HESI RN
HESI Exit Exam RN Capstone
1. A client is newly diagnosed with a duodenal ulcer. What information should the nurse provide during medication teaching?
- A. Take antacids regularly to manage symptoms.
- B. Avoid spicy foods and alcohol.
- C. Ensure proper administration of antibiotics.
- D. Stop all food intake until symptoms subside.
Correct answer: B
Rationale: The correct answer is B. Clients with duodenal ulcers should avoid spicy foods and alcohol as they can exacerbate symptoms and delay healing. Choice A is incorrect because while antacids may help with symptoms, they are not the primary focus of medication teaching for duodenal ulcers. Choice C is not directly related to medication teaching for duodenal ulcers unless antibiotics are specifically prescribed. Choice D is incorrect as stopping all food intake is not recommended and can lead to other complications.
2. The nurse is caring for a client with chronic heart failure who is receiving digoxin therapy. The nurse reviews the client's lab results and notes that the serum potassium level is 3.0 mEq/L. What action should the nurse take next?
- A. Administer a potassium supplement
- B. Notify the healthcare provider
- C. Hold the next dose of digoxin
- D. Increase dietary potassium intake
Correct answer: C
Rationale: In clients receiving digoxin therapy, low potassium levels can increase the risk of digoxin toxicity. Therefore, when the nurse notes a serum potassium level of 3.0 mEq/L, it is crucial to hold the next dose of digoxin. Notifying the healthcare provider is essential to ensure appropriate interventions, such as potassium supplementation, can be implemented. Administering a potassium supplement without healthcare provider guidance may lead to rapid potassium level changes and potential adverse effects. Increasing dietary potassium intake alone may not promptly address the low serum potassium level in this acute situation.
3. A client presents with severe dehydration due to prolonged vomiting. What is the nurse's priority intervention?
- A. Encourage the client to drink clear fluids.
- B. Assess the client's skin turgor and mucous membranes.
- C. Monitor the client's vital signs frequently.
- D. Administer an antiemetic as prescribed.
Correct answer: B
Rationale: The correct answer is to assess the client's skin turgor and mucous membranes. When a client presents with severe dehydration, assessing skin turgor (elasticity of the skin) and mucous membranes (such as checking for dryness in the mouth) is crucial in determining the extent of dehydration. Encouraging the client to drink clear fluids (Choice A) may be important but assessing dehydration severity takes precedence. Monitoring vital signs (Choice C) is essential but assessing dehydration status comes first. Administering an antiemetic (Choice D) addresses vomiting but does not directly assess dehydration.
4. The nurse is administering an intradermal injection for a tuberculosis skin test. Which technique should the nurse use?
- A. Use a 25-gauge needle at a 90-degree angle
- B. Use a 27-gauge needle at a 15-degree angle
- C. Use a 22-gauge needle at a 45-degree angle
- D. Use a 20-gauge needle at a 90-degree angle
Correct answer: B
Rationale: An intradermal injection for a tuberculosis skin test should be administered using a 27-gauge needle at a 15-degree angle. This technique ensures that the medication is delivered into the dermis layer of the skin. Choice A is incorrect because a 25-gauge needle is too large for an intradermal injection. Choice C is incorrect as a 22-gauge needle is also too large and the angle is too steep for an intradermal injection. Choice D is incorrect as a 20-gauge needle is too large for an intradermal injection, and a 90-degree angle would not deliver the medication accurately into the dermis.
5. A client with lupus erythematosus is prescribed prednisone. What teaching should the nurse include?
- A. Take the medication with food to prevent stomach upset.
- B. Avoid crowded places to reduce the risk of infection.
- C. Take the medication in the morning to prevent insomnia.
- D. Take extra calcium supplements to prevent osteoporosis.
Correct answer: B
Rationale: The correct teaching for a client with lupus erythematosus prescribed prednisone is to avoid crowded places to reduce the risk of infection. Prednisone suppresses the immune system, making individuals more susceptible to infections. Taking the medication with food may help reduce stomach upset but is not the priority teaching. Taking prednisone in the morning may help reduce insomnia, but infection prevention is more critical. While prednisone can lead to osteoporosis, advising extra calcium supplements is not the most immediate concern when starting the medication.
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