HESI RN
HESI RN Exit Exam 2023 Capstone
1. A client is diagnosed with chronic renal failure, and the nurse is teaching dietary modifications. What should be limited in this client's diet?
- A. Carbohydrates
- B. Fats
- C. Proteins
- D. Vitamins
Correct answer: C
Rationale: In chronic renal failure, proteins should be limited in the diet. When the kidneys are not functioning well, the buildup of protein byproducts can put additional stress on them. Limiting protein intake can help reduce the burden on the kidneys. Carbohydrates and fats do not need to be restricted in the same way as proteins. Vitamins are essential nutrients that should not be limited in the diet unless specified by a healthcare provider for a specific reason.
2. A client with pneumonia is receiving antibiotics and oxygen therapy. What assessment finding requires immediate intervention?
- A. Productive cough with yellow sputum.
- B. Oxygen saturation of 88%.
- C. Respiratory rate of 20 breaths per minute.
- D. Heart rate of 90 beats per minute.
Correct answer: B
Rationale: An oxygen saturation of 88% indicates hypoxemia, which is a critical condition requiring immediate intervention to improve oxygenation. Hypoxemia can lead to tissue hypoxia and further complications. A productive cough with yellow sputum is common in pneumonia but may not require immediate intervention unless it worsens or is associated with other concerning symptoms. A respiratory rate of 20 breaths per minute is within the normal range, indicating adequate ventilation. A heart rate of 90 beats per minute is also within a normal range and may not require immediate intervention unless it is accompanied by other abnormal findings.
3. A client with chronic obstructive pulmonary disease (COPD) is receiving supplemental oxygen. The client reports feeling short of breath and has a respiratory rate of 28 breaths per minute. What should the nurse do first?
- A. Increase the oxygen flow rate
- B. Notify the healthcare provider
- C. Administer a bronchodilator
- D. Elevate the head of the bed
Correct answer: D
Rationale: Elevating the head of the bed promotes lung expansion and improves oxygenation, making it the priority intervention for a client with shortness of breath. This position helps in maximizing lung expansion and aiding ventilation-perfusion matching in patients with COPD. Increasing the oxygen flow rate may be necessary but should come after optimizing the client's positioning. Notifying the healthcare provider and administering a bronchodilator are not the initial interventions for addressing shortness of breath in a client with COPD.
4. A client with a ruptured spleen underwent an emergency splenectomy. Twelve hours later, the client’s urine output is 25 ml/hour. What is the most likely cause?
- A. This is a normal finding after surgery.
- B. Oliguria signals tubular necrosis related to hypoperfusion.
- C. Oliguria signals dehydration and fluid loss.
- D. Urine output of 25 ml/hour is an expected finding after splenectomy.
Correct answer: B
Rationale: Oliguria, or decreased urine output, after surgery can indicate tubular necrosis due to hypoperfusion, which may require intervention to restore renal function. Choice A is incorrect as oliguria is not a normal finding after surgery. Choice C is incorrect because dehydration is less likely in this context compared to tubular necrosis. Choice D is incorrect as a urine output of 25 ml/hour is not expected after splenectomy and should raise concern for renal impairment.
5. A client with diabetes mellitus presents with a blood sugar level of 320 mg/dL. What is the nurse's initial action?
- A. Administer sliding scale insulin as prescribed
- B. Encourage the client to drink fluids
- C. Provide the client with a carbohydrate snack
- D. Assess the client for signs of hypoglycemia
Correct answer: A
Rationale: When a client with diabetes mellitus presents with a high blood sugar level of 320 mg/dL, the nurse's initial action should be to administer sliding scale insulin as prescribed. The priority is to bring down the elevated glucose level promptly to prevent further complications. Encouraging the client to drink fluids or providing a carbohydrate snack would not effectively address the elevated blood sugar level in this scenario. Assessing for signs of hypoglycemia is not appropriate as the client's blood sugar level is high, not low.
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