HESI RN
HESI RN Exit Exam 2023 Capstone
1. A client undergoing chemotherapy reports extreme fatigue. What should the nurse recommend to manage this symptom?
- A. Increase the dose of chemotherapy.
- B. Rest when needed and maintain a balanced diet.
- C. Perform light physical activity to reduce fatigue.
- D. Consider delaying the chemotherapy treatment.
Correct answer: B
Rationale: The correct recommendation for managing chemotherapy-induced fatigue is to advise the client to rest when needed and maintain a balanced diet. Increasing the dose of chemotherapy (Choice A) would exacerbate the fatigue and other side effects. While light physical activity (Choice C) can be beneficial, extreme fatigue may require more rest initially. Delaying chemotherapy treatment (Choice D) should only be considered after consultation with the healthcare provider, as timely treatment is usually crucial in cancer care.
2. What information should the nurse include in the client's health record after a fall in the bathroom?
- A. Client fell while trying to go to the bathroom
- B. The UAP left the client alone and a fall occurred
- C. The client was found on the floor with no pulse
- D. The client fell, sustaining a fracture to the left hip
Correct answer: D
Rationale: The correct answer is D because the nurse should document factual, objective information such as the injury sustained by the client. Reporting the specific injury, like a fracture to the left hip, is crucial for accurate medical records. Choices A, B, and C lack specific detail about the injury and focus on different aspects of the fall that are not as pertinent for the health record. Choice A only mentions the fall without specifying the injury, choice B introduces blame without focusing on the client's condition, and choice C adds unnecessary information about the client's pulse which is not directly related to the fall injury.
3. A client with acute kidney injury has an elevated creatinine level. What is the nurse's priority intervention?
- A. Administer diuretics as prescribed.
- B. Prepare the client for dialysis.
- C. Restrict the client’s fluid intake.
- D. Notify the healthcare provider immediately.
Correct answer: B
Rationale: The correct answer is B: Prepare the client for dialysis. Clients with acute kidney injury and elevated creatinine may require dialysis to support kidney function and remove waste products from the blood. Preparing for dialysis ensures timely intervention in preventing further complications. Administering diuretics (Choice A) may worsen the client's condition by further compromising kidney function. Restricting fluid intake (Choice C) may be necessary in some cases, but it is not the priority over preparing for dialysis. Notifying the healthcare provider (Choice D) is important, but the immediate priority is to prepare for dialysis to address the acute kidney injury and elevated creatinine level.
4. A client with diabetes mellitus reports tingling in their feet. What is the nurse's best intervention?
- A. Advise the client to avoid wearing tight shoes.
- B. Refer the client to a podiatrist for foot care.
- C. Teach the client about blood sugar control and foot care.
- D. Administer insulin as prescribed.
Correct answer: C
Rationale: The correct intervention for a client with diabetes mellitus experiencing tingling in their feet is to teach the client about blood sugar control and foot care. This is essential because tingling in the feet can be a sign of neuropathy, a common complication of diabetes. Educating the client on maintaining proper blood sugar levels and foot care practices can help manage neuropathy symptoms and prevent complications like ulcers or infections. Advising the client to avoid tight shoes (Choice A) may help with comfort but does not address the underlying issue. Referring the client to a podiatrist (Choice B) is important for foot care but does not directly address blood sugar control. Administering insulin (Choice D) is not the priority for managing tingling in the feet related to neuropathy.
5. A client is admitted with diabetic ketoacidosis (DKA). Which laboratory result would the nurse expect to find in this client?
- A. pH level of 7.45
- B. Serum calcium of 15 mg/dL
- C. Blood glucose of 450 mg/dL
- D. Sodium level of 120 mEq/L
Correct answer: C
Rationale: Clients with diabetic ketoacidosis typically present with elevated blood glucose levels, often above 300 mg/dL. This high blood glucose level, along with other symptoms, helps confirm the diagnosis of DKA. A pH level of 7.45 would be indicative of alkalosis, not the acidosis seen in DKA. A serum calcium level of 15 mg/dL is significantly elevated and is not a typical finding in DKA. A sodium level of 120 mEq/L indicates hyponatremia, which is not a characteristic laboratory finding in DKA.
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