HESI RN
HESI RN Exit Exam Capstone
1. A client with bipolar disorder is prescribed lithium. What should the nurse teach the client about lithium toxicity?
- A. Take the medication with meals to prevent gastrointestinal upset.
- B. Report any symptoms of nausea, vomiting, or diarrhea.
- C. Monitor lithium levels regularly and maintain hydration.
- D. Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs) while on lithium.
Correct answer: D
Rationale: The correct answer is D. Clients taking lithium should avoid NSAIDs as they can increase lithium levels leading to toxicity. It is essential to monitor lithium levels regularly and maintain hydration to prevent toxicity. Reporting symptoms like nausea, vomiting, or diarrhea is important, but the key teaching point regarding lithium toxicity is to avoid NSAIDs.
2. The nurse is preparing a client who had a BKA amputation for discharge to home. Which recommendations should the nurse provide this client?
- A. All of the above
- B. Inspect the skin for redness
- C. Use a residual limb shrinker
- D. Wash the stump with soap and water
Correct answer: A
Rationale: Proper care of the residual limb is essential in preventing complications like infection or poor healing. By choosing 'All of the above,' the nurse ensures that the client receives comprehensive care. Inspecting the skin for redness is crucial as it can help in early detection of infections. Using a residual limb shrinker helps reduce swelling and maintain proper shaping of the limb. Washing the stump with soap and water on a daily basis is important for hygiene and preventing infections. Therefore, all the recommendations (choices A, B, and C) are essential for the client's care, making choice A the correct answer. Choice D is incorrect as it does not encompass all the necessary recommendations for the client's care.
3. Which foods should a healthcare provider recommend for a child with phenylketonuria (PKU) to avoid?
- A. Fresh fruit and vegetables
- B. Foods sweetened with aspartame
- C. Bread with honey
- D. Gluten-rich bread
Correct answer: B
Rationale: The correct answer is B: 'Foods sweetened with aspartame.' Children with PKU must avoid foods containing aspartame because it breaks down into phenylalanine, which can worsen their condition. Choice A, fresh fruit and vegetables, are generally healthy and safe for individuals with PKU. Choice C, bread with honey, is also safe unless the bread contains artificial sweeteners like aspartame. Choice D, gluten-rich bread, is not specifically problematic for individuals with PKU unless it contains aspartame or other substances high in phenylalanine.
4. An older client is admitted to the intensive care unit unconscious after several days of vomiting and diarrhea. The nurse inserts a urinary catheter and observes dark amber urine output. Which intervention should the nurse implement first?
- A. Begin dopamine infusion at 2 mcg/kg/minute.
- B. Begin potassium chloride 10 mEq over 1 hour.
- C. Give a bolus of 0.9% sodium chloride 1000 mL over 30 minutes.
- D. Administer promethazine 25 mg IV push.
Correct answer: C
Rationale: In this scenario, the priority intervention is to give a bolus of 0.9% sodium chloride 1000 mL over 30 minutes. The client's dark amber urine output indicates dehydration and hypovolemia, requiring rapid fluid resuscitation. Dopamine infusion, potassium chloride, and promethazine are not the initial interventions needed for a client with hypovolemic symptoms.
5. A male client reports that he took tadalafil 10 mg two hours ago and now feels flushed. What action should the nurse take?
- A. Instruct the client to increase oral fluid intake.
- B. Reassure the client that flushing is a common side effect.
- C. Advise the client to take nitroglycerin as a precaution.
- D. Ask the client to come to the emergency room.
Correct answer: B
Rationale: The correct answer is B: Reassure the client that flushing is a common side effect. Tadalafil, a medication used for erectile dysfunction, can cause flushing as a common side effect. In this situation, the nurse should provide reassurance to the client that the flushing is expected and not necessarily a cause for concern. Increasing oral fluid intake (choice A) may be beneficial for other conditions but is not directly related to tadalafil-induced flushing. Advising the client to take nitroglycerin (choice C) is incorrect, as nitroglycerin is not indicated for flushing. Asking the client to come to the emergency room (choice D) is unnecessary at this point since flushing is a known side effect and does not typically require urgent medical attention.
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