HESI RN
HESI 799 RN Exit Exam
1. A client with newly diagnosed hypertension is being taught about lifestyle modifications by a nurse. Which client statement indicates a need for further teaching?
- A. ‘I will reduce my salt intake to help manage my blood pressure.’
- B. ‘I will start exercising regularly to help control my blood pressure.’
- C. ‘I will avoid drinking alcohol to help manage my blood pressure.’
- D. ‘I will limit my caffeine intake to help control my blood pressure.’
Correct answer: D
Rationale: The correct answer is D. Limiting caffeine intake is a positive lifestyle modification for managing hypertension. The statement indicates that the client understands the importance of reducing caffeine intake. Choices A, B, and C all reflect appropriate lifestyle modifications for managing hypertension, indicating good understanding by the client.
2. The home health care nurse is visiting a client who was recently diagnosed with type 2 diabetes mellitus. The client is prescribed repaglinide (Prandin) and metformin (Glucophage) and asks the nurse to explain these medications. The nurse should reinforce which instructions to the client? Select one that doesn't apply.
- A. Diarrhea can occur secondary to the metformin.
- B. The repaglinide is not taken if a meal is skipped.
- C. The repaglinide is taken 30 minutes before eating.
- D. Nausea and vomiting
Correct answer: D
Rationale: Repaglinide is a rapid-acting oral hypoglycemic that should be taken before meals and withheld if the client does not eat. Hypoglycemia is a side effect of repaglinide, so carrying a simple sugar is essential. Metformin decreases hepatic glucose production and can cause diarrhea. Muscle pain may occur as an adverse effect and should be reported to the HCP.
3. A client is admitted with deep vein thrombosis (DVT) and is receiving heparin therapy. What is the most important laboratory value to monitor during heparin therapy?
- A. Prothrombin time (PT)
- B. International normalized ratio (INR)
- C. Activated partial thromboplastin time (aPTT)
- D. Platelet count
Correct answer: C
Rationale: The activated partial thromboplastin time (aPTT) is the most important laboratory value to monitor during heparin therapy. It measures the intrinsic pathway of coagulation and is used to assess the effectiveness of heparin as an anticoagulant. Keeping the aPTT within the therapeutic range is crucial to prevent complications such as bleeding or clot formation. Prothrombin time (PT) and International normalized ratio (INR) are used to monitor warfarin therapy, not heparin. Platelet count is important to assess for thrombocytopenia, a potential side effect of heparin, but it is not the primary laboratory value to monitor the effectiveness of heparin therapy.
4. An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take?
- A. Perform a 12-lead electrocardiogram
- B. Document in the client's record
- C. Notify the healthcare provider immediately
- D. Assess for signs of heart failure
Correct answer: B
Rationale: An S3 heart sound is often a normal finding in pregnant women due to increased blood volume and cardiac output. The nurse should document the finding as part of the routine assessment unless accompanied by other abnormal symptoms. Performing a 12-lead electrocardiogram (Choice A) is unnecessary for a normal S3 heart sound in pregnancy. Notifying the healthcare provider immediately (Choice C) is premature and may lead to unnecessary interventions. Assessing for signs of heart failure (Choice D) is not indicated as an isolated S3 heart sound is typically benign in pregnancy.
5. A 2-year-old boy begins to cry when the mother starts to leave. What is the nurse's best response in this situation?
- A. Let me read this book to you.
- B. Two years old usually stop crying the minute the parent leaves.
- C. Now be a big boy. Mommy will be back soon.
- D. Let's wave bye-bye to mommy.
Correct answer: D
Rationale: Waving bye-bye to mommy helps the child understand that the separation is temporary.