history of the problem. There is a genetic predisposition associated with renal stone formation, making it essential to assess if other family members have experienced renal stones. Choices B, C, and D are not directly related to renal calculi. Consuming cranberry juice is more relevant to urinary tract health, urinating after sexual intercourse is related to preventing urinary tract infections, and experiencing a burning sensation during urination is a symptom commonly associated with urinary tract infections, not renal calculi.
4. The client is scheduled to begin continuous ambulatory peritoneal dialysis (CAPD). Which of the following statements by the client indicates that more teaching is required?
- A. I will need to limit my intake of protein.
- B. I can skip a dialysis session if I feel tired.
- C. I should increase my intake of potassium-rich foods.
- D. I can eat whatever I want, as long as I take my medications.
Correct answer: B
Rationale: The correct answer is B. Skipping a dialysis session can lead to serious complications as it disrupts the treatment schedule and can result in the accumulation of waste products and fluid in the body. The client must understand the importance of adhering to the prescribed dialysis regimen to maintain optimal health. Choices A, C, and D are incorrect because limiting protein intake, increasing potassium-rich foods, and taking medications do not pose the same risk as skipping dialysis sessions. These aspects are important in the management of peritoneal dialysis but do not outweigh the critical need for regular dialysis sessions to prevent complications.
5. A client with a history of deep vein thrombosis (DVT) is prescribed warfarin. Which laboratory value should the nurse monitor to assess the therapeutic effect of this medication?
- A. Platelet count
- B. Prothrombin time (PT)
- C. White blood cell count
- D. Hemoglobin level
Correct answer: B
Rationale: Prothrombin time (PT) is the correct laboratory value to monitor to assess the therapeutic effect of warfarin. Warfarin works by inhibiting clotting factors, and PT measures the time it takes for blood to clot. Monitoring PT helps ensure that the medication is working effectively to prevent clot formation without causing excessive bleeding. Platelet count (Choice A) is not specific to warfarin therapy and assesses the number of platelets in the blood. White blood cell count (Choice C) and hemoglobin level (Choice D) are not directly related to monitoring the therapeutic effect of warfarin.