HESI RN
HESI Exit Exam RN Capstone
1. A client with a urinary tract infection is prescribed ciprofloxacin. What is the most important teaching the nurse should provide?
- A. Take the medication with milk to prevent stomach upset.
- B. Increase fluid intake to 2-3 liters per day.
- C. Avoid taking the medication with dairy products.
- D. Continue taking the medication even if symptoms improve.
Correct answer: B
Rationale: Ciprofloxacin can cause crystalluria, so increasing fluid intake to 2-3 liters per day helps flush out the medication and prevent crystal formation in the kidneys. This also ensures adequate hydration, which supports the body's ability to fight the infection. Choice A is incorrect because ciprofloxacin should not be taken with dairy products as they can interfere with the absorption of the medication. Choice D is incorrect because although it's important to complete the full course of antibiotics, it's equally crucial to report any improvement in symptoms to the healthcare provider.
2. The nurse is caring for a client with pancreatitis who is receiving total parenteral nutrition (TPN). Which assessment finding requires immediate intervention by the nurse?
- A. Blood glucose level of 200 mg/dL
- B. The client reports feeling weak and shaky
- C. The TPN bag is 5% dextrose
- D. The client reports feeling thirsty
Correct answer: B
Rationale: The correct answer is B. Weakness and shakiness can indicate hypoglycemia, a potential complication of TPN. Immediate intervention is necessary to assess blood glucose levels and provide treatment as needed. Choice A is incorrect because a blood glucose level of 200 mg/dL is within an acceptable range and does not require immediate intervention. Choice C is incorrect as a 5% dextrose TPN bag is a standard concentration. Choice D is also incorrect as feeling thirsty is not a critical assessment finding requiring immediate intervention in this context.
3. A client with hyperthyroidism is experiencing palpitations. What intervention should the nurse implement?
- A. Encourage the client to rest and limit activity.
- B. Administer a beta-blocker to reduce heart rate.
- C. Encourage the client to drink cool fluids.
- D. Provide the client with a cool environment.
Correct answer: B
Rationale: In clients with hyperthyroidism experiencing palpitations, administering a beta-blocker is the appropriate intervention. Beta-blockers help reduce heart rate and control symptoms in hyperthyroidism. Encouraging rest (Choice A) may be helpful but does not directly address the palpitations. Drinking cool fluids (Choice C) and providing a cool environment (Choice D) are more focused on temperature regulation and comfort, which are not the primary interventions for palpitations in hyperthyroidism.
4. The nurse is caring for a client with deep vein thrombosis (DVT) who is receiving heparin therapy. Which assessment finding requires immediate intervention by the nurse?
- A. Localized warmth
- B. Calf pain
- C. Swelling in the affected leg
- D. Hematuria
Correct answer: D
Rationale: Hematuria is a sign of bleeding, which is a potential complication of heparin therapy. Immediate intervention is required to manage the bleeding and adjust the heparin dosage if necessary. Localized warmth, calf pain, and swelling in the affected leg are common findings in clients with DVT and receiving heparin therapy. While these symptoms should be monitored, hematuria indicates a more serious issue requiring immediate attention.
5. A client reports that the skin around the edges of a wound is red and swollen. What is the nurse's priority intervention?
- A. Monitor for signs of infection
- B. Reinforce the wound dressing
- C. Contact the healthcare provider
- D. Apply a warm compress to the wound
Correct answer: A
Rationale: The correct answer is to monitor for signs of infection. Redness and swelling around a wound are indicative of a potential infection. The priority intervention for the nurse is to closely monitor the wound for further signs of infection, such as increased drainage or fever. Reinforcing the wound dressing may be necessary, but it is not the priority when infection is suspected. Contacting the healthcare provider is important, but the nurse should first assess and monitor the wound to provide comprehensive information when contacting the provider. Applying a warm compress can potentially worsen the infection by promoting bacterial growth, so it is contraindicated in this situation.
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