HESI RN
HESI RN Exit Exam 2023 Capstone
1. A client with pancreatitis reports severe pain after eating fatty foods. What intervention should the nurse implement?
- A. Encourage the client to eat small, low-fat meals.
- B. Administer antispasmodic medication as prescribed.
- C. Instruct the client to avoid eating until the pain subsides.
- D. Increase the client’s intake of high-protein foods.
Correct answer: B
Rationale: In pancreatitis, pain after consuming fatty foods is common due to increased pancreatic stimulation. Administering antispasmodics is the appropriate intervention as it can help reduce the pain by decreasing pancreatic enzyme secretion. Encouraging the client to eat small, low-fat meals (Choice A) is beneficial in managing pancreatitis symptoms but does not directly address the acute pain. Instructing the client to avoid eating until the pain subsides (Choice C) may lead to nutritional deficiencies and is not the best approach. Increasing high-protein foods intake (Choice D) is not recommended as it can put additional strain on the pancreas.
2. When speaking with a group of teens about chemotherapy side effects for cancer, which side effect would the nurse expect this group to be more interested in discussing?
- A. Mouth sores
- B. Fatigue
- C. Diarrhea
- D. Hair loss
Correct answer: D
Rationale: Teens are more likely to be concerned with hair loss when discussing chemotherapy side effects because it is a visible and emotionally impactful side effect for them. While all the listed side effects are important to consider, hair loss can have a significant impact on a teenager's self-image and emotional well-being, making it a key point of interest for this age group. Mouth sores, fatigue, and diarrhea are also common side effects of chemotherapy, but they may not carry the same level of emotional weight and visibility as hair loss for teens.
3. A client is receiving IV fluid therapy for dehydration. Which assessment finding indicates that the client's fluid status is improving?
- A. Urine output increases to 50 mL/hour
- B. Client reports feeling more thirsty
- C. Blood pressure decreases from 120/80 to 110/70
- D. Heart rate increases from 80 to 100 beats per minute
Correct answer: A
Rationale: An increase in urine output is a positive sign that the client's hydration status is improving. It indicates that the kidneys are functioning well and that fluid therapy is effective. Increased urine output helps to eliminate excess fluid and waste products from the body. Choices B, C, and D are incorrect. Feeling more thirsty (choice B) is a sign of dehydration, not improvement. A decrease in blood pressure (choice C) and an increase in heart rate (choice D) are not typically indicative of improving fluid status during IV fluid therapy for dehydration.
4. The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high-protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?
- A. A tuna fish sandwich with chips and ice cream
- B. A vegetable salad with croutons and ranch dressing
- C. A grilled chicken breast with steamed vegetables
- D. A peanut butter and jelly sandwich with soda
Correct answer: C
Rationale: The correct answer is C. Grilled chicken is an excellent source of protein, which is important for wound healing. Choices A, B, and D are less ideal for wound healing. Choice A contains high-fat and high-sugar components like chips and ice cream, which may not support wound healing effectively. Choice B includes croutons and ranch dressing, which may not provide as much protein as needed for wound healing. Choice D with a peanut butter and jelly sandwich and soda lacks a balanced meal with adequate protein to promote wound healing.
5. A client with cirrhosis is admitted with jaundice, fatigue, and a distended abdomen. Which laboratory result is most important for the nurse to monitor?
- A. Ammonia level
- B. White blood cell count
- C. Albumin level
- D. Hemoglobin level
Correct answer: A
Rationale: Corrected Rationale: In clients with cirrhosis, elevated ammonia levels can lead to hepatic encephalopathy, which is a serious complication. Monitoring ammonia levels is crucial to assess for changes in mental status and initiate treatment if needed. White blood cell count (choice B) is not the most important parameter to monitor in this scenario as it does not directly relate to the complications of cirrhosis. Albumin level (choice C) and hemoglobin level (choice D) are also important in cirrhosis, but in this case, monitoring ammonia level takes precedence due to its direct association with hepatic encephalopathy.
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