HESI RN
HESI Exit Exam RN Capstone
1. A client with pheochromocytoma is admitted to the hospital. Which intervention has the highest priority?
- A. Monitor blood pressure frequently
- B. Start intravenous fluids at a fast rate
- C. Administer pain medication to reduce discomfort
- D. Give antihypertensive medications as prescribed
Correct answer: B
Rationale: The correct answer is B: Start intravenous fluids at a fast rate. In a client with pheochromocytoma, the highest priority intervention is to ensure adequate intravascular volume before initiating any other treatment. This helps prevent a sudden drop in blood pressure that can occur due to the release of catecholamines during tumor manipulation. While monitoring blood pressure frequently is essential, ensuring adequate intravascular volume takes precedence. Administering pain medication and antihypertensive medications are important but are not the highest priority in the initial management of pheochromocytoma.
2. What action should the nurse implement to prepare a client for the potential side effects of a newly prescribed medication?
- A. Assess the client for health alterations that may be impacted by the effects of the medication
- B. Teach the client how to administer the medication to promote the best absorption
- C. Administer a half dose and observe the client for side effects before administering a full dosage
- D. Encourage the client to drink plenty of fluids to promote effective drug distribution
Correct answer: A
Rationale: Before initiating a new medication, the nurse should conduct a thorough assessment of the client to identify any pre-existing health conditions or risk factors that could be affected by the medication. This assessment helps in establishing a baseline for monitoring potential side effects and determining the medication's appropriateness for the client. Choice B is incorrect as teaching the client how to administer the medication does not directly address preparing for potential side effects. Choice C is incorrect because administering a half dose without a proper assessment could be unsafe. Choice D is incorrect as encouraging fluid intake is not directly related to preparing for potential side effects of a medication.
3. A 5-week-old infant who developed projectile vomiting over the last two weeks is diagnosed with hypertrophic pyloric stenosis. Which intervention should the nurse plan to implement?
- A. Instruct the mother to give the child sugar water only.
- B. Offer oral rehydration solution every 2 hours.
- C. Provide Pedialyte feedings via nasogastric tube.
- D. Maintain intravenous fluid therapy per prescription.
Correct answer: D
Rationale: The correct intervention for a 5-week-old infant diagnosed with hypertrophic pyloric stenosis and experiencing projectile vomiting is to maintain intravenous fluid therapy. Intravenous fluids are crucial for rehydrating an infant suffering from dehydration due to rapid fluid loss from vomiting. Instructing the mother to provide sugar water only (choice A) is inappropriate and insufficient for rehydration. Offering oral rehydration solution every 2 hours (choice B) may not be effective if the infant continues to vomit. Providing Pedialyte feedings via nasogastric tube (choice C) may also not be as effective as intravenous fluid therapy in rapidly replenishing fluids and stabilizing the child's condition.
4. What is the most common cause of peptic ulcers?
- A. Helicobacter pylori infection
- B. NSAID use
- C. Excessive alcohol consumption
- D. Stress
Correct answer: A
Rationale: Helicobacter pylori infection is the most common cause of peptic ulcers. This bacterium can weaken the protective mucous coating of the stomach and duodenum, allowing acid to get through to the sensitive lining beneath. NSAID use (Choice B) can also cause peptic ulcers by disrupting the stomach's mucosal barrier. Excessive alcohol consumption (Choice C) and stress (Choice D) can exacerbate and contribute to ulcer formation but are not the primary cause.
5. An older adult client with eye dryness reports itching and excessive tearing. Which medication group is most likely to have produced this client's symptoms?
- A. Antiinfectives and antidepressants.
- B. Anticoagulants and antihistamines.
- C. Antiretrovirals and antivirals.
- D. Antihypertensives and anticholinergics.
Correct answer: D
Rationale: The correct answer is D: Antihypertensives and anticholinergics. Anticholinergics are known to cause dryness of secretions, including dry eyes, which can lead to symptoms of eye dryness, itching, and excessive tearing as reported by the client. Choices A, B, and C are incorrect as they do not typically cause the symptoms described by the client. Antiinfectives, antidepressants, anticoagulants, antihistamines, antiretrovirals, and antivirals do not commonly lead to dry eyes, itching, and excessive tearing.