HESI Exit Exam RN Capstone

Correct Answer: D

Rationale: The correct answer is D: Potassium. Spironolactone is a potassium-sparing diuretic, which can lead to hyperkalemia. Monitoring potassium levels is crucial to prevent complications like cardiac arrhythmias. Choices A, B, and C are incorrect because sodium, calcium, and magnesium levels are not directly affected by spironolactone use for managing ascites in cirrhosis.

Correct Answer: D

Rationale: The correct answer is D. A preschooler with intermittent alertness episodes is not a suitable candidate for patient-controlled analgesia (PCA) due to their inability to effectively manage the system. In the context of terminal cancer, it is crucial for the patient to be able to utilize the PCA system appropriately to manage pain effectively. Preschoolers may not have the cognitive ability or understanding to operate a PCA pump compared to the other clients. Choices A, B, and C present clients with conditions that do not inherently impede their ability to use a PCA pump effectively.

Correct Answer: B

Rationale: The correct action for the nurse to take is to continue obtaining client data to complete the fall risk survey. Even though the client reports never falling, it is essential to assess all fall risk factors comprehensively. Fall risk surveys provide valuable information on mobility, vision, medications, and other factors that can impact safety. Option A is incorrect because suggesting moving to an assisted living facility is premature without completing the fall risk assessment. Option C is incorrect as reducing the frequency of fall risk assessments could overlook potential risk factors. Option D is incorrect as the client's statement alone is not enough to confirm their safety living alone; a thorough assessment is necessary.

Correct Answer: D

Rationale: Determining the specific medications ingested is the priority for guiding immediate treatment in the Emergency Department. Knowing when the client last took medications and her current mood are also important, but the ingested medications are the most urgent information needed. The client's current mood and affect are crucial for assessing her immediate state, but the priority is to identify the substances she ingested to provide appropriate interventions. While understanding the history of previous suicide attempts is relevant for assessing the client's risk, the immediate focus should be on the medications taken during this specific incident.

Correct Answer: A

Rationale: The correct answer is A: 83. The pharmacy provided the infusion at 10 million units per liter, which requires a rate of 83 mL/hour. To calculate this, multiply the dosage by the volume of the IV solution and divide by the concentration of the IV solution in million units: 10 million units per liter x 8.3 L = 83 mL/hour. Choices B, C, and D are incorrect as they do not align with the calculation based on the given information.