HESI RN
HESI RN Exit Exam 2023 Capstone
1. The nurse is providing care for a client with heart failure who is prescribed furosemide. Which laboratory value should the nurse monitor closely?
- A. Calcium level
- B. Sodium level
- C. Magnesium level
- D. Potassium level
Correct answer: D
Rationale: The correct answer is D: Potassium level. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Monitoring potassium levels is crucial to prevent complications such as cardiac arrhythmias. While calcium, sodium, and magnesium levels are important in various conditions and treatments, they are not the primary electrolyte affected by furosemide.
2. A client receiving total parenteral nutrition (TPN) is experiencing nausea and vomiting. What is the nurse's first action?
- A. Check the client's blood glucose level.
- B. Decrease the rate of TPN infusion.
- C. Administer an antiemetic as prescribed.
- D. Check the client's TPN bag for solution accuracy.
Correct answer: D
Rationale: The correct first action for the nurse to take when a client receiving TPN is experiencing nausea and vomiting is to check the client's TPN bag for solution accuracy. This is crucial to ensure that the correct solution is being administered and to address any potential errors. Checking the blood glucose level or administering an antiemetic may be necessary interventions but addressing the TPN bag's accuracy should be the priority to prevent any complications related to incorrect TPN solution.
3. A client with a urinary tract infection is prescribed ciprofloxacin. What is the nurse's priority teaching?
- A. Take the medication with a full glass of water.
- B. Avoid direct sunlight while taking the medication.
- C. Take the medication with meals to prevent nausea.
- D. Discontinue the medication if you experience dizziness.
Correct answer: A
Rationale: The correct answer is A: 'Take the medication with a full glass of water.' It is crucial for the nurse to teach the client to take ciprofloxacin with a full glass of water to prevent crystalluria, a potential side effect of the medication. Choice B is incorrect because ciprofloxacin does not require avoiding direct sunlight. Choice C is incorrect as taking the medication with meals is not necessary to prevent nausea. Choice D is incorrect as dizziness is not a common reason to discontinue ciprofloxacin.
4. A client presents to the clinic with a large abscess on the right thigh. The healthcare provider incises and drains the abscess. Which instruction should the nurse provide to the client upon discharge?
- A. Avoid showering until the wound is completely closed
- B. Perform daily wound care and dressing changes
- C. Apply heat to the wound for 15 minutes twice a day
- D. Take the prescribed antibiotic until the wound is fully healed
Correct answer: B
Rationale: After incision and drainage of an abscess, it is crucial to perform daily wound care and dressing changes to prevent infection and promote healing. Avoiding showering until the wound is completely closed (choice A) may not be practical or necessary. Applying heat to the wound (choice C) can increase the risk of infection and delay healing. While taking the prescribed antibiotic (choice D) is important, wound care and dressing changes are more directly related to promoting healing and preventing complications.
5. The nurse is caring for a client with a nasogastric tube. Which of the following interventions is a priority to maintain client safety?
- A. Flush the tube with water every 4 hours
- B. Check the tube placement before each feeding
- C. Secure the tube to the client's nose with tape
- D. Keep the head of the bed elevated at 30 degrees
Correct answer: B
Rationale: Verifying the correct placement of a nasogastric tube before each feeding is essential to prevent aspiration and ensure that the tube is properly positioned in the stomach or intestine. This action is a priority to maintain client safety. Flushing the tube with water every 4 hours is important for tube patency but is not the priority over verifying placement. Securing the tube with tape and keeping the head of the bed elevated are crucial but are considered secondary measures compared to confirming the correct tube placement.
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