HESI RN
HESI RN Exit Exam Capstone
1. The nurse observes that a client’s wrist restraint is secured to the side rail of the bed. What action should the nurse take?
- A. Ensure that the restraint is snug against the client’s wrist.
- B. Reposition the restraint tie onto the bedframe.
- C. Double knot the restraint to ensure safety.
- D. Leave the restraint in place and notify the healthcare provider.
Correct answer: B
Rationale: The correct action for the nurse to take is to reposition the restraint tie onto the bedframe. Restraints should always be secured to the bedframe, not the side rails, to prevent injury to the client in case the bed is adjusted. Choice A is incorrect because the issue is with the attachment point, not the snugness of the restraint. Choice C is incorrect as double knotting the restraint does not address the incorrect attachment point. Choice D is incorrect as the nurse should not leave the restraint in the wrong position; instead, it should be moved to the correct location on the bedframe.
2. During a follow-up visit, a client with diabetes reports difficulty maintaining a healthy diet. What should the nurse do first?
- A. Provide the client with meal planning resources
- B. Explore the client's dietary habits and challenges
- C. Refer the client to a nutritionist
- D. Educate the client on the importance of a healthy diet
Correct answer: B
Rationale: When a client with diabetes reports difficulty in maintaining a healthy diet, the initial action should be to explore the client's dietary habits and challenges. By doing so, the nurse can identify specific issues and barriers the client faces, which is crucial in developing a personalized and effective intervention plan. Providing meal planning resources (Choice A) can be beneficial later but should come after understanding the client's unique situation. Referring the client to a nutritionist (Choice C) may be necessary in some cases but should follow an assessment of the client's current challenges. Simply educating the client on the importance of a healthy diet (Choice D) does not address the specific difficulties the client is facing and may not lead to sustainable behavior change.
3. A client with end-stage renal disease (ESRD) is receiving hemodialysis. Which laboratory value should the nurse monitor closely?
- A. Serum calcium level of 9 mg/dl
- B. Serum potassium level of 4.5 mEq/L
- C. Serum creatinine level of 2.0 mg/dl
- D. Serum sodium level of 138 mEq/L
Correct answer: C
Rationale: The correct answer is C: Serum creatinine level of 2.0 mg/dl. In a client with ESRD receiving hemodialysis, serum creatinine should be closely monitored. Elevated creatinine levels indicate impaired kidney function. Monitoring serum calcium levels (Choice A), serum potassium levels (Choice B), and serum sodium levels (Choice D) is also important in clients with ESRD, but the most crucial indicator of kidney function in this case is serum creatinine.
4. The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. What information should the nurse explore in-depth with the client based on this screening tool?
- A. Consumption, liver enzymes, gastrointestinal complaints, and bleeding.
- B. Minimizing drinking, frequently missing family events, guilt about drinking, and amount of daily intake.
- C. Cancer screening results, anger, gastritis, daily alcohol intake.
- D. Efforts to cut down, annoyance with questions, guilt, drinking as an “Eye-opener.”
Correct answer: D
Rationale: The correct answer is D. The CAGE questionnaire is a screening tool for alcohol use disorder. Each letter in CAGE represents a key question: Cutting down, Annoyance by criticisms, Guilty feelings, and Eye-openers. These questions help assess problematic drinking behaviors and can provide valuable insights into the client's alcohol consumption habits. Choices A, B, and C do not directly align with the specific areas of inquiry covered by the CAGE questionnaire, making them incorrect. Therefore, the nurse should focus on exploring the client's efforts to cut down, annoyance with questions, feelings of guilt, and the use of alcohol as an “Eye-opener” based on this screening tool.
5. The healthcare provider is caring for a 7-year-old patient who will receive oral antibiotics. Which antibiotic order will the healthcare provider question for this patient?
- A. Azithromycin (Zithromax)
- B. Clarithromycin (Biaxin)
- C. Clindamycin (Cleocin)
- D. Tetracycline (Sumycin)
Correct answer: D
Rationale: The correct answer is D, Tetracycline (Sumycin). Tetracyclines should not be given to children younger than 8 years of age because they irreversibly discolor the permanent teeth. Azithromycin, Clarithromycin, and Clindamycin are antibiotics that are generally safe for use in children and do not have the same tooth discoloration side effect as Tetracycline. Therefore, these antibiotics would be more appropriate choices for a 7-year-old patient.