HESI RN
RN HESI Exit Exam Capstone
1. The nurse is caring for a group of clients with the help of a PN. Which nursing actions should the nurse assign to the PN?
- A. All of the above
- B. Administer a dose of insulin per sliding scale for a client with Type 2 DM
- C. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty
- D. Perform daily surgical dressing change for a client who had an abdominal hysterectomy
Correct answer: A
Rationale: All of these tasks fall within the PN's scope of practice, which includes performing surgical dressing changes, taking postoperative vital signs, and administering insulin under supervision. The RN can delegate these tasks to the PN safely. Choice A is the correct answer because all the tasks mentioned are appropriate for delegation to a PN. Choice B should not be assigned to a PN as only RNs should administer insulin. Choice C is suitable for delegation to a PN as obtaining vital signs falls within their scope of practice. Choice D is also appropriate for delegation to a PN as performing surgical dressing changes is within their scope of practice.
2. An older adult client with eye dryness reports itching and excessive tearing. Which medication group is most likely to have produced this client's symptoms?
- A. Antiinfectives and antidepressants.
- B. Anticoagulants and antihistamines.
- C. Antiretrovirals and antivirals.
- D. Antihypertensives and anticholinergics.
Correct answer: D
Rationale: The correct answer is D: Antihypertensives and anticholinergics. Anticholinergics are known to cause dryness of secretions, including dry eyes, which can lead to symptoms of eye dryness, itching, and excessive tearing as reported by the client. Choices A, B, and C are incorrect as they do not typically cause the symptoms described by the client. Antiinfectives, antidepressants, anticoagulants, antihistamines, antiretrovirals, and antivirals do not commonly lead to dry eyes, itching, and excessive tearing.
3. A client with pneumonia is receiving oxygen via nasal cannula at 2 L/min. What assessment finding indicates the need for further intervention?
- A. The client reports feeling short of breath.
- B. The client's oxygen saturation is 92%.
- C. The client's respiratory rate is 20 breaths per minute.
- D. The client is unable to complete sentences without pausing.
Correct answer: D
Rationale: The correct answer is D because the inability to complete sentences without pausing indicates respiratory distress and the need for immediate intervention. This finding suggests an increased work of breathing and inadequate oxygenation. Choices A, B, and C are not as urgent as choice D. Feeling short of breath (choice A) is expected in pneumonia but does not necessarily indicate the need for immediate intervention. An oxygen saturation of 92% (choice B) is slightly below the normal range but may not require immediate intervention. A respiratory rate of 20 breaths per minute (choice C) is within the normal range and does not signify an urgent need for intervention.
4. When assessing a client with a diagnosis of bipolar disorder who reports taking a handful of medications, what information is most important to obtain?
- A. What drugs the client used in the suicide attempt.
- B. When the client last took medications for bipolar disorder.
- C. Whether the client has attempted suicide before.
- D. Which family member has the suicide note.
Correct answer: A
Rationale: The correct answer is to obtain information on what drugs the client used in the suicide attempt. This information is crucial for assessing the severity of the overdose, potential drug interactions, and determining the appropriate treatment plan. Choice B is not as urgent as identifying the drugs taken during the suicide attempt. Choice C, while important, is not as immediately critical as knowing the specific medications involved. Choice D is unrelated to the immediate medical needs of the client.
5. The nurse is providing care for a client with heart failure who is prescribed furosemide. Which laboratory value should the nurse monitor closely?
- A. Calcium level
- B. Sodium level
- C. Magnesium level
- D. Potassium level
Correct answer: D
Rationale: The correct answer is D: Potassium level. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Monitoring potassium levels is crucial to prevent complications such as cardiac arrhythmias. While calcium, sodium, and magnesium levels are important in various conditions and treatments, they are not the primary electrolyte affected by furosemide.
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