HESI RN
HESI RN CAT Exit Exam 1
1. A client who is taking ciprofloxacin (Cipro) reports to the nurse of having a loss of appetite and a metallic taste in the mouth. What action should the nurse implement?
- A. Reassure the client that these are common side effects of ciprofloxacin.
- B. Instruct the client to take ciprofloxacin with food.
- C. Notify the healthcare provider of the client's symptoms.
- D. Encourage the client to increase fluid intake.
Correct answer: C
Rationale: The correct action for the nurse to take when a client on ciprofloxacin reports loss of appetite and a metallic taste in the mouth is to notify the healthcare provider of the client's symptoms. These symptoms could indicate a need for a change in medication or additional treatment, which the healthcare provider would need to assess. Instructing the client to take ciprofloxacin with food (choice B) may help with gastrointestinal upset but will not address the reported symptoms. Reassuring the client (choice A) is important for providing emotional support but does not address the need for further evaluation. Encouraging increased fluid intake (choice D) is generally beneficial but may not directly address the specific side effects reported.
2. The mother of a 6-year-old anemic boy is taught by the nurse to give iron supplements. Which statement indicates that the mother understands the proper administration of iron?
- A. The iron tablets will be absorbed between meals, on an empty stomach
- B. I should give the iron tablets with his milk and cereal each morning
- C. Iron preparations can be taken with antibiotics if he develops an infection
- D. The iron tablets may cause him to sunburn more easily so he should wear sunscreen
Correct answer: A
Rationale: The correct answer is A because iron supplements are best absorbed on an empty stomach, which maximizes their effectiveness. Giving iron tablets with milk or calcium-rich foods, as mentioned in choice B, should be avoided as they can decrease iron absorption. Choice C is incorrect because iron preparations should not be taken with antibiotics due to potential interactions. Choice D is also incorrect as iron tablets do not cause an increased risk of sunburn, so sunscreen is not necessary specifically due to iron supplementation.
3. A nurse is planning care for a client who is receiving chemotherapy. Which intervention should the nurse include to manage the client's nausea?
- A. Administer an antiemetic before meals
- B. Provide frequent mouth care
- C. Encourage small, frequent meals
- D. Offer clear liquids
Correct answer: A
Rationale: Administering an antiemetic before meals is a crucial intervention to manage chemotherapy-induced nausea. Antiemetics are medications specifically designed to prevent or relieve nausea and vomiting. By administering the antiemetic before meals, the nurse can help prevent the onset of nausea, allowing the client to eat more comfortably. Providing frequent mouth care (Choice B) is important for maintaining oral hygiene but does not directly address nausea. Encouraging small, frequent meals (Choice C) and offering clear liquids (Choice D) are generally recommended for clients experiencing nausea, but administering an antiemetic is a more targeted approach to specifically address and manage the symptom.
4. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 liters per minute via nasal cannula. The client reports difficulty breathing. What action should the nurse take first?
- A. Increase the oxygen flow rate
- B. Instruct the client to breathe deeply and cough
- C. Check the client's oxygen saturation level
- D. Place the client in a high-Fowler's position
Correct answer: C
Rationale: The correct action for the nurse to take first when a client with COPD reports difficulty breathing while receiving oxygen is to check the client's oxygen saturation level. This helps in determining the adequacy of oxygenation and identifying the cause of the breathing difficulty. Increasing the oxygen flow rate (Choice A) may not be appropriate without knowing the current oxygen saturation level. Instructing the client to breathe deeply and cough (Choice B) may not address the immediate need for oxygen assessment. Placing the client in a high-Fowler's position (Choice D) can help with breathing but should come after ensuring proper oxygenation.
5. The nurse offers diet teaching to a female college student who was diagnosed with iron-deficiency anemia following her voluntary adoption of a lacto-vegetarian diet. What nutrients should the nurse suggest this client eat to best meet her nutritional needs while allowing her to adhere to a lacto-vegetarian diet?
- A. Drink whole milk instead of skim milk to enhance the body's production of amino acids
- B. Take vitamin K 10mg PO daily to enhance production of red blood cells
- C. Increase amounts of dark yellow vegetables such as carrots to fortify iron stores
- D. Combine several legumes and grains such as beans and rice to form complete proteins
Correct answer: D
Rationale: Combining legumes and grains ensures the client receives all essential amino acids to form complete proteins, which is crucial in a vegetarian diet. Options A, B, and C are incorrect. Option A is not necessary as there are plant-based sources of essential amino acids in a lacto-vegetarian diet. Option B suggests vitamin K, which is not directly related to enhancing red blood cell production. Option C mentions increasing dark yellow vegetables, which are sources of non-heme iron, but combining legumes and grains is more effective in addressing the protein needs of a lacto-vegetarian.
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