HESI RN
HESI 799 RN Exit Exam Capstone
1. A male client with schizophrenia is socially reclusive and pacing in the hallway. What is the most important intervention for the nurse to implement?
- A. Take the client's temperature and blood pressure.
- B. Encourage the client to rest.
- C. Plan an activity that includes physical exercise.
- D. Carefully observe the client throughout the shift.
Correct answer: D
Rationale: The correct answer is to carefully observe the client throughout the shift. In this situation, the client's behavior suggests agitation and restlessness, which could potentially escalate. Observation is crucial to monitor any changes in behavior, assess for signs of distress, and ensure the client's safety. Taking the client's temperature and blood pressure (Choice A) may not address the immediate need for managing the client's behavior. Encouraging the client to rest (Choice B) might not be effective if the client is highly agitated. Planning an activity that includes physical exercise (Choice C) could exacerbate the situation rather than address the current behavior. Therefore, the priority is to observe the client closely to provide appropriate support and intervention as needed.
2. Which of the following is a priority nursing diagnosis for a client with Addison's disease?
- A. Fluid volume deficit
- B. Risk for infection
- C. Imbalanced nutrition: Less than body requirements
- D. Disturbed body image
Correct answer: A
Rationale: The priority nursing diagnosis for a client with Addison's disease is 'Fluid volume deficit.' Addison's disease is characterized by adrenal insufficiency, resulting in decreased aldosterone production. Aldosterone plays a key role in sodium and water retention in the body. With its deficiency, there is an increased risk of dehydration and electrolyte imbalance, leading to fluid volume deficit. While infection risk, nutrition issues, and body image disturbances are also important considerations for holistic care, addressing the fluid volume deficit takes precedence due to the immediate physiological impact on the client's health and well-being.
3. What are the external organs of the female collectively known as?
- A. Vulva
- B. Frenulum
- C. Mons veneris
- D. Vestibule
Correct answer: A
Rationale: The correct answer is A: Vulva. The external organs of the female reproductive system, including the labia majora, labia minora, clitoris, vaginal opening, and Bartholin's glands, are collectively known as the vulva. Choice B, Frenulum, is incorrect as it refers to a small band of tissue. Choice C, Mons veneris, specifically refers to the rounded mass of fatty tissue located over the pubic bone, not all external female reproductive organs. Choice D, Vestibule, is incorrect as it is the space enclosed by the labia minora that includes the vaginal and urethral openings, not all external female reproductive organs.
4. A healthcare professional prepares to reinforce instructions to a client who is taking allopurinol (Zyloprim). The healthcare professional plans to include which of the following in the instructions?
- A. Instruct the client to drink 3000 mL of fluid per day.
- B. Instruct the client to take the medication with food.
- C. Inform the client that the effect of the medication will occur immediately.
- D. Instruct the client that, if swelling of the lips occurs, this is a normal expected response.
Correct answer: A
Rationale: Allopurinol is an antigout medication that works by reducing the production of uric acid in the body. To prevent kidney stones and promote the excretion of uric acid, increased fluid intake is essential. Instructing the client to drink 3000 mL of fluid per day helps to reduce the risk of kidney stones and assists in the elimination of uric acid, thereby enhancing the effectiveness of allopurinol therapy.
5. A client arrived to the medical-surgical unit 4 hours after a transurethral resection of the prostate (TURP). A triple-lumen catheter for continuous bladder irrigation with normal saline is infusing, and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take?
- A. Monitoring catheter drainage
- B. Decreasing the flow rate
- C. Irrigating the catheter manually
- D. Discontinuing infusing the solution
Correct answer: C
Rationale: In this scenario, the nurse should choose option C - irrigating the catheter manually. This action can help clear the clots from the catheter and ensure proper bladder drainage. Monitoring catheter drainage (option A) alone may not address the issue of clots obstructing the flow. Decreasing the flow rate (option B) could potentially worsen clot formation. Discontinuing the infusing solution (option D) without addressing the clots first may lead to inadequate irrigation and increase the risk of complications.