HESI RN
HESI RN Exit Exam Capstone
1. A client is scheduled for a colonoscopy. Which preparation is the most important for the nurse to implement?
- A. Administer an enema before the procedure.
- B. Ensure the client is NPO after midnight.
- C. Encourage the client to drink clear liquids.
- D. Verify the client has completed the bowel preparation.
Correct answer: D
Rationale: The correct answer is to verify that the client has completed the bowel preparation. This step is crucial to ensure the colon is clear for accurate visualization during the procedure. Administering an enema before the procedure may not always be necessary and can be uncomfortable for the client. Ensuring the client is NPO after midnight is important, but verifying bowel preparation takes precedence. Encouraging the client to drink clear liquids is a part of the preparation process but not the most critical step compared to verifying completion of bowel preparation.
2. A client with diabetes mellitus is experiencing diabetic ketoacidosis (DKA). What laboratory result should the nurse monitor closely?
- A. White blood cell count of 15,000.
- B. Blood glucose level of 320 mg/dL.
- C. Sodium level of 145 mEq/L.
- D. Serum creatinine level of 1.0 mg/dL.
Correct answer: B
Rationale: A blood glucose level of 320 mg/dL indicates the need for insulin to manage diabetic ketoacidosis.
3. The psychiatric nurse is caring for clients in an adolescent unit. Which client requires the nurse's immediate attention?
- A. A 17-year-old client with schizophrenia who is pacing the hallways
- B. An 18-year-old client with antisocial behavior who is being yelled at by other clients
- C. A 16-year-old client with depression who refuses to eat meals
- D. A 15-year-old client with anxiety who is quietly reading in a corner
Correct answer: B
Rationale: The client with antisocial behavior being yelled at by peers may escalate the situation, potentially leading to violence or self-harm. Addressing the situation quickly helps prevent harm and de-escalates the conflict. Choices A, C, and D do not present immediate risks that require urgent intervention compared to the potential danger of a conflict escalating to violence with the client exhibiting antisocial behavior.
4. The nurse has received funding to design a health promotion project for African American women who are at risk for developing breast cancer. Which resource is most important in designing this program?
- A. Participation of community leaders in planning the program
- B. Latest research on breast cancer risk factors
- C. Partnership with local healthcare providers
- D. Health surveys of African American women in the community
Correct answer: A
Rationale: The most important resource in designing a health promotion project for African American women at risk for breast cancer is the participation of community leaders in planning the program. Involving community leaders helps ensure that the program is culturally relevant, addresses the specific needs of the target population, and fosters trust and engagement. While the latest research on breast cancer risk factors, partnership with local healthcare providers, and health surveys of African American women are valuable resources, they are not as crucial as community involvement for tailoring the program effectively.
5. Which client is at greatest risk for developing delirium?
- A. An adult client who cannot sleep due to pain.
- B. An older client who attempted suicide 1 month ago.
- C. A young adult taking antipsychotic medications twice daily.
- D. A middle-aged woman using supplemental oxygen.
Correct answer: B
Rationale: The correct answer is B. Older adults who have attempted suicide are at higher risk for developing delirium, especially in the context of underlying mental health conditions. Choice A is incorrect as sleep disturbances due to pain may lead to discomfort but not necessarily delirium. Choice C is incorrect as taking antipsychotic medications, if managed well, does not inherently increase the risk of delirium. Choice D is incorrect as using supplemental oxygen alone does not significantly increase the risk of developing delirium.
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