HESI RN
HESI 799 RN Exit Exam Capstone
1. A client with anxiety disorder is experiencing increased anxiety prior to vaginal delivery. What should the nurse’s initial action be?
- A. Increase the client's sedative dose
- B. Encourage the client to express her feelings and provide emotional support
- C. Initiate breathing techniques to manage anxiety
- D. Administer anxiolytic medication to calm the client
Correct answer: B
Rationale: The correct initial action for a client with anxiety disorder experiencing increased anxiety prior to vaginal delivery is to encourage the client to express her feelings and provide emotional support. Emotional support is crucial in reducing anxiety during childbirth. Initiating breathing techniques or administering medications should come after emotional support has been provided. Increasing sedative doses may not address the underlying emotional needs of the client and can have potential risks.
2. A client with advanced chronic kidney disease (CKD) is scheduled for hemodialysis. Which dietary instruction should the nurse provide to the client?
- A. Limit fluid intake to prevent fluid overload
- B. Increase sodium intake to improve fluid balance
- C. Increase potassium intake to prevent hypokalemia
- D. Increase protein intake to promote healing
Correct answer: A
Rationale: The correct answer is A: 'Limit fluid intake to prevent fluid overload.' Clients with advanced chronic kidney disease are at risk of fluid retention, which can lead to complications like fluid overload and hypertension. Therefore, it is crucial to instruct the client to limit fluid intake. Choice B is incorrect because increasing sodium intake can exacerbate fluid retention and hypertension in clients with CKD. Choice C is incorrect as increasing potassium intake can be dangerous for clients with CKD who may already have elevated potassium levels. Choice D is incorrect because while protein intake may need to be adjusted for clients on hemodialysis, the priority in this case is managing fluid intake.
3. What does the nurse's signature on the client’s surgical consent form signify?
- A. The client voluntarily grants permission for the procedure to be done
- B. The client is competent to sign the consent without impairment of judgment
- C. The client understands the risks and benefits associated with the procedure
- D. The client has signed the form freely and voluntarily
Correct answer: A
Rationale: The nurse's signature on a surgical consent form signifies that the client voluntarily grants permission for the procedure to be done. This is the correct answer because the nurse's signature does not imply the client's competence, understanding of risks and benefits, or that the client signed the form freely and voluntarily. The nurse's role is to verify that the client has made an informed decision and is providing consent for the procedure.
4. The nurse leading a medical-surgical unit care team assigns client care to a PN and a UAP. Which task should the nurse delegate to the UAP?
- A. Assess a client's pain level post-surgery
- B. Turn and reposition a client with a total hip replacement
- C. Administer a dose of insulin per sliding scale
- D. Change a postoperative dressing
Correct answer: B
Rationale: Turning and repositioning a client is within the scope of practice of a UAP. This task helps prevent pressure ulcers and assists in maintaining the client's comfort and mobility. Assessing pain level post-surgery requires clinical judgment and interpretation, making it appropriate for a PN or RN. Administering medication like insulin involves critical thinking and potential adjustments based on the client's condition, which is the responsibility of a licensed nurse. Changing postoperative dressings involves wound assessment, infection control, and knowledge of aseptic techniques, tasks that fall under the purview of a PN or RN.
5. A client with chronic kidney disease is prescribed erythropoietin. What is the nurse's priority action?
- A. Monitor the client's hemoglobin and hematocrit.
- B. Monitor the client's blood pressure.
- C. Assess the client for signs of infection.
- D. Monitor the client for signs of bleeding.
Correct answer: A
Rationale: The correct answer is A: 'Monitor the client's hemoglobin and hematocrit.' When a client with chronic kidney disease is prescribed erythropoietin, the nurse's priority action is to monitor the client's hemoglobin and hematocrit. Erythropoietin stimulates red blood cell production, so monitoring these lab values helps evaluate the effectiveness of erythropoietin in treating anemia. Monitoring the client's blood pressure (choice B) is important but not the priority in this scenario. Assessing the client for signs of infection (choice C) is important but not the priority related to the prescription of erythropoietin. Monitoring the client for signs of bleeding (choice D) is relevant but not the priority action when erythropoietin is prescribed.
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