HESI RN
RN HESI Exit Exam Capstone
1. A client with cirrhosis is receiving spironolactone. What electrolyte level should the nurse monitor closely?
- A. Monitor potassium levels.
- B. Monitor sodium levels.
- C. Monitor calcium levels.
- D. Monitor magnesium levels.
Correct answer: A
Rationale: The correct answer is to monitor potassium levels. Spironolactone is a potassium-sparing diuretic, which means it helps the body retain potassium and excrete sodium. Monitoring potassium levels closely is essential because spironolactone can cause hyperkalemia (high potassium levels). Sodium levels are not typically affected by spironolactone. Calcium and magnesium levels are also not directly impacted by spironolactone, making choices B, C, and D incorrect.
2. During a well-baby exam, a nurse finds that a 2-month-old's right testicle is not descended into the scrotum, but the left one is palpable. What should the nurse do?
- A. Ask if the right testis has been seen in the scrotum before
- B. Address potential concerns about future fertility
- C. Schedule an ultrasound to confirm the position of the testicle
- D. Prepare to obtain a urine specimen for culture
Correct answer: A
Rationale: The correct answer is to ask if the right testis has been seen in the scrotum before. The initial step in managing an undescended testicle is to determine if it has been previously observed in the scrotum or if this is a new finding. This information is crucial in deciding the next course of action. Choice B is incorrect because addressing future fertility concerns comes after confirming the status of the testicle. Choice C is unnecessary at this stage as the first step is to gather more history. Choice D is unrelated to the issue described and is not indicated in this scenario.
3. A client with a history of epilepsy is admitted with status epilepticus. Which medication should the nurse prepare to administer?
- A. Acetaminophen (Tylenol)
- B. Lorazepam (Ativan)
- C. Phenytoin (Dilantin)
- D. Carbamazepine (Tegretol)
Correct answer: B
Rationale: In the management of status epilepticus, the initial medication of choice is a benzodiazepine such as lorazepam (Ativan) to rapidly terminate the seizure activity. Lorazepam acts quickly and effectively in stopping seizures. Phenytoin (Dilantin) is often used as a second-line agent for status epilepticus, and carbamazepine (Tegretol) is not typically indicated for the acute treatment of status epilepticus. Acetaminophen (Tylenol) is a pain reliever and antipyretic but is not used in the treatment of status epilepticus.
4. A client with chronic kidney disease (CKD) is receiving erythropoietin therapy. Which laboratory value should the nurse monitor closely?
- A. Serum potassium
- B. Hemoglobin
- C. White blood cell count
- D. Serum creatinine
Correct answer: A
Rationale: The correct answer is A: Serum potassium. When a client with chronic kidney disease is receiving erythropoietin therapy, monitoring serum potassium closely is essential. Erythropoietin therapy can lead to increased red blood cell production, which may cause potassium levels to rise, potentially resulting in hyperkalemia. Monitoring potassium levels helps prevent complications associated with hyperkalemia. Choices B, C, and D are incorrect because they are not directly impacted by erythropoietin therapy in the context of CKD.
5. The nurse enters a client's room and observes the unlicensed assistive personnel (UAP) making an occupied bed as seen in the picture. What action should the nurse take first?
- A. Place the side rails in an up position.
- B. Assist the UAP in turning the client.
- C. Provide instructions on proper bed-making techniques.
- D. Ask the client if they are comfortable.
Correct answer: A
Rationale: Correct Answer: The nurse should first place the side rails in an up position. This action is crucial to prevent the client from falling while the bed is being made. Choice B is incorrect as moving or turning the client is not necessary at this point. Choice C is not a priority when immediate safety concerns are present. Choice D, asking the client if they are comfortable, though important, should come after ensuring the client's safety by raising the side rails.