HESI RN
HESI 799 RN Exit Exam Capstone
1. A client with diabetic ketoacidosis (DKA) is receiving an insulin infusion. Which finding indicates that the treatment is effective?
- A. Potassium level of 4.0 mEq/L.
- B. Blood glucose level of 180 mg/dL.
- C. Urine output of 50 mL/hour.
- D. Absence of ketones in the urine.
Correct answer: D
Rationale: The correct answer is D: Absence of ketones in the urine. In a client with diabetic ketoacidosis (DKA) receiving an insulin infusion, the absence of ketones in the urine indicates that ketoacidosis is resolving. This is a crucial finding as it shows that the insulin therapy is effectively addressing the metabolic imbalance causing DKA. Choices A, B, and C are incorrect: A potassium level of 4.0 mEq/L is within normal range but does not directly reflect the resolution of DKA; a blood glucose level of 180 mg/dL, while improved, is still high and does not specifically indicate the resolution of ketoacidosis; urine output of 50 mL/hour is within normal limits but does not directly point to the resolution of DKA.
2. A client whose labor is being augmented with an oxytocin (Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a -2 station. What action should the nurse implement first?
- A. Decrease the oxytocin infusion rate
- B. Determine current cervical dilation
- C. Request placement of the epidural
- D. Give a bolus of intravenous fluids
Correct answer: D
Rationale: In a client receiving an oxytocin infusion who requests an epidural, it is crucial to give a bolus of intravenous fluids first. This action helps prevent hypotension, a common side effect of epidural anesthesia, before the placement of the epidural. Maintaining adequate hydration is essential to support maternal blood pressure stability during the procedure.
3. What should be included in the differential diagnosis of ectopic pregnancy?
- A. Inevitable abortion
- B. Dysmenorrhea
- C. Twisted ovarian cyst
- D. Fibroids
Correct answer: C
Rationale: In the differential diagnosis of ectopic pregnancy, conditions such as twisted ovarian cysts should be considered. Twisted ovarian cysts can present with similar symptoms to ectopic pregnancy, making it important to include them in the differential diagnosis. Choices A, B, and D are not typically part of the differential diagnosis of ectopic pregnancy. Inevitable abortion refers to an imminent miscarriage, dysmenorrhea is characterized by painful menstruation, and fibroids are benign growths in the uterus, none of which are directly related to ectopic pregnancy.
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. A client is receiving desmopressin acetate (DDAVP), and a healthcare provider is monitoring for adverse effects. Which of the following indicates the presence of an adverse effect?
- A. Insomnia
- B. Drowsiness
- C. Weight loss
- D. Increased urination
Correct answer: B
Rationale: Drowsiness can be a sign of water intoxication or hyponatremia, which are potential adverse effects of desmopressin acetate (DDAVP). It is crucial to monitor for this symptom and promptly address it to prevent complications.