HESI RN
HESI RN Exit Exam 2024 Capstone
1. The nurse is providing education to a client who experiences recurrent levels of moderate anxiety in response to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?
- A. Practice using muscle relaxation techniques
- B. Take medication only when anxiety is at its worst
- C. Avoid interactions that trigger stress
- D. Engage in exercise during anxious periods
Correct answer: A
Rationale: Teaching relaxation techniques, such as muscle relaxation, helps the client manage anxiety more effectively. These techniques can be practiced regularly to reduce overall anxiety and can complement prescribed medications. Choice B is incorrect because medication should be taken as prescribed, not only when anxiety is at its worst. Choice C is incorrect as avoiding interactions that trigger stress may not always be feasible and does not teach the client coping mechanisms. Choice D is incorrect as engaging in exercise during anxious periods may not be the most effective strategy for managing moderate anxiety levels.
2. 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.
3. The nurse is preparing to administer a subcutaneous injection to a thin, elderly client. What is the most appropriate site for the injection?
- A. Dorsal aspect of the upper arm.
- B. Upper outer thigh.
- C. Lower abdomen.
- D. Lateral aspect of the upper arm.
Correct answer: B
Rationale: The correct answer is the upper outer thigh. In thin, elderly clients, the upper outer thigh is a recommended site for subcutaneous injections due to the presence of adequate subcutaneous tissue and muscle mass. The dorsal aspect of the upper arm may not provide enough subcutaneous tissue for proper absorption of the medication. The lower abdomen is not ideal for thin individuals as it may lead to injection into muscle rather than subcutaneous tissue. The lateral aspect of the upper arm is also not a commonly recommended site for subcutaneous injections.
4. A client tells the nurse about working out with a personal trainer and swimming three times a week in an effort to lose weight and sleep better. The client states that it still takes hours to fall asleep at night. Which action should the nurse implement?
- A. Advise the client to reduce exercise intensity
- B. Ask the client for a description of the exercise schedule that is being followed
- C. Encourage the client to try relaxation techniques before bed
- D. Suggest avoiding water-based exercise before bed
Correct answer: B
Rationale: Asking the client for a description of the exercise schedule being followed is the most appropriate action for the nurse to take in this scenario. Understanding the timing and intensity of the client's exercise routine can help identify if the activity is contributing to sleep disturbances. Exercise too close to bedtime can cause difficulty falling asleep. Choices A, C, and D do not directly address the need to assess the exercise schedule and may not provide the necessary information to identify the potential cause of the client's sleep issue.
5. A client with hypothyroidism is prescribed levothyroxine. What assessment finding suggests the medication dosage is too high?
- A. Increased sensitivity to cold.
- B. Increased heart rate and palpitations.
- C. Improved energy levels.
- D. Improved tolerance to heat.
Correct answer: B
Rationale: The correct answer is B: Increased heart rate and palpitations. When a client with hypothyroidism is prescribed levothyroxine, these symptoms may indicate that the dosage is too high, causing the client to develop hyperthyroidism. Choices A, C, and D are incorrect. Increased sensitivity to cold is a symptom of hypothyroidism, improved energy levels are an expected outcome of levothyroxine therapy for hypothyroidism, and improved tolerance to heat is not a common sign of levothyroxine overdose.
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