HESI RN
HESI 799 RN Exit Exam Capstone Questions
Question 1 of 5
A client with anxiety disorder is experiencing increased anxiety prior to vaginal delivery. What should the nurse's initial action be?
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.
Question 2 of 5
A nurse is caring for a 73-year-old male client with Alzheimer's disease. Which action should the nurse take to enhance the client's nutritional intake?
Correct Answer: B
Rationale: Offering frequent snacks of foods the client enjoys is the most appropriate action to enhance the nutritional intake of a client with Alzheimer's disease. This approach helps to ensure that the client receives an adequate amount of nutrients throughout the day, especially when larger meals might be challenging for individuals with Alzheimer's. Encouraging large meals in one sitting (Choice A) may overwhelm the client and lead to decreased food intake. While foods high in fiber (Choice C) are beneficial for digestion, the primary focus should be on providing foods the client enjoys to increase intake. Discouraging eating late at night (Choice D) is not directly related to enhancing nutritional intake in this scenario.
Question 3 of 5
A client with a history of atrial fibrillation is prescribed warfarin. What is the nurse's priority teaching?
Correct Answer: B
Rationale: The correct answer is B: 'Avoid foods high in vitamin K.' Warfarin is an anticoagulant medication that works by interfering with vitamin K-dependent clotting factors. Therefore, consuming foods high in vitamin K can affect the medication's effectiveness. Choices A, C, and D are incorrect because: A) Warfarin is not affected by foods high in potassium; C) Warfarin should be taken with food to minimize gastrointestinal side effects; D) There is no specific requirement for taking warfarin at bedtime for best results.
Question 4 of 5
During an excretory urogram, which observation made by the nurse indicates a complication?
Correct Answer: B
Rationale: The correct answer is B because a whole-body bright red color indicates a severe reaction to the contrast dye and must be addressed immediately. Choices A, C, and D do not indicate a severe complication during an excretory urogram. Choice A is a common side effect of the dye, choice C could be a normal sensation due to the injection, and choice D may indicate nausea which is less severe compared to a whole-body red color reaction.
Question 5 of 5
A client with Type 1 diabetes reports feeling shaky and lightheaded. The nurse checks the client's blood glucose level and it is 60 mg/dL. What action should the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Administer 15 grams of a fast-acting carbohydrate. The first step in treating hypoglycemia is to quickly raise the client's blood sugar level. Fast-acting carbohydrates like glucose tablets or juice are essential for this purpose. Giving a glucagon injection is typically reserved for severe hypoglycemia when the client is unable to take anything by mouth. Encouraging the client to eat a high-protein snack is not appropriate for immediate treatment of hypoglycemia. Rechecking the blood glucose level in 15 minutes is important after administering the fast-acting carbohydrate to ensure that the blood sugar has returned to a safe level.
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