HESI RN Exit Exam 2023 Capstone

Correct Answer: A

Rationale: The correct answer is A: A 79-year-old malnourished client on bed rest. This client is at the highest risk for developing decubitus ulcers due to being malnourished and on bed rest, leading to decreased mobility and poor nutrition. This combination puts the client at significant risk for skin breakdown and pressure ulcers. Choice B is incorrect because although obesity is a risk factor for developing pressure ulcers, immobility and poor nutrition are higher risk factors. Choice C is incorrect as incontinence can contribute to skin breakdown but is not as high a risk factor as immobility and poor nutrition. Choice D is incorrect as an ambulatory client, even if diabetic, has better mobility than a bedridden client and is at lower risk for developing decubitus ulcers.

Correct Answer: D

Rationale: The correct answer is D because some antianxiety medications are considered safe during breastfeeding. The nurse should reassure the client and encourage her to discuss options with her healthcare provider to manage anxiety safely while continuing to breastfeed. Choice A is incorrect because it focuses on the transmission of drugs rather than providing guidance on safe medication use. Choice B, while promoting stress-relieving techniques, does not address the potential need for medication. Choice C is incorrect as it minimizes the woman's reported anxiety, which may require professional intervention.

Correct Answer: C

Rationale: In chronic renal failure, proteins should be limited in the diet. When the kidneys are not functioning well, the buildup of protein byproducts can put additional stress on them. Limiting protein intake can help reduce the burden on the kidneys. Carbohydrates and fats do not need to be restricted in the same way as proteins. Vitamins are essential nutrients that should not be limited in the diet unless specified by a healthcare provider for a specific reason.

Correct Answer: A

Rationale: In this scenario, the priority action for the nurse is to administer oxygen and elevate the head of the bed. These interventions help relieve dyspnea and chest pain, which can be indicative of a pulmonary embolism or other complications during heparin therapy. Administering nitroglycerin (Choice B) is not the initial priority in this situation as the client's symptoms are not suggestive of angina. Assessing for bleeding (Choice C) is important but not the first action needed to address chest pain and dyspnea. Administering albuterol (Choice D) is not indicated unless there are specific respiratory issues requiring it, which are not described in the scenario.

Correct Answer: D

Rationale: In clients with altered renal function being treated at home, weekly weight is the most accurate indicator of fluid balance. Fluid retention or loss can significantly affect weight, making it a reliable measure. Choices A, B, and C are not as accurate indicators of fluid balance as weekly weight. Intake and output differences can vary in accuracy and may not capture all aspects of fluid balance. Changes in mucous membranes and skin turgor can be influenced by factors other than fluid balance, making them less precise indicators.