HESI RN
HESI 799 RN Exit Exam Capstone
1. The nurse is caring for a client with an indwelling urinary catheter. Which of the following actions should the nurse prioritize to prevent infection?
- A. Maintain a closed drainage system
- B. Cleanse the catheter insertion site daily
- C. Increase the client's fluid intake
- D. Empty the collection bag every 4 hours
Correct answer: A
Rationale: The correct answer is to maintain a closed drainage system. This action is crucial in preventing infection as it helps prevent bacteria from entering the urinary tract. While cleansing the catheter insertion site and ensuring adequate hydration are important aspects of catheter care, the top priority is maintaining the integrity of the closed system to prevent infection. Emptying the collection bag regularly is also important but not as critical as ensuring a closed drainage system to minimize infection risk.
2. A male client with diabetes mellitus type 2, who is taking pioglitazone PO daily, reports to the nurse the recent onset of nausea, accompanied by dark-colored urine, and a yellowish cast to his skin. What instructions should the nurse provide?
- A. Seek immediate medical assistance to evaluate the cause of these symptoms.
- B. Discontinue the medication and follow up with a healthcare provider.
- C. Increase fluid intake and monitor urine color.
- D. Continue taking the medication and report any changes.
Correct answer: A
Rationale: The correct answer is A: 'Seek immediate medical assistance to evaluate the cause of these symptoms.' The symptoms described by the client, including nausea, dark-colored urine, and yellowish skin, are indicative of possible liver toxicity, a serious side effect of pioglitazone. Therefore, immediate medical evaluation is necessary to assess the severity of the condition and prevent further complications. Choices B, C, and D are incorrect: B advises discontinuing the medication without seeking immediate medical assistance, which could delay necessary treatment; C focuses solely on increasing fluid intake and monitoring urine color, overlooking the urgency of the situation; and D suggests continuing the medication when prompt evaluation is crucial in this scenario.
3. A client with a spinal cord injury is admitted to the ICU. Which nursing intervention is most important to include in this client's plan of care?
- A. Monitor for signs of autonomic dysreflexia.
- B. Implement measures to prevent pressure ulcers.
- C. Perform passive range of motion exercises.
- D. Ensure that the client is turned every two hours.
Correct answer: A
Rationale: The correct answer is A: Monitor for signs of autonomic dysreflexia. Autonomic dysreflexia is a life-threatening condition that can occur in clients with spinal cord injuries, especially those with injuries above the T6 level. It is characterized by a sudden onset of excessively high blood pressure, pounding headache, profuse sweating, and flushing above the level of injury. Failure to recognize and treat autonomic dysreflexia promptly can lead to seizures, stroke, or even death. Therefore, monitoring for signs of autonomic dysreflexia is crucial in clients with spinal cord injuries. Choices B, C, and D are important interventions too, but in the context of a spinal cord injury, monitoring for autonomic dysreflexia takes priority due to its potentially life-threatening nature.
4. A child is recovering from an appendectomy. The parent asks when the child can resume normal activities. What is the best response by the nurse?
- A. The child can resume normal activities as soon as they feel up to it
- B. The child should avoid strenuous activities for at least 2 weeks
- C. The child can resume normal activities after the stitches are removed
- D. The child should avoid all physical activities for the next month
Correct answer: B
Rationale: After an appendectomy, it is important for the child to avoid strenuous activities for at least 2 weeks to allow for proper healing. Resuming normal activities too soon can put unnecessary strain on the healing process and increase the risk of complications.
5. A client with a history of adrenal insufficiency is admitted with acute adrenal crisis. The client complains of nausea and joint pain, vital signs show a temperature of 102°F, heart rate of 138, and blood pressure of 80/60. Which intervention should the nurse implement first?
- A. Obtain an analgesic prescription.
- B. Infuse an intravenous fluid bolus.
- C. Administer PRN oral antipyretic.
- D. Cover the client with a cooling blanket.
Correct answer: B
Rationale: In acute adrenal crisis, the priority intervention is to infuse an intravenous fluid bolus to address the hypotension (blood pressure of 80/60) and help stabilize the client's condition. Adequate fluid volume is crucial in managing adrenal insufficiency crisis. Options A, C, and D do not directly address the hypotension and fluid volume depletion that are critical in this situation. Analgesics, antipyretics, and cooling blankets may be considered later, but the immediate focus should be on fluid resuscitation.