HESI RN
HESI RN Exit Exam Capstone
1. A client with diabetes insipidus is admitted due to a pituitary tumor. What complication should the nurse monitor closely?
- A. Monitor for elevated blood pressure.
- B. Monitor for ketonuria.
- C. Monitor for peripheral edema.
- D. Monitor for hypokalemia.
Correct answer: D
Rationale: The correct answer is to monitor for hypokalemia. In diabetes insipidus, excessive urination can lead to electrolyte imbalances, particularly low potassium levels (hypokalemia). The loss of potassium through increased urination can result in muscle weakness, cardiac dysrhythmias, and other serious complications. Elevated blood pressure (Choice A) is not a typical complication of diabetes insipidus due to pituitary tumors. Ketonuria (Choice B) is more commonly associated with diabetes mellitus due to inadequate insulin levels. Peripheral edema (Choice C) is not a direct complication of diabetes insipidus.
2. A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse?
- A. Arterial blood pH is 7.32.
- B. Serum calcium is 18 mg/dL.
- C. Serum potassium is 5.1 mEq/L
- D. Arterial oxygen saturation is 91%.
Correct answer: B
Rationale: The correct answer is B. A serum calcium level of 18 mg/dL is significantly elevated, posing a high risk for cardiac dysrhythmias. Immediate action is required to initiate cardiac monitoring and notify the healthcare provider. While the abnormalities in arterial blood pH, serum potassium, and arterial oxygen saturation also need attention, they are not as immediately life-threatening as the critically high serum calcium level. Therefore, addressing the serum calcium level takes precedence in this scenario.
3. The instructor is teaching a prenatal class about the importance of folic acid. Which outcome indicates that the teaching was effective?
- A. participants can list foods high in folic acid
- B. participants plan to take folic acid supplements daily
- C. participants understand the risks of folic acid deficiency
- D. participants demonstrate how to read nutrition labels for folic acid content
Correct answer: B
Rationale: The correct answer is B because planning to take folic acid supplements daily is a proactive step towards preventing folic acid deficiency and reducing the risk of neural tube defects in pregnancy. While choice A is important for dietary knowledge, the direct action of taking supplements is more effective. Choice C, understanding the risks, is good but does not ensure action. Choice D, reading nutrition labels, is helpful but doesn't guarantee intake of folic acid.
4. Which of these methods can be used for the transfer of zygote or early embryo into the fallopian tube?
- A. GIFT
- B. IUT
- C. ZIFT
- D. ICSI
Correct answer: C
Rationale: The correct answer is C, ZIFT (Zygote Intrafallopian Transfer). ZIFT involves transferring a zygote or early embryo into the fallopian tube. GIFT (Gamete Intrafallopian Transfer - A) involves transferring unfertilized eggs and sperm into the fallopian tube for fertilization to occur inside the woman's body, not a zygote or early embryo. IUT (Intrauterine Transfer - B) is not specifically for transferring the zygote or early embryo into the fallopian tube, but rather into the uterus. ICSI (Intracytoplasmic Sperm Injection - D) is a technique where a single sperm is injected directly into an egg, not related to transferring embryos into the fallopian tube.
5. A school nurse is developing a health risk screening protocol for use at an elementary school. What information is most important for the nurse to include in this protocol?
- A. annual flu vaccination status
- B. weight and height measurement
- C. total cholesterol level
- D. long bone deformity testing
Correct answer: B
Rationale: Weight and height measurements are crucial components of health screenings in children as they help assess growth patterns and identify potential health concerns such as obesity or growth disorders. Monitoring weight and height regularly can aid in early intervention and prevention of health issues. Annual flu vaccination status, total cholesterol level, and long bone deformity testing are not typically primary components of routine health screenings in elementary school children and may not directly contribute to identifying common health risks in this population.