HESI RN Exit Exam Capstone

Correct Answer: B

Rationale: Weakness and shakiness can indicate hypoglycemia, a potential complication of TPN. Immediate intervention is necessary to assess blood glucose levels and provide treatment as needed.

Correct Answer: C

Rationale: Hyperglycemia in postoperative clients, especially those with diabetes, can be a sign of infection. The nurse should assess blood glucose levels to confirm hyperglycemia.

Correct Answer: A

Rationale: Urine specific gravity is the most accurate indicator of hydration status in this scenario.

Correct Answer: C

Rationale: Keeping the chest tube drainage system below chest level ensures that gravity assists with drainage and prevents fluid or air from flowing back into the pleural space, which could compromise lung function.

Correct Answer: B

Rationale: Diminished breath sounds in a sedated client with ARDS and on a ventilator indicate collapsed alveoli, which requires immediate intervention, such as chest tube insertion, to prevent further lung damage.