HESI RN
HESI RN Exit Exam 2023 Capstone
1. A client with diabetes mellitus reports tingling in their feet. What is the nurse's best intervention?
- A. Advise the client to avoid wearing tight shoes.
- B. Refer the client to a podiatrist for foot care.
- C. Teach the client about blood sugar control and foot care.
- D. Administer insulin as prescribed.
Correct answer: C
Rationale: The correct intervention for a client with diabetes mellitus experiencing tingling in their feet is to teach the client about blood sugar control and foot care. This is essential because tingling in the feet can be a sign of neuropathy, a common complication of diabetes. Educating the client on maintaining proper blood sugar levels and foot care practices can help manage neuropathy symptoms and prevent complications like ulcers or infections. Advising the client to avoid tight shoes (Choice A) may help with comfort but does not address the underlying issue. Referring the client to a podiatrist (Choice B) is important for foot care but does not directly address blood sugar control. Administering insulin (Choice D) is not the priority for managing tingling in the feet related to neuropathy.
2. 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.
3. A postoperative client with a history of diabetes mellitus is showing signs of hyperglycemia. What should the nurse assess first?
- A. Assess for signs of infection.
- B. Monitor the client’s fluid intake and output.
- C. Check the client’s capillary blood glucose level.
- D. Assess the client’s serum potassium level.
Correct answer: C
Rationale: The correct answer is to check the client’s capillary blood glucose level first. In a postoperative client with a history of diabetes mellitus showing signs of hyperglycemia, assessing blood glucose levels is crucial to confirm hyperglycemia and initiate appropriate interventions. While signs of infection are important to assess due to the client's postoperative status and diabetic history, checking the blood glucose level takes precedence to address the immediate concern of hyperglycemia. Monitoring fluid intake and output is essential but not the priority in this scenario. Assessing the client’s serum potassium level is important for overall assessment but not the initial step when hyperglycemia is suspected.
4. A client asks the nurse for information about reducing risk factors for BPH. Which information should the nurse provide?
- A. Increase physical activity
- B. Decrease alcohol consumption
- C. Reduce intake of dairy products
- D. Avoid caffeine and spicy foods
Correct answer: A
Rationale: The correct answer is A: Increase physical activity. Physical activity can help reduce the risk of benign prostatic hyperplasia (BPH) by improving overall circulation and reducing inflammation. While decreasing alcohol consumption and avoiding caffeine and spicy foods may help with symptom management, increasing physical activity is more strongly linked to the prevention of BPH.
5. A young adult visits the clinic reporting symptoms associated with gastritis. Which information in the client's history is most important for the nurse to address in the teaching plan?
- A. Experiences occasional heartburn after eating spicy food
- B. Consumes 10 or more drinks of alcohol every weekend
- C. Reports frequent use of NSAIDs
- D. Has a history of peptic ulcers
Correct answer: B
Rationale: Excessive alcohol consumption is a major risk factor for gastritis and should be prioritized in the teaching plan. While spicy foods and NSAIDs can contribute to gastritis, alcohol consumption is the most significant factor that needs immediate lifestyle changes to prevent worsening of gastritis symptoms. Peptic ulcers, although relevant, are not as directly linked to exacerbating gastritis symptoms as alcohol consumption.
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