HESI RN
HESI RN Exit Exam 2024 Quizlet Capstone
1. A client with diabetes mellitus is scheduled for surgery, and their blood glucose level is 280 mg/dL. What is the nurse's priority action?
- A. Administer insulin as prescribed.
- B. Delay surgery until the blood glucose is below 180 mg/dL.
- C. Check the client’s hemoglobin A1C level.
- D. Administer IV fluids to flush excess glucose.
Correct answer: A
Rationale: The correct answer is A: Administer insulin as prescribed. In clients with diabetes, high blood glucose levels can increase the risk of infection and impair healing after surgery. Administering insulin as prescribed helps reduce blood glucose to a safer level before surgery, preventing complications. Choice B is incorrect because delaying surgery without addressing the high blood glucose level does not address the immediate issue. Choice C is incorrect as checking the client's hemoglobin A1C level is not the priority when dealing with acute high blood glucose levels before surgery. Choice D is incorrect as administering IV fluids may help with hydration but does not directly address the high blood glucose level that needs immediate attention.
2. When performing an admission assessment of a client diagnosed with a brain tumor, which question is most important for the nurse to ask the client?
- A. When did your symptoms first begin?
- B. Can you describe the pain and how it feels?
- C. Do you have any changes in vision?
- D. Have you experienced any seizures?
Correct answer: D
Rationale: The correct answer is D. When assessing a client diagnosed with a brain tumor, asking about seizures is crucial because they can be a common symptom associated with brain tumors. Seizures in this context could provide valuable information regarding the progression and impact of the brain tumor on the client's neurological status. Choices A, B, and C are important questions in a general assessment, but when specifically focusing on a client with a brain tumor, inquiring about seizures takes priority due to its direct relevance to the condition.
3. Capillary glucose monitoring is being performed every 4 hours for a female client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which she receives 8 U of regular insulin. Nurse Vince should expect the dose's:
- A. Onset to be at 2 p.m. and its peak to be at 3 p.m.
- B. Onset to be at 2:15 p.m. and its peak to be at 3 p.m.
- C. Onset to be at 2:30 p.m. and its peak to be at 4 p.m.
- D. Onset to be at 4 p.m. and its peak to be at 6 p.m.
Correct answer: C
Rationale: The correct answer is C. Regular insulin typically has an onset of action within 30 minutes and peaks 2-4 hours after administration. Given that the insulin was administered at 2 p.m., the onset of action can be expected around 2:30 p.m., and the peak effect would occur between 4-6 p.m. Choice A is incorrect as the onset and peak are too close together for regular insulin. Choice B is incorrect because the onset time is too soon after administration. Choice D is incorrect as the onset time is too delayed for regular insulin.
4. In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client’s respiratory rate is 14 breaths/minute. What action should the nurse implement?
- A. Remove the mask immediately
- B. Document the assessment data
- C. Increase the oxygen flow
- D. Increase the respiratory rate setting
Correct answer: B
Rationale: The correct answer is to document the assessment data. In a partial rebreather mask, it is normal for the oxygen reservoir bag not to deflate completely during inspiration. Additionally, a respiratory rate of 14 breaths/minute falls within the normal range. Therefore, these findings indicate that the mask is functioning as intended. Removing the mask immediately is unnecessary as there are no signs of distress. Increasing the oxygen flow or adjusting the respiratory rate setting is not warranted based on the assessment findings, as they are within normal parameters.
5. What are the primary pathophysiological mechanisms responsible for ascites in liver failure?
- A. Decreased liver enzymes.
- B. Increased hydrostatic pressure in portal circulation.
- C. High bilirubin levels.
- D. Fluid shifts due to decreased serum proteins.
Correct answer: B
Rationale: The correct answer is B: Increased hydrostatic pressure in portal circulation. Ascites in liver failure is primarily caused by fluid shifts from the intravascular space to the interstitial space due to increased hydrostatic pressure in the portal circulation. Choice A is incorrect as ascites is not caused by decreased liver enzymes. Choice C is incorrect as high bilirubin levels are not the primary mechanism for ascites in liver failure. Choice D is incorrect as fluid shifts in ascites are due to decreased serum proteins, not increased serum proteins.