HESI RN
RN HESI Exit Exam Capstone
1. A client receiving total parenteral nutrition (TPN) is experiencing nausea and vomiting. What is the nurse's first action?
- A. Check the client's blood glucose level.
- B. Decrease the rate of TPN infusion.
- C. Administer an antiemetic as prescribed.
- D. Check the client's TPN bag for solution accuracy.
Correct answer: D
Rationale: The correct first action for the nurse to take when a client receiving TPN is experiencing nausea and vomiting is to check the client's TPN bag for solution accuracy. This is crucial to ensure that the correct solution is being administered and to address any potential errors. Checking the blood glucose level or administering an antiemetic may be necessary interventions but addressing the TPN bag's accuracy should be the priority to prevent any complications related to incorrect TPN solution.
2. Oxygen at liters/min per nasal cannula PRN difficult breathing is prescribed for a client with pneumonia. Which nursing intervention is effective in preventing oxygen toxicity?
- A. Avoiding the administration of high levels of oxygen for extended periods.
- B. Administering a sedative at bedtime to slow the client's respiratory rate.
- C. Removing the nasal cannula during the night to prevent oxygen buildup.
- D. Running oxygen through a hydration source prior to administration.
Correct answer: A
Rationale: The correct answer is A: Avoiding the administration of high levels of oxygen for extended periods. Oxygen toxicity can occur when high levels of oxygen are given for a prolonged period. It is important to monitor and adjust the oxygen levels as needed to prevent toxicity. Choice B is incorrect because administering a sedative to slow the respiratory rate does not directly prevent oxygen toxicity. Choice C is incorrect as removing the nasal cannula during the night can compromise the client's oxygenation. Choice D is incorrect as running oxygen through a hydration source does not prevent oxygen toxicity; instead, it may introduce risks associated with the hydration source.
3. A client who is taking clonidine (Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make?
- A. How long has the client been taking the medication?
- B. Assess the client's dietary habits.
- C. Check for signs of infection.
- D. Evaluate the client's sleep pattern.
Correct answer: A
Rationale: The correct answer is A. When a client reports drowsiness while taking clonidine, the nurse should assess how long the client has been taking the medication. Drowsiness is a common side effect that can occur in the early weeks of treatment with clonidine. By understanding the duration of medication use, the nurse can determine if the drowsiness is a temporary effect that may decrease over time. Choices B, C, and D are incorrect because assessing the client's dietary habits, checking for signs of infection, or evaluating the client's sleep pattern would not directly address the drowsiness associated with clonidine use.
4. The nurse is caring for a client with fluid overload. The most reliable indicator of fluid volume status is
- A. Body weight
- B. Intake and output
- C. Daily weight
- D. Skin turgor
Correct answer: C
Rationale: Daily weight is the most reliable indicator of fluid volume status as it reflects changes in body fluid balance accurately. Body weight alone can fluctuate due to various factors, including food intake and bowel movements, which may not accurately represent fluid status. Intake and output provide information on fluid balance over time but may not reflect immediate changes. Skin turgor is a physical assessment finding that indicates hydration status, not overall fluid volume status.
5. The client with non-Hodgkin's lymphoma is receiving daunorubicin (DaunoXome). Which of the following would indicate to the nurse that the client is experiencing a toxic effect related to the medication?
- A. Fever
- B. Diarrhea
- C. Complaints of nausea and vomiting
- D. Crackles on auscultation of the lungs
Correct answer: D
Rationale: Crackles on auscultation of the lungs would indicate a toxic effect related to daunorubicin, known to cause cardiotoxicity. Cardiotoxicity can manifest as heart failure, abnormal ECG findings, or cardiomyopathy. It is crucial for the nurse to monitor for signs of cardiotoxicity to ensure timely intervention and prevent further complications. Fever, diarrhea, and complaints of nausea and vomiting are common side effects of daunorubicin but do not specifically indicate a toxic effect like cardiotoxicity.