HESI RN Exit Exam 2023 Capstone

Correct Answer: D

Rationale: The correct answer is D because the nurse should document factual, objective information such as the injury sustained by the client. Reporting the specific injury, like a fracture to the left hip, is crucial for accurate medical records. Choices A, B, and C lack specific detail about the injury and focus on different aspects of the fall that are not as pertinent for the health record. Choice A only mentions the fall without specifying the injury, choice B introduces blame without focusing on the client's condition, and choice C adds unnecessary information about the client's pulse which is not directly related to the fall injury.

Correct Answer: B

Rationale: Muscle cramps and tingling in clients with chronic renal failure are often associated with hypocalcemia. Monitoring calcium levels is crucial to identify imbalances and manage symptoms appropriately. Sodium, phosphate, and potassium levels are important in renal failure but are not directly related to the symptoms of muscle cramps and tingling reported by the client.

Correct Answer: B

Rationale: The correct answer is B. Young children, like the 2-year-old playing on aging playground equipment, are at higher risk of lead poisoning due to their hand-to-mouth behavior and exploration of their environment. Aging playground equipment may have lead-based paint that can be ingested by the child. While children living in housing projects are also at risk due to lead-based paint in older buildings, the 2-year-old child playing on potentially lead-contaminated playground equipment is the most susceptible in this scenario. The adolescent working in a paint factory may face occupational hazards related to lead exposure, but the immediate risk from environmental sources is higher for the 2-year-old. Type 1 diabetes in a 10-year-old is not directly linked to an increased susceptibility to lead poisoning.

Correct Answer: B

Rationale: The correct answer is B: Administer intravenous fluids. In a client with severe burn injury, the priority intervention is to administer intravenous fluids to prevent shock. Monitoring urine output (Choice A) is important but not the priority. Applying cool, moist compresses (Choice C) can be beneficial but is not the priority over fluid resuscitation. Covering the burn area with a sterile dressing (Choice D) is important for wound care but is not the immediate priority in managing severe burns.

Correct Answer: B

Rationale: In pancreatitis, pain after consuming fatty foods is common due to increased pancreatic stimulation. Administering antispasmodics is the appropriate intervention as it can help reduce the pain by decreasing pancreatic enzyme secretion. Encouraging the client to eat small, low-fat meals (Choice A) is beneficial in managing pancreatitis symptoms but does not directly address the acute pain. Instructing the client to avoid eating until the pain subsides (Choice C) may lead to nutritional deficiencies and is not the best approach. Increasing high-protein foods intake (Choice D) is not recommended as it can put additional strain on the pancreas.