HESI RN
HESI RN Exit Exam 2023 Capstone
1. A client with chronic liver disease develops jaundice. What is the most important assessment the nurse should perform?
- A. Assess the client’s skin for lesions or sores.
- B. Monitor the client’s liver function tests.
- C. Assess for changes in mental status and behavior.
- D. Monitor the client’s urine output closely.
Correct answer: D
Rationale: In a client with chronic liver disease developing jaundice, the most important assessment the nurse should perform is to monitor the client’s urine output closely. Jaundice can indicate worsening liver function, so monitoring urine output helps assess kidney function and fluid balance, which are critical in chronic liver disease. Assessing the client’s skin for lesions or sores (Choice A) may be relevant for dermatological conditions but is not the priority in this case. Monitoring liver function tests (Choice B) is important but may not provide immediate information on the client’s current status. Assessing for changes in mental status and behavior (Choice C) is important for detecting hepatic encephalopathy but does not directly address the immediate concern of fluid balance and kidney function in the presence of jaundice.
2. A client with diabetes mellitus reports tingling in their feet. What is the nurse's best intervention?
- A. Advise the client to avoid wearing tight shoes.
- B. Refer the client to a podiatrist for foot care.
- C. Teach the client about blood sugar control and foot care.
- D. Administer insulin as prescribed.
Correct answer: C
Rationale: The correct intervention for a client with diabetes mellitus experiencing tingling in their feet is to teach the client about blood sugar control and foot care. This is essential because tingling in the feet can be a sign of neuropathy, a common complication of diabetes. Educating the client on maintaining proper blood sugar levels and foot care practices can help manage neuropathy symptoms and prevent complications like ulcers or infections. Advising the client to avoid tight shoes (Choice A) may help with comfort but does not address the underlying issue. Referring the client to a podiatrist (Choice B) is important for foot care but does not directly address blood sugar control. Administering insulin (Choice D) is not the priority for managing tingling in the feet related to neuropathy.
3. A male client with hypertension, who received new antihypertensive prescriptions at his last visit, returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106, and he admits that he has not been taking the prescribed medication because the drugs make him 'feel bad'. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?
- A. Blindness due to cataracts
- B. Acute kidney injury due to glomerular damage
- C. Stroke secondary to hemorrhage
- D. Heart block due to myocardial damage
Correct answer: C
Rationale: The correct answer is C, 'Stroke secondary to hemorrhage.' Uncontrolled hypertension can lead to the weakening of blood vessels in the brain, increasing the risk of a stroke due to hemorrhage. This can result in serious neurological deficits or even death. Choices A, B, and D are incorrect because while hypertension can have various complications including vision changes, kidney damage, and heart problems, the most immediate and severe risk associated with uncontrolled hypertension is a stroke from cerebral hemorrhage.
4. What should the nurse recommend to a woman with mastitis?
- A. Apply heat to the affected area.
- B. Apply cold compresses to the affected area.
- C. Use a breast pump to express milk.
- D. Continue breastfeeding as usual.
Correct answer: A
Rationale: The nurse should recommend applying heat to the affected area for a woman with mastitis. Heat can help reduce pain and inflammation associated with mastitis by improving blood flow to the area and promoting healing.
5. A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which laboratory value requires immediate intervention?
- A. Serum glucose of 300 mg/dl
- B. Serum potassium of 5.5 mEq/L
- C. Serum bicarbonate of 18 mEq/L
- D. Serum sodium of 135 mEq/L
Correct answer: C
Rationale: A serum bicarbonate level of 18 mEq/L requires immediate intervention in a client with diabetic ketoacidosis (DKA). A low serum bicarbonate level indicates metabolic acidosis, which can be life-threatening. This condition needs urgent correction to restore acid-base balance. Serum glucose of 300 mg/dl, serum potassium of 5.5 mEq/L, and serum sodium of 135 mEq/L are abnormal values, but they do not pose an immediate threat to the client's life compared to the metabolic acidosis indicated by the low serum bicarbonate level.