HESI RN
HESI RN Exit Exam Capstone
1. The nurse is caring for a client with pancreatitis who is receiving total parenteral nutrition (TPN). Which assessment finding requires immediate intervention by the nurse?
- A. Blood glucose level of 200 mg/dL
- B. The client reports feeling weak and shaky
- C. The TPN bag is 5% dextrose
- D. The client reports feeling thirsty
Correct answer: B
Rationale: The correct answer is B. Weakness and shakiness can indicate hypoglycemia, a potential complication of TPN. Immediate intervention is necessary to assess blood glucose levels and provide treatment as needed. Choice A is incorrect because a blood glucose level of 200 mg/dL is within an acceptable range and does not require immediate intervention. Choice C is incorrect as a 5% dextrose TPN bag is a standard concentration. Choice D is also incorrect as feeling thirsty is not a critical assessment finding requiring immediate intervention in this context.
2. A client with a history of hypertension is prescribed a beta-blocker. Which client statement indicates that further teaching is needed?
- A. ‘I will take my medication in the morning before breakfast.’
- B. ‘I should avoid eating foods high in potassium.’
- C. ‘I should change positions slowly to avoid dizziness.’
- D. ‘I should avoid abrupt discontinuation of the medication.’
Correct answer: B
Rationale: The correct answer is B: ‘I should avoid eating foods high in potassium.’ This statement indicates a misunderstanding as beta-blockers do not typically affect potassium levels. The other choices (A, C, and D) are all appropriate statements for a client prescribed a beta-blocker. Choice A shows understanding of the timing of medication administration, choice C addresses orthostatic hypotension concerns, and choice D highlights the importance of not abruptly stopping the medication to prevent adverse effects.
3. What maternal behavior is typically observed when a new mother first receives her infant?
- A. She eagerly reaches for the infant, undresses the infant, and examines the infant completely.
- B. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips.
- C. Her arms and hands receive the infant and she then cuddles the infant to her own body.
- D. She eagerly reaches for the infant and then holds the infant close to her own body.
Correct answer: B
Rationale: When a new mother first receives her infant, a typical maternal behavior is to use her arms and hands to receive the infant and then trace the infant's profile with her fingertips. This action is a gentle way of bonding with the newborn and aids in recognizing the infant's features. Choices A, C, and D are incorrect as they do not accurately describe the common behavior of tracing the infant's profile, which is a significant part of the initial interaction between a mother and her newborn.
4. During the counseling session, you can also use the acronym, CLEAR. The letter E stands for:
- A. Encourage and assure the client of effective use of the method
- B. Explain how to use the method
- C. Tell the client about modern FP methods available, and discuss each in detail
- D. Explain all possible complications
Correct answer: B
Rationale: The correct answer is B: 'Explain how to use the method.' In the acronym CLEAR, the letter E specifically refers to explaining how to use the method, emphasizing the importance of providing clear instructions and guidance to the client. Choices A, C, and D are incorrect because they do not accurately represent what the letter E stands for in the given context. Encouraging and assuring the client, discussing modern FP methods in detail, and explaining possible complications are important aspects of counseling but do not align with the specific focus of 'Explain how to use the method,' as indicated by the acronym.
5. Which client requires careful nursing assessment for signs and symptoms of hypomagnesaemia?
- A. A young adult client with intractable vomiting due to food poisoning
- B. A client who developed hyperparathyroidism in late adolescence
- C. A middle-aged male client in renal failure following an unsuccessful kidney transplant
- D. A female client who excessively consumes simple carbohydrates
Correct answer: C
Rationale: The correct answer is C. Clients in renal failure are at high risk for hypomagnesemia due to their impaired kidney function. Renal failure can lead to decreased excretion of magnesium, resulting in its buildup in the body and potential hypomagnesemia. This client requires careful nursing assessment for signs and symptoms of hypomagnesemia to prevent complications. Choices A, B, and D are not as directly associated with renal failure and its impact on magnesium levels. Intractable vomiting, hyperparathyroidism, and excessive consumption of simple carbohydrates may have other health implications but are not as strongly linked to hypomagnesemia as renal failure.