HESI RN
HESI RN Exit Exam Capstone
1. A postoperative client with a history of diabetes mellitus is showing signs of hyperglycemia. What should the nurse assess first?
- A. Assess for signs of infection.
- B. Monitor the client’s fluid intake and output.
- C. Check the client’s capillary blood glucose level.
- D. Assess the client’s serum potassium level.
Correct answer: C
Rationale: The correct answer is to check the client’s capillary blood glucose level first. In a postoperative client with a history of diabetes mellitus showing signs of hyperglycemia, assessing blood glucose levels is crucial to confirm hyperglycemia and initiate appropriate interventions. While signs of infection are important to assess due to the client's postoperative status and diabetic history, checking the blood glucose level takes precedence to address the immediate concern of hyperglycemia. Monitoring fluid intake and output is essential but not the priority in this scenario. Assessing the client’s serum potassium level is important for overall assessment but not the initial step when hyperglycemia is suspected.
2. While suctioning a tracheostomy tube, the client starts to cough. What is the best action for the nurse to take?
- A. Suction deeper to remove secretions.
- B. Gently withdraw suction tubing to allow suction or coughing out of mucus.
- C. Remove the suction as quickly as possible.
- D. Insert and remove the suction multiple times to clear secretions.
Correct answer: B
Rationale: When a client coughs during tracheostomy tube suctioning, the nurse should gently withdraw the suction tubing. This action allows the client to cough out mucus naturally, reducing the risk of further irritation and promoting effective airway clearance. Choice A is incorrect because suctioning deeper can cause trauma and increase the risk of complications. Choice C is incorrect as removing the suction quickly may not allow the client to clear the mucus adequately. Choice D is incorrect as inserting and removing the suction multiple times can lead to unnecessary trauma and discomfort for the client.
3. The provider has ordered Kayexalate and sorbitol to be administered to a patient. The nurse caring for this patient would expect which serum electrolyte values prior to administration of this therapy?
- A. Sodium 125 mEq/L and potassium 2.5 mEq/L
- B. Sodium 150 mEq/L and potassium 3.6 mEq/L
- C. Sodium 135 mEq/L and potassium 6.9 mEq/L
- D. Sodium 148 mEq/L and potassium 5.5 mEq/L
Correct answer: C
Rationale: Severe hyperkalemia, with a potassium level of 6.9 mEq/L, requires aggressive treatment with Kayexalate and sorbitol to increase the body’s excretion of potassium. The normal range for serum potassium is 3.5 to 5.5 mEq/L, so patients with the other potassium levels would not be treated aggressively or would need potassium supplementation. Therefore, option C (Sodium 135 mEq/L and potassium 6.9 mEq/L) is the correct choice as it indicates severe hyperkalemia warranting the administration of Kayexalate and sorbitol. Options A, B, and D have either potassium levels within normal limits, which would not necessitate this aggressive treatment, or potassium levels that are lower than what would typically prompt the need for Kayexalate and sorbitol.
4. The nurse is caring for a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value should be monitored closely?
- A. Serum potassium
- B. Hemoglobin
- C. Serum sodium
- D. White blood cell count
Correct answer: A
Rationale: The correct answer is A: Serum potassium. When a client with chronic kidney disease is undergoing erythropoietin therapy, monitoring serum potassium levels is crucial. Erythropoietin can stimulate red blood cell production, which may lead to an increase in potassium levels, predisposing the client to hyperkalemia. Monitoring serum potassium levels helps in early detection of hyperkalemia and appropriate intervention. Choices B, C, and D are incorrect because although hemoglobin, serum sodium, and white blood cell count are important parameters to monitor in various clinical conditions, they are not specifically associated with erythropoietin therapy in chronic kidney disease.
5. A postmenopausal client asks the nurse why she is experiencing discomfort during intercourse. What response is best for the nurse to provide?
- A. Estrogen deficiency causes the vaginal tissues to become dry and thinner.
- B. Infrequent intercourse results in the vaginal tissues losing their elasticity.
- C. Dehydration from inadequate fluid intake causes vulva tissue dryness.
- D. Lack of adequate stimulation is the most common reason for dyspareunia.
Correct answer: A
Rationale: Estrogen deficiency in postmenopausal clients leads to a decrease in the moisture-secreting capacity of vaginal cells. This results in vaginal tissues becoming thinner, drier, and smoother, which reduces vaginal stretching and contributes to discomfort during intercourse. Choice B is incorrect because the primary reason for discomfort is not infrequent intercourse but rather physiological changes due to estrogen deficiency. Choice C is incorrect as dehydration may cause dryness but is not the primary reason for discomfort in this scenario. Choice D is incorrect as lack of stimulation is not the most common reason for dyspareunia in postmenopausal clients; estrogen deficiency is the key factor.