HESI 799 RN Exit Exam Capstone

Correct Answer: D

Rationale: In emergency situations where immediate surgery is required to save a patient's life and no family members are available, consent can be waived to proceed with necessary interventions. The priority in this scenario is to proceed with surgery preparation without waiting for consent, as any delay could jeopardize the patient's life. Asking the friend to sign informed consent or notifying the unit manager for a court order would cause unnecessary delays, which are not advisable in this critical situation. Continuing life support until a guardian is found is not the most appropriate action when immediate surgical intervention is necessary.

Correct Answer: C

Rationale: The most important instruction for the nurse to provide to a client scheduled for a colonoscopy and prescribed a bowel preparation is to take the entire bowel preparation as directed. Completing the entire bowel preparation as prescribed is crucial to ensure the colon is properly cleansed for the colonoscopy. Incomplete bowel prep can interfere with the visualization of the colon, leading to inaccurate results. Choices A, B, and D are important but not as crucial as ensuring the complete intake of the bowel preparation for an effective procedure.

Correct Answer: B

Rationale: A client with a higher gravida and para count is at greater risk for uterine atony, which can lead to postpartum hemorrhage. The uterus may be less effective at contracting after multiple pregnancies, causing increased vaginal bleeding. Choices A, C, and D are incorrect because delivering a large baby, having a cesarean delivery, or experiencing prolonged labor do not directly correlate with an increased risk of postpartum hemorrhage in a multigravida client as compared to the gravida and para count.

Correct Answer: B

Rationale: Fixed, dilated pupils are a sign of increased intracranial pressure or brain injury, indicating a potentially serious neurological condition. Flaccid paralysis, although concerning, may not always indicate immediate life-threatening issues. Diminished spinal reflexes and reduced sensory responses are important neurological assessments but are not as acutely concerning as fixed, dilated pupils in this context.

Correct Answer: D

Rationale: Severe nausea in a client with a head injury may be a sign of increased intracranial pressure. The nurse should notify the healthcare provider immediately to ensure timely intervention, as increased pressure can lead to further complications such as brain herniation. Administering anti-nausea medication or preparing for a CT scan may delay necessary treatment for the underlying cause of the nausea, which could be related to the head injury. Elevating the head of the bed and providing an emesis basin may help manage symptoms but should not be the priority over addressing the potential increase in intracranial pressure.