HESI RN
HESI RN Exit Exam Capstone
1. A client with a deep vein thrombosis (DVT) is prescribed enoxaparin. What teaching should the nurse provide?
- A. Rotate injection sites to prevent bruising.
- B. Administer the injection in the abdomen only.
- C. Report any unusual bleeding or bruising.
- D. Avoid contact sports to prevent injury.
Correct answer: C
Rationale: The correct teaching for a client prescribed enoxaparin for deep vein thrombosis (DVT) is to report any unusual bleeding or bruising. Enoxaparin is an anticoagulant, and these symptoms could indicate excessive anticoagulation. Choice A is incorrect because with enoxaparin, injections are usually given in the abdomen, not rotated to different sites. Choice D is not directly related to the medication but is a general precaution for individuals at risk of injury.
2. A client taking fexofenadine (Allegra) is scheduled for allergy skin testing and tells the nurse in the healthcare provider's office that a dose was taken this morning. The nurse determines that:
- A. The client should reschedule the appointment.
- B. A lower dose of allergen will need to be injected.
- C. A higher dose of allergen will need to be injected.
- D. The client should have the skin test read a day later than usual.
Correct answer: A
Rationale: Fexofenadine, an antihistamine, can cause false-negative readings in allergy skin testing and should be discontinued 3 days prior. Therefore, the client should reschedule the appointment to ensure accurate test results.
3. A diet rich in _______ controls menopause symptoms:
- A. Carbohydrates
- B. Soya items
- C. Fruits and veggies
- D. Eggs and meat
Correct answer: B
Rationale: A diet rich in soya items can help control menopause symptoms. Soya contains phytoestrogens, which are plant-based compounds that mimic the hormone estrogen in the body. These compounds may help alleviate menopause symptoms such as hot flashes and night sweats. Choice A, Carbohydrates, do not specifically target menopause symptoms. Choice C, Fruits and veggies, while generally healthy, do not have the same impact on menopause symptoms as soya. Choice D, Eggs and meat, do not contain phytoestrogens like soya, making them less effective in managing menopause symptoms.
4. When should a mother introduce solid foods to her 4-month-old baby girl? The mother states, 'My mother says I should put rice cereal in the baby's bottle now.' The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?
- A. Stops rooting when hungry
- B. Opens mouth when food comes her way
- C. Awakens once for nighttime feedings
- D. Gives up a bottle for a cup
Correct answer: B
Rationale: The correct answer is B: 'Opens mouth when food comes her way.' This behavior indicates readiness to start trying solid foods. Infants should be introduced to solid foods based on developmental cues, such as showing an interest in food and the ability to accept it. Choices A, C, and D are not indicative of readiness for solid foods. Stopping rooting when hungry is a reflex that may persist beyond the readiness for solids. Awakening for nighttime feedings is a normal behavior for a 4-month-old, and transitioning from a bottle to a cup is a later developmental milestone.
5. A home health care nurse is visiting a client with elevated triglyceride levels and a serum cholesterol level of 398 mg/dL. The client is taking cholestyramine (Questran). Which of the following statements, if made by the client, indicates the need for further education?
- A. Constipation and bloating might be a problem.
- B. I'll continue to watch my diet and reduce my fats.
- C. Walking a mile each day will help the whole process.
- D. I'll continue my nicotinic acid from the health food store.
Correct answer: D
Rationale: Nicotinic acid, even an over-the-counter form, should be avoided because it may lead to liver abnormalities. All lipid-lowering medications also can cause liver abnormalities, so a combination of nicotinic acid and cholestyramine resin is to be avoided. Constipation and bloating are the two most common side effects. Walking and the reduction of fats in the diet are therapeutic measures to reduce cholesterol and triglyceride levels.