HESI RN
HESI RN Exit Exam 2024 Capstone
1. A female client experiences a sudden loss of consciousness and is taken to the emergency department. Initial assessment indicates her blood glucose level is critically low. Once stabilized, she reports being treated for anorexia nervosa. What intervention is most important for the nurse to include in the client’s discharge plan?
- A. Encourage a high-protein, low-carbohydrate diet.
- B. Encourage her to join a group focusing on self-esteem.
- C. Schedule an outpatient psychosocial assessment.
- D. Teach relaxation techniques to manage stress.
Correct answer: B
Rationale: Joining a group that focuses on self-esteem is the most important intervention for the nurse to include in the client's discharge plan. This can help the client address underlying emotional issues related to her anorexia nervosa and improve her mental health. Choice A is incorrect because a high-protein, low-carbohydrate diet may not address the psychological factors contributing to anorexia nervosa. Choice C is incorrect as scheduling an outpatient psychosocial assessment is important but not the most crucial intervention for discharge planning in this case. Choice D is also not the priority as teaching relaxation techniques, although beneficial, may not directly address the self-esteem and emotional issues that need to be tackled in this situation.
2. A client with DM is being taught about the importance of foot care by a nurse. Which instruction should the nurse include?
- A. Use a heating pad to warm your feet.
- B. Avoid walking barefoot.
- C. Soak your feet in hot water every night.
- D. Wear tight shoes to protect your feet.
Correct answer: B
Rationale: The correct instruction for the nurse to include is to advise the client to avoid walking barefoot. This recommendation is crucial for clients with diabetes to prevent foot injuries and infections. Walking barefoot can lead to unnoticed wounds or ulcers due to reduced sensation in the feet (neuropathy) common in diabetes. Choice A is incorrect as heating pads can cause burns and should be avoided. Choice C is incorrect because soaking feet in hot water can also lead to burns and skin damage. Choice D is incorrect as tight shoes can increase the risk of pressure sores and restrict blood flow, which is detrimental for individuals with diabetes.
3. A nurse administers scopolamine as prescribed to a client in preparation for surgery. For which side effect of this medication does the nurse monitor the client?
- A. Pupil constriction
- B. Increased urine output
- C. Complaints of dry mouth
- D. Complaints of feeling sweaty
Correct answer: D
Rationale: The correct answer is D: 'Complaints of feeling sweaty.' Scopolamine, an anticholinergic medication, commonly causes the side effect of decreased sweating, not increased urine output or pupil constriction. While dry mouth is a possible side effect, it is less likely than the altered sweating pattern. Therefore, the nurse should monitor the client for complaints of feeling sweaty due to the potential side effect of decreased sweating associated with scopolamine.
4. A client is being taught about the use of nitroglycerin (Nitrostat) for angina. Which statement by the client indicates a need for further teaching?
- A. I will sit or lie down when I take the medication.
- B. I can take up to three tablets, 5 minutes apart, if needed.
- C. I will call 911 if my chest pain is not relieved after taking three tablets.
- D. I will keep the medication in its original dark container.
Correct answer: B
Rationale: The correct administration of nitroglycerin for angina is to take up to three tablets, 5 minutes apart. If the chest pain persists after the third tablet, emergency medical services should be called. Taking more than three tablets or reducing the time interval between doses may lead to hypotension and indicates a need for further teaching.
5. The nurse is providing dietary instructions to a client with DM. The nurse instructs the client to include which item in the diet?
- A. High-fat foods
- B. Low-carbohydrate foods
- C. High-protein foods
- D. High-fiber foods
Correct answer: D
Rationale: High-fiber foods are beneficial for clients with diabetes because they help regulate blood glucose levels by slowing down the absorption of sugar. Additionally, high-fiber foods aid in maintaining satiety, supporting weight management, and preventing constipation. High-fat foods (choice A) are not recommended for clients with diabetes due to their potential negative impact on heart health and weight. While low-carbohydrate foods (choice B) can be part of a diabetes-friendly diet, high-fiber foods are more specifically beneficial for managing blood sugar levels. High-protein foods (choice C) can be included in moderation in a diabetic diet, but they are not the primary focus when it comes to improving glycemic control.