HESI RN
HESI 799 RN Exit Exam Capstone
1. The nurse is providing discharge teaching to a client with gastroesophageal reflux disease (GERD). Which instruction should the nurse include in the teaching?
- A. Increase fluid intake with meals
- B. Avoid lying down for at least 30 minutes after eating
- C. Eat small, frequent meals throughout the day
- D. Consume spicy foods in moderation
Correct answer: C
Rationale: The correct instruction for the nurse to include in the teaching for a client with GERD is to eat small, frequent meals throughout the day. This recommendation helps reduce symptoms by preventing the stomach from becoming overly full, which can increase pressure on the lower esophageal sphincter and lead to acid reflux. Choices A, B, and D are incorrect because increasing fluid intake with meals can exacerbate GERD symptoms, lying down after eating can worsen reflux, and consuming spicy foods can trigger acid reflux in individuals with GERD.
2. The healthcare provider prescribes a sepsis protocol for a client with multi-organ failure caused by a ruptured appendix. Which intervention is most important for the nurse to include in the care plan?
- A. Ensure early ambulation
- B. Administer antibiotics as prescribed
- C. Maintain strict intake and output
- D. Monitor blood glucose levels
Correct answer: C
Rationale: In sepsis with multi-organ failure, monitoring intake and output is critical to assess renal function and fluid balance, as organ failure can cause fluid shifts and decreased kidney function. Antibiotics are essential to treat the infection, but monitoring intake and output provides real-time insight into the client's status, helping to detect early signs of worsening organ function. Early ambulation and blood glucose monitoring are important aspects of care but are not as crucial as maintaining strict intake and output in this situation.
3. The client with chronic renal failure is on a fluid restriction. Which of the following statements by the client indicates that the teaching has been effective?
- A. I will limit my fluid intake to prevent fluid overload.
- B. I can drink as much fluid as I want as long as I take my medication.
- C. I will skip dialysis sessions if I feel tired.
- D. I will limit my fluid intake to 1 liter per day.
Correct answer: A
Rationale: Choice A is the correct answer because it demonstrates the client's understanding of the need to limit fluid intake to prevent fluid overload, which is crucial in managing chronic renal failure. Adequate fluid restriction is essential to prevent complications such as fluid overload and electrolyte imbalances. Choice B is incorrect as it promotes excessive fluid intake, which can worsen the client's condition by putting additional stress on the kidneys. Choice C is incorrect as skipping dialysis sessions can lead to a buildup of toxins in the body, worsening renal failure and potentially leading to life-threatening complications. Choice D is incorrect because limiting fluid intake to a specific volume may not be appropriate for all clients and can vary depending on individual needs, medical condition, and healthcare provider recommendations.
4. The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the procedure?
- A. Experiences facial swelling after eating crab
- B. Reports left chest wall pain prior to the admission
- C. Verbalizes a fear of being in a confined space
- D. Drank a glass of water
Correct answer: A
Rationale: The correct answer is A. Allergy to shellfish can indicate a potential allergy to iodine, which is used in contrast dye for the procedure. This must be explored further to prevent an allergic reaction. Choice B is not directly related to the angioplasty procedure. Choice C pertains to claustrophobia, which can be addressed but is not directly related to the safety of the procedure. Choice D is a routine activity and does not pose a risk to the client during the procedure.
5. What is a priority goal for the diabetic client who is taking insulin and experiencing nausea and vomiting from a viral illness or influenza?
- A. Ensuring adequate food intake.
- B. Managing personal health.
- C. Relieving pain.
- D. Increasing physical activity.
Correct answer: A
Rationale: Ensuring adequate food intake is a priority goal for a diabetic client taking insulin and experiencing nausea and vomiting due to a viral illness or influenza because maintaining proper nutrition is essential to prevent complications such as ketoacidosis. During illness, it is crucial for diabetic individuals to continue to consume appropriate amounts of food to maintain stable blood sugar levels and prevent hypoglycemia. Managing personal health (choice B) is important but not the priority in this situation. Relieving pain (choice C) may be necessary if present but is not the priority over ensuring food intake. Increasing physical activity (choice D) is not recommended during illness, especially when the individual is experiencing nausea and vomiting.