HESI RN
HESI RN Exit Exam 2023 Capstone
1. A client at 12 weeks gestation is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum. Which action is most important for the nurse to implement?
- A. Provide emotional support
- B. Monitor daily weight
- C. Encourage small frequent meals
- D. Initiate prescribed intravenous fluids
Correct answer: D
Rationale: Hyperemesis gravidarum, characterized by severe nausea and vomiting, leads to dehydration and electrolyte imbalances. The priority intervention is initiating IV fluids to correct these imbalances. Providing emotional support is important for the client's well-being, but addressing fluid and electrolyte imbalances takes precedence. Monitoring daily weight and encouraging small frequent meals are beneficial interventions but are not the priority when managing hyperemesis gravidarum.
2. A client with Parkinson's disease is prescribed levodopa/carbidopa. The nurse instructs the client to take the medication with meals. Which rationale should the nurse provide for taking the medication with food?
- A. It enhances the effectiveness of the medication
- B. It helps to improve absorption
- C. It prevents orthostatic hypotension
- D. It reduces gastrointestinal upset
Correct answer: D
Rationale: The correct answer is D: 'It reduces gastrointestinal upset.' Levodopa/carbidopa can cause nausea and other gastrointestinal side effects. Taking the medication with food can help reduce these side effects and improve the client's comfort. Choices A, B, and C are incorrect because taking the medication with food does not primarily enhance effectiveness, improve absorption, or prevent orthostatic hypotension. The main reason for advising to take the medication with meals is to minimize gastrointestinal upset.
3. A young male client with an above-knee amputation (AKA) reports that his 'right foot is aching.' What is the most important intervention for the nurse to implement?
- A. Encourage discussion of feelings about the loss of his limb.
- B. Administer a prescription for gabapentin.
- C. Teach the client how to wrap the stump with an elastic bandage.
- D. Offer to assist the client to a quieter location to relax.
Correct answer: B
Rationale: The correct answer is B because gabapentin is prescribed to treat phantom limb pain, which is common in individuals with amputations. Option A is not the most important intervention at this time since the client is reporting physical pain, not emotional distress. Option C is not appropriate because the client is reporting aching in the foot, not the stump. Option D does not address the underlying issue of phantom limb pain that needs to be managed.
4. A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge?
- A. Nutritional guidelines to support blood health
- B. Signs of infection to monitor for
- C. When to give pain medication
- D. Instructions about how much fluid the child should drink daily
Correct answer: D
Rationale: Proper hydration is crucial in managing sickle cell anemia (SCA) as it helps prevent sickling of red blood cells and reduces blood viscosity, which can lead to painful crises. Ensuring the child drinks enough fluids is essential to maintain adequate hydration levels and reduce the risk of complications. While nutritional guidelines and recognizing signs of infection are important aspects of care, maintaining proper hydration is the most immediate and critical factor in managing SCA and preventing crises.
5. The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high-protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?
- A. A tuna fish sandwich with chips and ice cream
- B. A vegetable salad with croutons and ranch dressing
- C. A grilled chicken breast with steamed vegetables
- D. A peanut butter and jelly sandwich with soda
Correct answer: C
Rationale: The correct answer is C. Grilled chicken is an excellent source of protein, which is important for wound healing. Choices A, B, and D are less ideal for wound healing. Choice A contains high-fat and high-sugar components like chips and ice cream, which may not support wound healing effectively. Choice B includes croutons and ranch dressing, which may not provide as much protein as needed for wound healing. Choice D with a peanut butter and jelly sandwich and soda lacks a balanced meal with adequate protein to promote wound healing.
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