HESI RN
HESI 799 RN Exit Exam Capstone
1. A client with anxiety disorder is experiencing increased anxiety prior to vaginal delivery. What should the nurse’s initial action be?
- A. Increase the client's sedative dose
- B. Encourage the client to express her feelings and provide emotional support
- C. Initiate breathing techniques to manage anxiety
- D. Administer anxiolytic medication to calm the client
Correct answer: B
Rationale: The correct initial action for a client with anxiety disorder experiencing increased anxiety prior to vaginal delivery is to encourage the client to express her feelings and provide emotional support. Emotional support is crucial in reducing anxiety during childbirth. Initiating breathing techniques or administering medications should come after emotional support has been provided. Increasing sedative doses may not address the underlying emotional needs of the client and can have potential risks.
2. During the physical examination, Nurse Noah expects to assess which sign in a female client with a serum calcium level of 7.2 mg/dl?
- A. Trousseau's sign
- B. Homans' sign
- C. Hegar's sign
- D. Goodell's sign
Correct answer: A
Rationale: Trousseau's sign is a clinical indicator of hypocalcemia, characterized by carpal spasm when a blood pressure cuff is inflated above systolic pressure and maintained for a few minutes. This occurs due to increased neuromuscular irritability associated with low serum calcium levels. Homans' sign is used to assess for deep vein thrombosis and involves calf pain upon dorsiflexion of the foot. Hegar's sign is a softening of the lower uterine segment seen in pregnancy, while Goodell's sign is softening of the cervix also seen in pregnancy. Therefore, in this scenario, the correct assessment related to hypocalcemia would be Trousseau's sign.
3. Basal body temperature rise of _____ is seen in the luteal phase due to the thermogenic effects of a metabolite of progesterone in a normal cycle:
- A. 0.1-0.5
- B. 0.2-0.5
- C. 1.0-2.0
- D. 1.5-2.0
Correct answer: B
Rationale: A basal body temperature rise of 0.2-0.5 degrees Celsius is typically seen in the luteal phase of the menstrual cycle due to the thermogenic effects of a metabolite of progesterone. This temperature rise helps to indicate ovulation has occurred. Choices A, C, and D are incorrect as they do not reflect the usual range of temperature increase observed during the luteal phase. A rise of 0.1-0.5 degrees Celsius is too narrow (eliminating choice A), while ranges of 1.0-2.0 and 1.5-2.0 degrees Celsius are too high and not consistent with the expected basal body temperature changes during the menstrual cycle.
4. A client is prescribed calcium gluconate after thyroidectomy. The medication is most likely prescribed to:
- A. Treat thyroid storm.
- B. Prevent cardiac irritability.
- C. Treat hypocalcemic tetany.
- D. Stimulate the release of parathyroid hormone.
Correct answer: C
Rationale: After a thyroidectomy, the parathyroid glands can be inadvertently removed or damaged, leading to a decrease in calcium levels and potentially causing hypocalcemic tetany. Calcium gluconate is given to supplement calcium levels and prevent or treat hypocalcemia-related symptoms, such as muscle spasms and tetany.
5. A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L. Which action is most important for the nurse to implement?
- A. Administer 20 mEq of potassium chloride.
- B. Initiate continuous cardiac monitoring.
- C. Arrange a consultation with the dietitian.
- D. Educate about the side effects of diuretics.
Correct answer: B
Rationale: Hypokalemia, defined as a serum potassium level below the normal range of 3.5 to 5 mEq/L, can lead to changes in myocardial irritability and ECG waveform, potentially causing life-threatening dysrhythmias. Therefore, the priority action for the nurse is to initiate continuous cardiac monitoring to promptly detect any abnormal heart rhythms or ventricular ectopy. This monitoring is crucial for assessing the impact of potassium replacement therapy on the cardiac rhythm and ensuring the safety of the client. While administering potassium chloride is important for correcting the hypokalemia, it should occur after cardiac monitoring is in place. Consulting with a dietitian and educating about diuretic side effects are relevant aspects of care but are not the immediate priority in this situation where cardiac monitoring takes precedence for timely intervention.