HESI RN
HESI 799 RN Exit Exam Capstone
1. The nurse is caring for a 24-month-old toddler who has sensory sensitivity, difficulty engaging in social interactions, and has not yet spoken two-word phrases. Which assessment should the nurse administer?
- A. Peabody Picture Vocabulary Test
- B. The Modified Checklist for Autism in Toddlers (M-CHAT)
- C. Wechsler Preschool and Primary Scale of Intelligence
- D. Denver Developmental Screening Test
Correct answer: B
Rationale: The Modified Checklist for Autism in Toddlers (M-CHAT) is specifically designed to screen for autism spectrum disorders in young children. It is appropriate for this child, given the signs of social and communication delays. The Peabody Picture Vocabulary Test (Choice A) assesses receptive vocabulary and may not capture the social and communication aspects seen in autism. The Wechsler Preschool and Primary Scale of Intelligence (Choice C) measures cognitive ability and may not address the social and communication delays. The Denver Developmental Screening Test (Choice D) is a broad developmental assessment tool, but the M-CHAT is more specific to screening for autism in this case.
2. The nurse is caring for a client who is scheduled for hemodialysis. Which of the following laboratory values should the nurse monitor closely before, during, and after the procedure?
- A. Hemoglobin level.
- B. Blood urea nitrogen (BUN) level.
- C. Creatinine level.
- D. Serum potassium level.
Correct answer: D
Rationale: The correct answer is D: Serum potassium level. Before, during, and after hemodialysis, monitoring the serum potassium level is crucial to prevent hyperkalemia, a potentially life-threatening complication. Hemodialysis is done to remove waste products and excess electrolytes like potassium from the blood. Monitoring other laboratory values like hemoglobin, BUN, and creatinine is important in assessing kidney function and anemia, but serum potassium level requires close monitoring during hemodialysis due to the risk of rapid shifts that can lead to cardiac arrhythmias.
3. A client is scheduled for a spiral CT scan with contrast to evaluate for pulmonary embolism. Which information in the client's history requires follow-up by the nurse?
- A. Is allergic to shellfish
- B. Has a history of smoking
- C. Takes metformin for type 2 diabetes mellitus
- D. Has hypertension controlled with medication
Correct answer: A
Rationale: An allergy to shellfish often indicates an allergy to iodine, which is used in contrast dyes for CT scans. This poses a significant risk of an allergic reaction during the procedure. The nurse must ensure appropriate precautions or alternative imaging are considered. Choices B, C, and D are not directly contraindicated for a CT scan with contrast. Smoking history, metformin use, and controlled hypertension do not typically impact the safety or feasibility of the procedure.
4. Which hormone is released from the testes?
- A. Progesterone
- B. Vasopressin
- C. Testosterone
- D. None of the above
Correct answer: C
Rationale: The correct answer is testosterone. Testosterone is the primary male sex hormone produced in the testes. Progesterone is a female sex hormone primarily produced in the ovaries, not in the testes. Vasopressin is a hormone released by the pituitary gland to regulate water balance in the body, not produced by the testes. Therefore, choices A, B, and D are incorrect.
5. What intervention should the nurse implement first for a male toddler brought to the emergency center approximately three hours after swallowing tablets from his grandmother's bottle of digoxin (Lanoxin)?
- A. Administer activated charcoal
- B. Prepare gastric lavage
- C. Obtain a 12-lead electrocardiogram
- D. Give IV digoxin immune fab (Digibind)
Correct answer: A
Rationale: Administering activated charcoal is the priority intervention as it binds with digoxin, preventing further absorption in the gastrointestinal tract. This helps reduce the amount of digoxin available for systemic circulation and minimizes its toxic effects. Gastric lavage is no longer recommended due to potential complications and lack of evidence of efficacy. Obtaining an electrocardiogram may help assess the effects of digoxin toxicity, but it is not the initial priority. IV digoxin immune fab (Digibind) is used in severe cases of digoxin toxicity but is not the first-line intervention.