HESI RN
HESI RN Exit Exam Capstone
1. A nurse is caring for a client with a chest tube following lung surgery. What is the most important intervention to ensure the chest tube functions properly?
- A. Clamp the tube if there is excessive drainage
- B. Empty the drainage chamber every 2 hours
- C. Keep the drainage system below chest level
- D. Milk the tube to prevent clots from forming
Correct answer: C
Rationale: The correct answer is C. Keeping the chest tube drainage system below chest level ensures that gravity assists with drainage and prevents fluid or air from flowing back into the pleural space, which could compromise lung function. Clamping the tube if there is excessive drainage (choice A) is incorrect as it can lead to a buildup of pressure and compromise the drainage system. Emptying the drainage chamber every 2 hours (choice B) is important but not as crucial as maintaining the drainage system below chest level. Milking the tube to prevent clots from forming (choice D) is incorrect and could lead to complications such as tube occlusion or damage to the tissue.
2. A client is prescribed allopurinol (Zyloprim) for chronic gout. Which instruction should the nurse include in the teaching plan?
- A. Take the medication with a full glass of water.
- B. Increase your intake of purine-rich foods.
- C. Stop taking the medication if you experience a gout attack.
- D. Take the medication with or without food.
Correct answer: A
Rationale: The correct instruction for a client prescribed allopurinol (Zyloprim) for chronic gout is to take the medication with a full glass of water. This helps prevent kidney stones which can be a side effect of the medication. It is important for the client to avoid purine-rich foods to help manage gout symptoms. They should continue taking the medication even during a gout attack as prescribed by the healthcare provider. Allopurinol can be taken with or without food, so there is no need to take it on an empty stomach. Therefore, option A is the correct choice. Options B, C, and D are incorrect as increasing purine-rich foods is not recommended, stopping the medication during a gout attack is not advised, and allopurinol can be taken with or without food.
3. A client with a history of coronary artery disease is admitted with chest pain. Which of these findings would be most concerning to the nurse?
- A. Blood pressure of 130/80 mm Hg
- B. Respiratory rate of 20 breaths per minute
- C. Heart rate of 72 beats per minute
- D. Temperature of 98.6 degrees Fahrenheit
Correct answer: B
Rationale: The correct answer is B. A respiratory rate of 20 breaths per minute may indicate respiratory distress in a client with chest pain. In a client with a history of coronary artery disease presenting with chest pain, signs of respiratory distress can be an alarming finding. Blood pressure within the normal range (130/80 mm Hg), heart rate of 72 beats per minute, and a temperature of 98.6 degrees Fahrenheit are generally considered within normal limits and may not be as concerning in this context.
4. The nurse is teaching a group of new mothers about infant care. Which topic should the nurse prioritize?
- A. signs of infant dehydration
- B. proper diaper changing techniques
- C. immunization schedule
- D. breastfeeding positions
Correct answer: A
Rationale: The correct answer is A: signs of infant dehydration. Recognizing signs of dehydration is crucial for ensuring the health and well-being of infants. Dehydration can be life-threatening for infants if not addressed promptly. While proper diaper changing techniques, immunization schedules, and breastfeeding positions are also important topics in infant care, being able to identify signs of dehydration takes precedence as it requires immediate attention to prevent serious consequences.
5. A client is instructed to take levothyroxine (Synthroid). The medication should be taken:
- A. With food
- B. At lunchtime
- C. On an empty stomach
- D. At bedtime with a snack
Correct answer: C
Rationale: Levothyroxine should be taken on an empty stomach to enhance absorption. Taking it with food or at bedtime can interfere with its absorption, reducing its effectiveness. Therefore, it is essential for the client to take levothyroxine on an empty stomach to ensure optimal therapeutic outcomes.