HESI RN
HESI 799 RN Exit Exam Capstone
1. A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client's mental status and adjustment. The appropriate response of the nurse should be which of these statements?
- A. I am sorry. Referral information can only be provided by the client's health care providers.
- B. I can never give any information out by telephone. How do I know who you are?
- C. Since this is a referral, I can give you this information.
- D. I need to get the client's written consent before I release any information to you.
Correct answer: D
Rationale: The correct answer is D: "I need to get the client's written consent before I release any information to you." In this scenario, the nurse must obtain the client's written consent before disclosing any information to the social worker. This process ensures compliance with privacy laws like HIPAA, which are designed to protect client confidentiality. Choice A is incorrect because it does not address the need for consent. Choice B is incorrect as it is unprofessional and does not focus on obtaining consent. Choice C is incorrect as it suggests information can be shared without consent, which goes against privacy laws.
2. Each breast is situated on each side of the sternum and extends between the:
- A. 1st and 6th rib
- B. 2nd and 6th rib
- C. 3rd and 6th rib
- D. 4th and 6th rib
Correct answer: B
Rationale: The correct answer is B: 2nd and 6th rib. Each breast is situated between the 2nd and 6th ribs. This anatomical location is important for understanding breast examination techniques and identifying potential abnormalities. Choices A, C, and D are incorrect because the breasts do not extend as far as the 1st, 3rd, or 4th rib, respectively. Understanding the precise anatomical location of structures is crucial in healthcare to ensure accurate assessments and interventions.
3. The nurse observes that a client’s wrist restraint is secured to the side rail of the bed. What action should the nurse take?
- A. Ensure that the restraint is snug against the client’s wrist.
- B. Reposition the restraint tie onto the bedframe.
- C. Double knot the restraint to ensure safety.
- D. Leave the restraint in place and notify the healthcare provider.
Correct answer: B
Rationale: The correct action for the nurse to take is to reposition the restraint tie onto the bedframe. Restraints should always be secured to the bedframe, not the side rails, to prevent injury to the client in case the bed is adjusted. Choice A is incorrect because the issue is with the attachment point, not the snugness of the restraint. Choice C is incorrect as double knotting the restraint does not address the incorrect attachment point. Choice D is incorrect as the nurse should not leave the restraint in the wrong position; instead, it should be moved to the correct location on the bedframe.
4. A nurse assesses a client who is recovering from a radical nephrectomy for renal cell carcinoma. The nurse notes that the client’s blood pressure has decreased from 134/90 to 100/56 mm Hg and urine output is 20 mL for this past hour. Which action should the nurse take?
- A. Position the client to lay on the surgical incision.
- B. Measure the specific gravity of the client’s urine.
- C. Administer intravenous pain medications.
- D. Assess the rate and quality of the client’s pulse.
Correct answer: D
Rationale: The nurse should first fully assess the client for signs of volume depletion and shock, and then notify the provider. The radical nature of the surgery and the proximity of the surgery to the adrenal gland put the client at risk for hemorrhage and adrenal insufficiency. Hypotension is a clinical manifestation associated with both hemorrhage and adrenal insufficiency. Hypotension is particularly dangerous for the remaining kidney, which must receive adequate perfusion to function effectively. Re-positioning the client, measuring specific gravity, and administering pain medication would not provide data necessary to make an appropriate clinical decision, nor are they appropriate interventions at this time.
5. A male client who has been taking propranolol (Inderal) for 18 months tells the nurse the healthcare provider discontinued the medication because his blood pressure has been normal for the past three months. Which instruction should the nurse provide?
- A. Abruptly stop the medication.
- B. Continue the medication at the same dose.
- C. Ask the healthcare provider about tapering the drug dose over the next week.
- D. Increase the dose of the medication.
Correct answer: C
Rationale: Gradually tapering the dose over one to two weeks should be recommended to prevent rebound tachycardia, hypertension, and ventricular dysrhythmias.