HESI RN
HESI RN Exit Exam 2024 Capstone
1. A client with tuberculosis is prescribed rifampin. What side effect should the nurse inform the client about?
- A. Report orange-colored urine as a sign of kidney dysfunction.
- B. Expect red-orange discoloration of urine as a harmless side effect.
- C. Monitor for signs of liver toxicity.
- D. Call the healthcare provider if vision changes occur.
Correct answer: B
Rationale: The correct answer is B. Rifampin can cause red-orange discoloration of bodily fluids, including urine, saliva, and tears. This is a harmless side effect, but clients should be informed beforehand to prevent alarm. Choice A is incorrect as orange-colored urine is not a sign of kidney dysfunction related to rifampin. Choice C is incorrect because rifampin is more commonly associated with liver toxicity rather than kidney dysfunction. Choice D is incorrect as vision changes are not a typical side effect of rifampin.
2. A client is receiving instructions from a healthcare provider about intranasal desmopressin acetate (DDAVP). The healthcare provider explains that which of the following is a side effect of the medication?
- A. Headache
- B. Vulval pain
- C. Runny nose
- D. Flushed skin
Correct answer: C
Rationale: Intranasal desmopressin can cause a runny or stuffy nose as a side effect due to its mode of administration through the nasal passages.
3. A client with chronic kidney disease is prescribed erythropoietin. What lab value should the nurse monitor to evaluate the effectiveness of the therapy?
- A. White blood cell count.
- B. Hemoglobin level.
- C. Serum creatinine level.
- D. Platelet count.
Correct answer: B
Rationale: Erythropoietin therapy stimulates red blood cell production in clients with chronic kidney disease. Hemoglobin levels should be monitored to assess the effectiveness of the therapy and ensure the client is not developing anemia. Increased hemoglobin levels indicate successful treatment, whereas very high levels may suggest erythropoietin is overcorrecting the anemia. Monitoring the white blood cell count is not directly related to erythropoietin therapy for anemia. Serum creatinine level is used to assess kidney function rather than the effectiveness of erythropoietin therapy. Platelet count is not typically affected by erythropoietin therapy and is not a key indicator of its effectiveness.
4. One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large, and her fundus is boggy despite massage. The client's pulse is 84 beats/minute, and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM × 1. What action should the healthcare provider take immediately?
- A. Give the medication as prescribed and monitor for efficacy.
- B. Encourage the client to breastfeed rather than bottle-feed.
- C. Have the client empty her bladder and massage the fundus.
- D. Call the healthcare provider to question the prescription.
Correct answer: D
Rationale: The correct action for the healthcare provider to take immediately is to call the healthcare provider to question the prescription. Methergine is contraindicated in clients with hypertension due to its potential to elevate blood pressure further. In this scenario, the client's blood pressure is already elevated at 156/96, making it unsafe to administer Methergine. The LPN/LVN should advocate for the client's safety by questioning the prescription to prevent potential harm.
5. What is the inner lining of the non-pregnant uterus called?
- A. Decidua
- B. Myometrium
- C. Endometrium
- D. Sponge layer
Correct answer: C
Rationale: The correct answer is C, Endometrium. The endometrium is the inner lining of the non-pregnant uterus that undergoes cyclic changes in response to hormonal fluctuations during the menstrual cycle. Choice A, Decidua, is the specialized membrane formed during pregnancy. Choice B, Myometrium, refers to the middle layer of the uterine wall composed of smooth muscle. Choice D, Sponge layer, is not a term used to describe the inner lining of the uterus.