HESI RN
HESI RN Exit Exam Capstone
1. At 0600 while admitting a woman for a scheduled repeat cesarean section, the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?
- A. Cancel the surgery
- B. Inform the anesthesia care provider
- C. Ask the client if she has had any other liquids
- D. Proceed with routine preparations
Correct answer: B
Rationale: Drinking liquids before surgery can increase the risk of aspiration during anesthesia. Therefore, the anesthesia care provider must be informed immediately to determine how to proceed, as this could delay or alter the surgical plan. Canceling the surgery without consulting the anesthesia care provider would be premature and could potentially lead to unnecessary actions. Asking the client if she has had any other liquids is important but not the first priority. Proceeding with routine preparations without addressing the potential issue of ingesting liquids before surgery could compromise the client's safety.
2. The nurse is providing discharge teaching to a client with coronary artery disease (CAD). Which of the following statements by the client indicates a need for further teaching?
- A. I will take my medication only when I have chest pain.
- B. I will follow a heart-healthy diet and exercise regularly.
- C. I will avoid smoking and limit alcohol intake.
- D. I will contact my doctor if I experience chest pain or shortness of breath.
Correct answer: A
Rationale: The statement indicates a misunderstanding because medication for CAD should be taken as prescribed, not only when chest pain occurs.
3. A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which intervention is most important?
- A. Administer intravenous fluids as prescribed.
- B. Monitor the client's urine output.
- C. Administer insulin as prescribed.
- D. Administer 50% dextrose IV push.
Correct answer: C
Rationale: Administering insulin is the most important intervention in managing diabetic ketoacidosis. In DKA, there is a lack of insulin leading to hyperglycemia and ketosis. Insulin administration helps to reduce blood glucose levels and correct metabolic acidosis, which are crucial in treating DKA. Administering intravenous fluids helps with dehydration, monitoring urine output is important to assess renal function, but the priority is addressing the underlying cause of DKA by administering insulin. Administering 50% dextrose IV push is incorrect as it would further elevate blood glucose levels, which is contraindicated in DKA.
4. A client with Parkinson's disease is prescribed levodopa/carbidopa. The nurse instructs the client to take the medication with meals. Which rationale should the nurse provide for taking the medication with food?
- A. It enhances the effectiveness of the medication
- B. It helps to improve absorption
- C. It prevents orthostatic hypotension
- D. It reduces gastrointestinal upset
Correct answer: D
Rationale: The correct answer is D: 'It reduces gastrointestinal upset.' Levodopa/carbidopa can cause nausea and other gastrointestinal side effects. Taking the medication with food can help reduce these side effects and improve the client's comfort. Choices A, B, and C are incorrect because taking the medication with food does not primarily enhance effectiveness, improve absorption, or prevent orthostatic hypotension. The main reason for advising to take the medication with meals is to minimize gastrointestinal upset.
5. A client without a history of respiratory disease has a pulse oximeter in place after surgery. The nurse monitors the pulse oximeter readings to ensure that oxygen saturation remains above:
- A. 85%
- B. 89%
- C. 95%
- D. 100%
Correct answer: C
Rationale: Pulse oximetry is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2). In the absence of underlying respiratory disease, the expected oxygen saturation level is at least 95%. Oxygen saturation levels below 95% may indicate hypoxemia, which can compromise tissue perfusion and oxygen delivery to vital organs. Therefore, maintaining oxygen saturation above 95% is crucial to ensure adequate oxygenation post-surgery. Choices A, B, and D are incorrect as they represent oxygen saturation levels that are below the expected value for a client without a history of respiratory disease, which should be at least 95%.