HESI RN
HESI 799 RN Exit Exam Capstone
1. A client with Cushing's syndrome presents with excessive bruising and elevated blood glucose. What action should the nurse take first?
- A. Check the client's blood glucose level.
- B. Administer insulin per sliding scale protocol.
- C. Administer intravenous fluids.
- D. Check the client's skin for signs of bruising.
Correct answer: A
Rationale: Excessive bruising and elevated blood glucose are common symptoms of Cushing's syndrome. The nurse should first check the client's blood glucose level to assess and address the hyperglycemia promptly. Administering insulin or IV fluids would be premature without knowing the current blood glucose level. Checking the skin for bruising, although important for overall assessment, does not address the immediate concern of elevated blood glucose.
2. A client with heart failure receiving furosemide develops muscle weakness. What is the nurse's priority action?
- A. Administer potassium supplements as prescribed.
- B. Monitor the client’s potassium levels.
- C. Instruct the client to increase their salt intake.
- D. Discontinue the furosemide.
Correct answer: B
Rationale: Muscle weakness in a client receiving furosemide (a diuretic) is often a sign of hypokalemia, as furosemide increases potassium loss. Monitoring potassium levels is essential to identify and address any imbalances and prevent complications such as arrhythmias. Administering potassium supplements without monitoring the levels can lead to hyperkalemia, which has its own set of serious complications. Instructing the client to increase salt intake is not appropriate in this situation as it does not address the underlying electrolyte imbalance. Discontinuing furosemide abruptly can worsen heart failure symptoms; therefore, monitoring potassium levels and adjusting the treatment accordingly is the most appropriate action.
3. A client who is admitted to the mental health unit reports shortness of breath and dizziness. The client tells the nurse, “I feel like I’m going to die.” Which nursing problem should the nurse include in this client’s plan of care?
- A. Mood disturbance
- B. Moderate anxiety
- C. Altered thoughts
- D. Social isolation
Correct answer: B
Rationale: The correct answer is B: Moderate anxiety. When a client presents with symptoms such as shortness of breath, dizziness, and a fear of dying, it indicates moderate anxiety. Anxiety can manifest physically with symptoms like these. Mood disturbance (choice A) refers to a change in mood, while altered thoughts (choice C) relate to cognitive changes. Social isolation (choice D) involves a lack of social interaction, which is not the primary concern in this scenario where the client is experiencing acute anxiety symptoms.
4. The nurse is assessing an older adult client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding?
- A. Ptosis on the left eyelid.
- B. Nystagmus.
- C. Astigmatism.
- D. Exophthalmos.
Correct answer: A
Rationale: The correct answer is A: 'Ptosis on the left eyelid.' Ptosis is the term used to describe an eyelid droop that covers a large portion of the iris, which may be caused by issues with the oculomotor nerve or eyelid muscles. Choice B, 'Nystagmus,' refers to involuntary eye movements and is not related to eyelid drooping. Choice C, 'Astigmatism,' is a refractive error affecting vision due to an irregularly shaped cornea or lens, not an eyelid condition. Choice D, 'Exophthalmos,' is a protrusion of the eyeball associated with conditions like hyperthyroidism, not eyelid drooping.
5. A client with a chest tube following a pneumothorax is complaining of increased shortness of breath. What is the nurse's first action?
- A. Check for kinks in the chest tube tubing.
- B. Assess the client's lung sounds.
- C. Elevate the head of the bed to 30 degrees.
- D. Prepare for chest tube replacement.
Correct answer: C
Rationale: The correct first action for a client with a chest tube experiencing increased shortness of breath is to elevate the head of the bed to 30 degrees. This position promotes lung expansion, improves oxygenation, and can help relieve shortness of breath. Checking for kinks in the chest tube tubing would be important but not the first action in this situation. Assessing the client's lung sounds is also important but not the initial priority. Preparing for chest tube replacement is not indicated based solely on the client's complaint of increased shortness of breath.