HESI RN
HESI 799 RN Exit Exam
1. An older female client tells the nurse that her muscles have gradually been getting weaker over time. What is the best initial response by the nurse?
- A. Explain that this is an expected occurrence with aging.
- B. Observe the lower extremities for signs of muscle atrophy.
- C. Review the medical record for recent diagnostic test results.
- D. Ask the client to describe the changes that have occurred.
Correct answer: D
Rationale: The best initial response by the nurse should be to ask the client to describe the changes that have occurred. This open-ended question allows the nurse to gather valuable information directly from the client, aiding in assessing the situation accurately and formulating an appropriate care plan. Choice A is incorrect as assuming muscle weakness is an expected occurrence with aging without further assessment may overlook potential underlying issues. Choice B is premature as it jumps straight to physical examination without first gathering subjective data. Choice C is unnecessary at this point as reviewing diagnostic test results should come after initial assessment and data collection from the client.
2. The healthcare provider is evaluating the effects of thyroid therapy used to treat a 5-month-old with hypothyroidism. Which behavior indicates that the treatment has been effective?
- A. Laughs readily, turns from back to side.
- B. Has strong Moro and tonic neck reflexes.
- C. Keeps fists clenched, opens hands when grasping an object.
- D. Can lift head, but not chest when lying on abdomen.
Correct answer: A
Rationale: In infants, laughing readily and turning from back to side are indicative of normal development. These behaviors indicate that the thyroid therapy is effective, as they suggest the baby is achieving age-appropriate milestones. A 5-month-old infant should be able to laugh readily and turn from back to side, showing progress in motor and social development. Choices B, C, and D describe behaviors that are not specific to the expected developmental milestones of a 5-month-old. Strong Moro and tonic neck reflexes, clenched fists, and limited ability to lift the chest when lying on the abdomen are not necessarily indicative of the effectiveness of thyroid therapy for hypothyroidism.
3. 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.
4. A client is receiving dietary instructions from a nurse regarding warfarin sodium (Coumadin) therapy. The nurse advises the client to avoid which food item?
- A. Grapes
- B. Spinach
- C. Watermelon
- D. Cottage cheese
Correct answer: B
Rationale: The correct answer is B: Spinach. Spinach is high in vitamin K, which antagonizes the effects of warfarin sodium, an anticoagulant medication. Clients taking warfarin should avoid consuming foods rich in vitamin K, like spinach, to maintain the medication's effectiveness. Grapes (choice A), watermelon (choice C), and cottage cheese (choice D) do not interfere with the effects of warfarin, so they are safe for the client to consume while on warfarin therapy.
5. What assessment finding places a client at risk for problems associated with impaired skin integrity?
- A. Scattered macules on the face
- B. Capillary refill of 5 seconds
- C. Smooth nail texture
- D. Presence of skin tenting
Correct answer: B
Rationale: The correct answer is B. A capillary refill time greater than 3 seconds indicates poor perfusion, leading to impaired skin integrity. Delayed capillary refill can compromise blood flow to the skin, increasing the risk of pressure ulcers or wounds due to reduced tissue perfusion. Choices A, C, and D are incorrect because scattered macules on the face, smooth nail texture, and presence of skin tenting are not direct indicators of impaired skin integrity or risk for skin problems.