HESI RN
HESI RN Exit Exam 2024 Capstone
1. When conducting diet teaching for a client on a postoperative full liquid diet, which foods should the nurse encourage the client to eat?
- A. Yogurt, milk, and pudding
- B. Tea, lentils, and potato soup
- C. Ice cream, broth, and fruit smoothies
- D. Orange juice, mashed potatoes, and soft cheese
Correct answer: A
Rationale: A full liquid diet includes foods that are liquid or will turn liquid at room temperature. Yogurt, milk, and pudding are appropriate choices as they align with the consistency requirements of a full liquid diet. Choices B, C, and D are incorrect. Tea, lentils, potato soup, ice cream, fruit smoothies, orange juice, mashed potatoes, and soft cheese are not typically part of a full liquid diet. These options either contain solid elements or are not in liquid form, which makes them unsuitable for a postoperative full liquid diet.
2. A client with chronic kidney disease has a potassium level of 6.2 mEq/L. Which intervention should the nurse implement?
- A. Encourage the client to eat foods rich in potassium
- B. Administer a potassium-sparing diuretic
- C. Administer a potassium-binding medication
- D. Hold all medications containing potassium
Correct answer: C
Rationale: A potassium level of 6.2 mEq/L indicates hyperkalemia, which is dangerous and requires immediate treatment. Administering a potassium-binding medication will help lower potassium levels and prevent life-threatening complications.
3. Which intervention should be prioritized by the nurse when assessing tissue perfusion post-above knee amputation (AKA)?
- A. Evaluate the closest proximal pulse.
- B. Observe color and amount of wound drainage.
- C. Observe for swelling around the stump.
- D. Assess the skin elasticity of the stump.
Correct answer: A
Rationale: The correct answer is to evaluate the closest proximal pulse when assessing tissue perfusion post-above knee amputation (AKA). Checking the closest proximal pulse provides the best indication of tissue perfusion in the extremities after an AKA procedure. Observing the color and amount of wound drainage (Choice B) is important for wound care but does not directly assess tissue perfusion. Observing for swelling around the stump (Choice C) may indicate inflammation or fluid accumulation but is not the most direct way to assess tissue perfusion. Assessing the skin elasticity of the stump (Choice D) is more related to skin integrity and wound healing rather than tissue perfusion.
4. A client with heart failure reports nausea, vomiting, yellow vision, and palpitations. What should the nurse assess first?
- A. Administer antiemetics to reduce nausea.
- B. Obtain a list of the client's cardiac medications.
- C. Perform an ECG to evaluate heart function.
- D. Review the client's dietary intake for possible causes.
Correct answer: B
Rationale: The combination of nausea, vomiting, yellow vision, and palpitations in a heart failure patient is indicative of digoxin toxicity. The nurse should first obtain a list of the client's medications to verify if they are taking digoxin.
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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