HESI RN
HESI RN Exit Exam 2023 Capstone
1. A client with diabetes mellitus presents with a blood sugar level of 320 mg/dL. What is the nurse's initial action?
- A. Administer sliding scale insulin as prescribed
- B. Encourage the client to drink fluids
- C. Provide the client with a carbohydrate snack
- D. Assess the client for signs of hypoglycemia
Correct answer: A
Rationale: When a client with diabetes mellitus presents with a high blood sugar level of 320 mg/dL, the nurse's initial action should be to administer sliding scale insulin as prescribed. The priority is to bring down the elevated glucose level promptly to prevent further complications. Encouraging the client to drink fluids or providing a carbohydrate snack would not effectively address the elevated blood sugar level in this scenario. Assessing for signs of hypoglycemia is not appropriate as the client's blood sugar level is high, not low.
2. A client with Crohn's disease reports diarrhea. What intervention should the nurse implement?
- A. Instruct the client to drink clear fluids and avoid solid foods.
- B. Administer antidiarrheal medication as prescribed.
- C. Encourage a high-fiber diet and regular physical activity.
- D. Restrict fluid intake and monitor electrolytes.
Correct answer: C
Rationale: The correct intervention for a client with Crohn's disease reporting diarrhea is to encourage a high-fiber diet and regular physical activity. A high-fiber diet helps manage diarrhea in Crohn's disease by adding bulk to the stool and promoting more regular bowel movements. Instructing the client to drink clear fluids and avoid solid foods (Choice A) may not be appropriate as it can further exacerbate diarrhea. Administering antidiarrheal medication (Choice B) without addressing the underlying cause may not be the best initial approach. Encouraging a high-fiber diet and physical activity (Choice C) is beneficial for managing symptoms. Restricting fluid intake and monitoring electrolytes (Choice D) is not recommended as it can lead to dehydration, which is a concern in clients with diarrhea.
3. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 4 liters per minute via nasal cannula. The client becomes lethargic and confused. What action should the nurse take first?
- A. Decrease the oxygen flow rate
- B. Increase the oxygen flow rate
- C. Encourage the client to cough and deep breathe
- D. Monitor the client's oxygen saturation level
Correct answer: A
Rationale: In this scenario, the priority action for the nurse is to decrease the oxygen flow rate. Clients with COPD are sensitive to high levels of oxygen and can develop oxygen toxicity, leading to symptoms like lethargy and confusion. Decreasing the oxygen flow rate helps prevent this complication. Increasing the oxygen flow rate would worsen the client's condition. Encouraging coughing and deep breathing may not address the immediate issue of oxygen toxicity. While monitoring the client's oxygen saturation level is important, taking action to address the oxygen toxicity by decreasing the flow rate is the priority in this situation.
4. Which of the following is true about effective leadership?
- A. Leadership traits can be learned through experience and reflection.
- B. Nurses can learn to become good leaders by acting as good leaders and reflecting on leadership qualities they have and those they can improve upon.
- C. Focus on leadership activities required for the day is essential for effective leadership.
- D. Taking advantage of every opportunity to be a leader is crucial, creating those opportunities as often as possible, especially after gaining experience as a nurse.
Correct answer: B
Rationale: Choice B is correct because nurses can develop effective leadership skills by actively engaging as good leaders and reflecting on their existing leadership qualities and areas for improvement. This process of self-assessment and continuous improvement is crucial in becoming a successful leader. Choice A is incorrect as leadership traits can be learned through experience and reflection rather than being impossible to acquire from a book. Choice C is incorrect as effective leadership involves focusing on long-term goals and strategies, not just daily activities. Choice D is incorrect because while seizing leadership opportunities is important, it should be done strategically and with a solid foundation of experience in nursing to ensure successful leadership outcomes.
5. A nurse plans care for clients with urinary incontinence. Which client is correctly paired with the appropriate intervention?
- A. A 29-year-old client after a difficult vaginal delivery – Habit training
- B. A 58-year-old postmenopausal client who is not taking estrogen therapy – Electrical stimulation
- C. A 64-year-old female with Alzheimer’s-type senile dementia – Bladder training
- D. A 77-year-old female who has difficulty ambulating – Exercise therapy
Correct answer: B
Rationale: The correct pairing is a 58-year-old postmenopausal client who is not taking estrogen therapy with electrical stimulation. Electrical stimulation is used for clients with stress incontinence related to menopause and low estrogen levels. Exercise therapy improves pelvic wall strength and is not specifically for ambulation issues. Habit training is more effective for cognitively impaired clients, like those with Alzheimer's-type senile dementia. Bladder training requires the client to be alert, aware, and able to resist the urge to urinate, which may not be suitable for clients with cognitive impairments.