HESI RN
HESI 799 RN Exit Exam Capstone
1. A male client with HIV on antiretroviral therapy complains of constant hunger and thirst while losing weight. What action should the nurse implement?
- A. Check the client's glucose level with a glucometer.
- B. Measure the client's weight accurately.
- C. Reassure the client that weight will stabilize as viral load decreases.
- D. Increase the dose of saquinavir.
Correct answer: A
Rationale: The correct action for the nurse to implement is to check the client's glucose level with a glucometer. Constant hunger and thirst along with weight loss can be indicative of hyperglycemia, a possible side effect of saquinavir. Monitoring the client's glucose levels is crucial in this situation. Measuring the client's weight accurately (Choice B) is important for monitoring purposes but does not address the immediate concern of hunger, thirst, and weight loss. Reassuring the client that weight will stabilize as viral load decreases (Choice C) is not appropriate in this scenario as the symptoms described need immediate attention. Increasing the dose of saquinavir (Choice D) without assessing the client's glucose level can worsen the hyperglycemia.
2. A nurse is reviewing the medication list for a client with heart failure. Which medication should the nurse question?
- A. Furosemide
- B. Digoxin
- C. Ibuprofen
- D. Carvedilol
Correct answer: C
Rationale: The correct answer is C: Ibuprofen. Ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), can cause fluid retention, which may worsen heart failure symptoms. It should be used with caution or avoided in clients with heart failure. Furosemide (choice A) is a diuretic commonly used in heart failure to reduce fluid overload. Digoxin (choice B) is a medication that helps the heart beat stronger and slower, often used in heart failure. Carvedilol (choice D) is a beta-blocker that is beneficial in heart failure management. Therefore, Ibuprofen is the medication that the nurse should question in this scenario.
3. An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9 is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of ketoacidosis?
- A. Had a cold and ear infection for the past two days
- B. Missed a dose of insulin
- C. Did not follow dietary restrictions
- D. Overexerted during exercise
Correct answer: A
Rationale: The correct answer is A. Infections, like a cold and ear infection, increase the body's metabolic needs and insulin resistance, making diabetic ketoacidosis (DKA) more likely. While missing insulin doses or not following dietary restrictions can trigger DKA, an illness is the most common precipitating factor in pediatric Type 1 diabetes. Option B is less likely as missing insulin can lead to hyperglycemia but might not be the immediate cause of ketoacidosis. Option C can contribute to DKA over time, but the acute trigger is usually an illness. Option D, overexertion during exercise, is less likely to cause DKA compared to an infection.
4. A client with asthma is experiencing wheezing. What is the nurse’s priority intervention?
- A. Administer a bronchodilator immediately.
- B. Increase the client's oxygen flow rate.
- C. Perform a chest x-ray to assess lung function.
- D. Place the client in a high Fowler’s position.
Correct answer: A
Rationale: The correct answer is A: Administer a bronchodilator immediately. Wheezing in a client with asthma indicates bronchoconstriction, which can compromise airflow. Administering a bronchodilator is the priority intervention as it helps to open the airways, relieve bronchoconstriction, and improve breathing. Increasing the oxygen flow rate (choice B) may be necessary but is not the priority when the airways are constricted. Performing a chest x-ray (choice C) is not the immediate action needed in this situation. Placing the client in a high Fowler's position (choice D) may provide some relief, but administering a bronchodilator to address the bronchoconstriction is the priority intervention.
5. A woman who is breastfeeding calls her obstetrician’s office and reports increased anxiety since the vaginal delivery of her son three weeks ago. She stopped taking her antianxiety medications but is thinking of restarting them. What response should the nurse provide?
- A. Describe the potential transmission of drugs to the infant through breast milk.
- B. Encourage her to utilize stress-relieving alternatives, such as deep breathing.
- C. Explain that anxiety is a common reaction for mothers of 3-week-old infants.
- D. Inform her that some antianxiety medications are safe to take while breastfeeding.
Correct answer: D
Rationale: The correct answer is D because some antianxiety medications are considered safe during breastfeeding. The nurse should reassure the client and encourage her to discuss options with her healthcare provider to manage anxiety safely while continuing to breastfeed. Choice A is incorrect because it focuses on the transmission of drugs rather than providing guidance on safe medication use. Choice B, while promoting stress-relieving techniques, does not address the potential need for medication. Choice C is incorrect as it minimizes the woman's reported anxiety, which may require professional intervention.
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