HESI RN
HESI RN Exit Exam 2024 Quizlet Capstone
1. A client with a urinary tract infection is prescribed ciprofloxacin. What is the nurse's priority teaching?
- A. Take the medication with a full glass of water.
- B. Avoid direct sunlight while taking the medication.
- C. Take the medication with meals to prevent nausea.
- D. Discontinue the medication if you experience dizziness.
Correct answer: A
Rationale: The correct answer is A: 'Take the medication with a full glass of water.' It is crucial for the nurse to teach the client to take ciprofloxacin with a full glass of water to prevent crystalluria, a potential side effect of the medication. Choice B is incorrect because ciprofloxacin does not require avoiding direct sunlight. Choice C is incorrect as taking the medication with meals is not necessary to prevent nausea. Choice D is incorrect as dizziness is not a common reason to discontinue ciprofloxacin.
2. An older client with type 1 diabetes arrives at the clinic with abdominal cramping, vomiting, lethargy, and confusion. What should the nurse implement first?
- A. Start an IV infusion of normal saline.
- B. Obtain a serum potassium level.
- C. Administer the client's usual dose of insulin.
- D. Assess the pupillary response to light.
Correct answer: A
Rationale: The correct answer is A: Start an IV infusion of normal saline. The client is showing signs of dehydration, such as abdominal cramping, vomiting, lethargy, and confusion, which can be exacerbated by hyperglycemia. Rehydration is the initial priority to address the fluid imbalance. Option B, obtaining a serum potassium level, though important in the management of diabetes, is not the immediate priority over rehydration. Option C, administering the client's usual dose of insulin, should only be done after addressing the dehydration and confirming the client's blood glucose levels. Option D, assessing the pupillary response to light, is not the most urgent intervention needed in this situation compared to rehydration to correct fluid imbalance.
3. The charge nurse is planning assignments on a medical unit. Which client should be assigned to the PN?
- A. Test a stool specimen for occult blood
- B. Assist with the ambulation of a client with a chest tube
- C. Irrigate and redress a leg wound
- D. Admit a client from the emergency room
Correct answer: C
Rationale: Irrigating and redressing a leg wound is a common task within the PN's scope of practice, making this assignment appropriate. Tasks like testing stool specimens for occult blood and assisting with ambulation of a client with a chest tube may require a higher level of training and assessment, typically performed by RNs. Admitting a client from the emergency room involves a comprehensive assessment and decision-making process, which is usually within the RN's responsibility.
4. A child has a nosebleed (epistaxis) while playing soccer. In what position should the nurse place the child?
- A. Position the child lying flat and apply pressure to the bridge of the nose.
- B. Position the child sitting up and leaning forward.
- C. Have the child tilt the head back and pinch the nose.
- D. Position the child lying on their side and apply ice to the nose.
Correct answer: B
Rationale: The correct answer is to position the child sitting up and leaning forward. This position helps prevent blood from flowing down the throat, reducing the risk of choking or vomiting. Choice A is incorrect because lying flat can cause blood to flow down the throat. Choice C is wrong as tilting the head back may lead to blood entering the throat. Choice D is also incorrect as applying ice is not recommended for nosebleeds and lying on the side may not prevent blood from flowing down the throat.
5. An adult male is brought to the emergency department following a motorcycle accident, presenting with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse?
- A. Rebound abdominal tenderness.
- B. Diminished bilateral breath sounds.
- C. Rib pain with deep inspiration.
- D. Nausea with projectile vomiting.
Correct answer: D
Rationale: In this scenario, the patient's presentation with periorbital bruising and bloody ear drainage suggests a basilar skull fracture. Projectile vomiting, as described in choice D, is concerning for increased intracranial pressure due to the skull fracture. This finding warrants immediate intervention to prevent further neurological compromise. Choices A, B, and C are not the priority in this situation. Rebound abdominal tenderness (choice A) is indicative of intra-abdominal injury but is not as urgent as managing potential intracranial issues. Diminished breath sounds (choice B) and rib pain with deep inspiration (choice C) may suggest underlying chest injuries, which need attention but are not as immediately life-threatening as increased intracranial pressure.
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