HESI RN
HESI 799 RN Exit Exam Capstone
1. A client with diabetes mellitus reports feeling shaky, dizzy, and sweaty. The nurse checks the client's blood glucose level and it is 55 mg/dL. What is the nurse's next action?
- A. Give the client a glucagon injection
- B. Encourage the client to eat a high-protein snack
- C. Administer 15 grams of a fast-acting carbohydrate
- D. Recheck the blood glucose level in 15 minutes
Correct answer: C
Rationale: A blood glucose level of 55 mg/dL indicates hypoglycemia, which should be treated with a fast-acting carbohydrate to quickly raise the blood sugar. Administering 15 grams of a fast-acting carbohydrate, such as glucose tablets or juice, is the appropriate initial intervention for hypoglycemia. Giving a glucagon injection is reserved for severe cases or when the client is unconscious. Encouraging the client to eat a high-protein snack is not appropriate for treating acute hypoglycemia, as it is a slower-acting form of glucose. Rechecking the blood glucose level is important but should occur after providing immediate treatment to raise the blood sugar level.
2. While changing a client's post-operative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given there is a positive MRSA, which is the most important action for the nurse to take?
- A. Force oral fluids
- B. Request a nutrition consult
- C. Initiate contact precautions
- D. Limit visitors to immediate family only
Correct answer: C
Rationale: The most important action for the nurse to take when a client has a positive MRSA and presents with a wound showing signs of infection is to initiate contact precautions. MRSA is highly contagious and placing the patient on contact precautions helps prevent the spread of the bacteria to others in the healthcare setting. (A) Forcing oral fluids will not directly address the MRSA infection. (B) Requesting a nutrition consult is not the priority in this situation. (D) Limiting visitors to immediate family only is not necessary as MRSA precautions are primarily focused on healthcare workers and close contacts who provide direct care.
3. A nurse is monitoring a client receiving lithium carbonate for bipolar disorder. Which finding should the nurse report immediately to the healthcare provider?
- A. Increased thirst
- B. Fine hand tremors
- C. Frequent urination
- D. Persistent vomiting
Correct answer: D
Rationale: Persistent vomiting can be a sign of lithium toxicity, which requires immediate medical attention. Increased thirst, fine hand tremors, and frequent urination are common side effects of lithium.
4. While assessing the vital signs of a 10-year-old who underwent a tonsillectomy this morning, the nurse observes the child swallowing every 2-3 minutes. Which assessment should the nurse implement?
- A. Inspect the posterior oropharynx
- B. Assess for teeth clenching or grinding
- C. Touch the tonsillar pillars to stimulate the gag reflex
- D. Ask the child to speak to evaluate a change in voice tone
Correct answer: A
Rationale: Frequent swallowing post-tonsillectomy may indicate bleeding. Inspecting the posterior oropharynx is essential to assess for any signs of bleeding, such as fresh blood or clots, which may necessitate immediate intervention. Option B is incorrect as teeth clenching or grinding is not directly related to the observation of frequent swallowing in this scenario. Option C is incorrect because stimulating the gag reflex is not necessary at this point and may be uncomfortable for the child. Option D is incorrect as evaluating a change in voice tone is not relevant to the situation of observing frequent swallowing.
5. A client with chronic obstructive pulmonary disease (COPD) is prescribed tiotropium (Spiriva). Which instruction should the nurse include in the teaching plan?
- A. Use the medication as a rescue inhaler.
- B. Rinse your mouth after using the inhaler.
- C. Take the medication on an empty stomach.
- D. Take the medication with a full glass of water.
Correct answer: B
Rationale: Tiotropium (Spiriva) is not a rescue inhaler but a maintenance medication for COPD. The correct instruction for the nurse to include in the teaching plan is to advise the client to rinse their mouth after using the inhaler. This practice helps prevent dry mouth and throat irritation, common side effects of tiotropium. There are no specific recommendations to take tiotropium on an empty stomach or with a full glass of water.