HESI RN
HESI 799 RN Exit Exam Capstone
1. A female client taking prednisone reports feeling tired after stopping the corticosteroid abruptly. What is the priority nursing intervention?
- A. Auscultate breath sounds.
- B. Measure vital signs.
- C. Palpate the abdomen.
- D. Observe the skin for bruising.
Correct answer: C
Rationale: The correct answer is to palpate the abdomen. When a client abruptly stops taking prednisone, there is a risk of adrenal insufficiency, which can present with symptoms like fatigue. Palpating the abdomen is crucial to assess for signs of adrenal crisis, such as abdominal pain, which can indicate severe adrenal insufficiency. Auscultating breath sounds (Choice A) and observing the skin for bruising (Choice D) are not the priority interventions in this situation. While measuring vital signs (Choice B) is important, palpating the abdomen takes precedence in this case to assess for potential adrenal insufficiency.
2. Following a gunshot wound to the abdomen, a young adult male had an emergency bowel resection and received multiple blood products while in the operating room. His current blood pressure is 78/52 mm Hg, he is being mechanically ventilated, and his oxygen saturation is 87%. His laboratory values include hemoglobin 7.0 g/dL, platelets 20,000/mm³, and white blood cells 1,500/mm³. Based on these assessment findings, which intervention should the nurse implement first?
- A. Transfuse packed red blood cells.
- B. Obtain blood and sputum cultures.
- C. Infuse 1000 ml of normal saline.
- D. Titrate oxygen to keep O2 saturation at 90%.
Correct answer: A
Rationale: The client is exhibiting signs of severe anemia and hypovolemic shock, indicated by low hemoglobin levels and hypotension. The first priority is to address the low hemoglobin by transfusing packed red blood cells to improve oxygen-carrying capacity and perfusion to vital organs. While obtaining blood and sputum cultures is important for identifying potential infections, infusing normal saline can help with volume expansion but does not address the primary issue of severe anemia. Titrating oxygen to maintain an oxygen saturation of 90% is crucial but should follow the administration of packed red blood cells to optimize oxygen delivery.
3. To provide effective care for a patient diagnosed with schizophrenia, what associated condition should the nurse frequently assess for? Select all that apply.
- A. Alcohol use disorder
- B. Major depressive disorder
- C. Stomach cancer
- D. Polydipsia
Correct answer: A
Rationale: Alcohol use disorder is commonly associated with schizophrenia, leading to a dual diagnosis. Assessing for alcohol use disorder is crucial in managing the patient's overall well-being and treatment plan. Major depressive disorder can co-occur with schizophrenia but is not the most commonly associated condition. Stomach cancer is not typically associated with schizophrenia. Polydipsia, excessive thirst, can be a symptom in some individuals with schizophrenia due to medication side effects, but it is not an associated condition that requires frequent assessment compared to alcohol use disorder.
4. The healthcare professional is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued?
- A. Alprazolam (Xanax)
- B. Benztropine (Cogentin)
- C. Magnesium (Milk of Magnesia)
- D. Lithium (Lithotabs)
Correct answer: B
Rationale: When an antipsychotic medication is discontinued, medications like Benztropine (Cogentin), which are given to reduce extrapyramidal side effects associated with traditional antipsychotic medications, should also be discontinued. Alprazolam (Xanax) is not directly related to antipsychotic medication use in this context. Magnesium (Milk of Magnesia) is a laxative and not typically indicated for bipolar disorder. Lithium (Lithotabs) is a mood stabilizer commonly used in bipolar disorder, and its discontinuation should be carefully managed under the guidance of a healthcare provider to prevent relapse of symptoms.
5. Which assessment finding requires immediate intervention for a client receiving enteral feedings via a nasogastric tube?
- A. Auscultate the client's lungs for breath sounds
- B. Check the client's blood glucose level
- C. Monitor the client's bowel sounds
- D. Elevate the head of the bed to 45 degrees
Correct answer: D
Rationale: Elevating the head of the bed to 45 degrees is crucial for clients receiving enteral feedings via a nasogastric tube to prevent aspiration. Aspiration can lead to serious complications such as pneumonia. Auscultating the client's lungs for breath sounds (choice A) is important but not as urgent as preventing aspiration. Checking the client's blood glucose level (choice B) and monitoring bowel sounds (choice C) are also essential aspects of care for a client receiving enteral feedings, but they do not take precedence over preventing aspiration.