HESI RN Exit Exam Capstone

Correct Answer: B

Rationale: The pillows along the side rails do not provide sufficient protection in the event of a seizure. The nurse should inform the UAP to remove the pillows and ensure proper padding of the side rails. This prevents injury, such as hitting the head or limbs during a seizure.

Correct Answer: B

Rationale: Spironolactone is a potassium-sparing diuretic, so the nurse should closely monitor for signs of hyperkalemia, which can lead to cardiac arrhythmias.

Correct Answer: B

Rationale: Before administering nitroglycerin, which can lower blood pressure and heart rate, it is important to assess both to avoid exacerbating hypotension or bradycardia. Nitroglycerin helps relieve chest pain by dilating coronary arteries, but its vasodilating effect can also cause a significant drop in blood pressure, which can be dangerous for some clients.

Correct Answer: A

Rationale: Supporting the client's birth plan helps reduce anxiety while ensuring informed decision-making.

Correct Answer: B

Rationale: Fine hand tremors are an early sign of lithium toxicity, and the healthcare provider should be notified to adjust the dose or monitor serum levels more closely.