HESI 799 RN Exit Exam Capstone

Questions 82

HESI RN

HESI RN Test Bank

HESI 799 RN Exit Exam Capstone Questions

Question 1 of 5

After receiving hemodialysis, what is the nurse's priority assessment for a client with chronic kidney disease?

Correct Answer: A

Rationale: The correct answer is to monitor the client's potassium level. During hemodialysis, there is a risk of potassium shifting, which can lead to life-threatening arrhythmias if not properly managed. Assessing the potassium level is crucial to prevent complications. While assessing blood pressure, checking hemoglobin and hematocrit levels, and monitoring for signs of infection are important aspects of care for a client with chronic kidney disease, monitoring potassium levels takes precedence due to its immediate life-threatening potential post-dialysis.

Question 2 of 5

A client with a history of closed head injury has a radial artery catheter in place and complains of numbness and pain distal to the insertion site. What action should the nurse take?

Correct Answer: B

Rationale: A weak pulse and numbness distal to a radial artery catheter may indicate occlusion or damage to the artery, and immediate removal of the catheter is necessary to prevent complications. Therefore, promptly removing the catheter from the radial artery (Choice B) is the correct action. Monitoring the site (Choice A) would delay necessary intervention, elevating the client's arm (Choice C) may not address the underlying issue, and notifying the healthcare provider for surgery (Choice D) without removing the catheter promptly could lead to further complications.

Question 3 of 5

A client is recovering from a hip replacement surgery. What is the priority nursing intervention to prevent complications?

Correct Answer: B

Rationale: The correct answer is B: Assist the client with early ambulation. Early ambulation is a key intervention to prevent complications like deep vein thrombosis (DVT) and promote circulation after hip replacement surgery. It also helps with overall recovery and reduces the risk of complications related to immobility, such as muscle atrophy and pressure ulcers. Choice A is incorrect as bed rest should be avoided to prevent complications associated with immobility. Choice C, continuous passive motion therapy, is not the priority intervention immediately post-hip replacement surgery. Choice D, administering pain medication before activity, is important but not the priority intervention to prevent complications in this case.

Question 4 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 5 of 5

A client with a history of adrenal insufficiency is admitted with acute adrenal crisis. The client complains of nausea and joint pain, vital signs show a temperature of 102�F, heart rate of 138, and blood pressure of 80/60. Which intervention should the nurse implement first?

Correct Answer: B

Rationale: In acute adrenal crisis, the priority intervention is to infuse an intravenous fluid bolus to address the hypotension (blood pressure of 80/60) and help stabilize the client's condition. Adequate fluid volume is crucial in managing adrenal insufficiency crisis. Options A, C, and D do not directly address the hypotension and fluid volume depletion that are critical in this situation. Analgesics, antipyretics, and cooling blankets may be considered later, but the immediate focus should be on fluid resuscitation.

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