HESI RN
HESI RN Exit Exam 2023 Capstone
1. A client is scheduled for surgery in the morning and is NPO. Which statement indicates that the client understands the reason for being NPO?
- A. Being NPO helps reduce the risk of nausea.
- B. I should not eat or drink anything to prevent complications during surgery.
- C. NPO reduces the risk of aspiration during surgery.
- D. NPO helps ensure the stomach is empty during surgery.
Correct answer: C
Rationale: The correct answer is C: 'NPO reduces the risk of aspiration during surgery.' When a client is NPO (nothing by mouth) before surgery, it is to prevent aspiration, which can lead to serious complications such as pneumonia. Choice A is incorrect because being NPO is more about preventing aspiration than nausea. Choice B is a general statement without specifying the reason for being NPO. Choice D is partially correct but does not emphasize the crucial aspect of preventing aspiration, which is the primary reason for fasting before surgery.
2. 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.
3. A client with acute pancreatitis is prescribed nothing by mouth (NPO). What should the nurse prioritize in this client's care?
- A. Administer oral pain medication.
- B. Monitor the client's intake and output.
- C. Monitor the client for signs of infection.
- D. Insert a nasogastric tube for decompression.
Correct answer: B
Rationale: The correct answer is B: Monitor the client's intake and output. When a client with acute pancreatitis is prescribed nothing by mouth (NPO), the nurse should prioritize monitoring the client's intake and output. This is crucial for assessing the client's fluid balance and ensuring that they are not becoming dehydrated or developing complications related to fluid status. Option A is incorrect because oral pain medication should not be administered to a client who is NPO. Option C is not the priority at this time, although monitoring for infection is important in the overall care of the client. Option D is not the initial priority unless there are specific indications for decompression, which would be determined by the healthcare provider.
4. A client with cirrhosis is prescribed spironolactone to manage ascites. Which serum laboratory value is most important for the nurse to monitor?
- A. Sodium
- B. Calcium
- C. Magnesium
- D. Potassium
Correct answer: D
Rationale: The correct answer is D: Potassium. Spironolactone is a potassium-sparing diuretic, which can lead to hyperkalemia. Monitoring potassium levels is crucial to prevent complications like cardiac arrhythmias. Choices A, B, and C are incorrect because sodium, calcium, and magnesium levels are not directly affected by spironolactone use for managing ascites in cirrhosis.
5. What is the most important assessment for a nurse to conduct on a child diagnosed with intussusception?
- A. Monitor for signs of infection.
- B. Measure abdominal girth and monitor for pain.
- C. Check for bowel movement and changes in stool.
- D. Assess hydration status and monitor urine output.
Correct answer: C
Rationale: The correct answer is C: 'Check for bowel movement and changes in stool.' Intussusception can cause obstruction in the bowel, leading to symptoms like abdominal pain, vomiting, and 'currant jelly' stools. Monitoring for changes in bowel movement, especially the passage of 'currant jelly' stools, is crucial for early detection of worsening conditions. Choices A, B, and D are important assessments in pediatric care but are not as specific or crucial as checking for changes in bowel movement in a child diagnosed with intussusception.
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