HESI RN
HESI RN Exit Exam 2024 Capstone
1. When conducting diet teaching for a client on a postoperative full liquid diet, which foods should the nurse encourage the client to eat?
- A. Yogurt, milk, and pudding
- B. Tea, lentils, and potato soup
- C. Ice cream, broth, and fruit smoothies
- D. Orange juice, mashed potatoes, and soft cheese
Correct answer: A
Rationale: A full liquid diet includes foods that are liquid or will turn liquid at room temperature. Yogurt, milk, and pudding are appropriate choices as they align with the consistency requirements of a full liquid diet. Choices B, C, and D are incorrect. Tea, lentils, potato soup, ice cream, fruit smoothies, orange juice, mashed potatoes, and soft cheese are not typically part of a full liquid diet. These options either contain solid elements or are not in liquid form, which makes them unsuitable for a postoperative full liquid diet.
2. A client receiving IV antibiotics for sepsis reports itching and has a rash on the chest. What is the nurse's first action?
- A. Administer an antihistamine as prescribed.
- B. Stop the infusion and notify the healthcare provider.
- C. Slow the infusion rate and monitor the client.
- D. Administer epinephrine subcutaneously.
Correct answer: B
Rationale: The correct action for the nurse to take first when a client receiving IV antibiotics for sepsis reports itching and a rash on the chest is to stop the infusion and notify the healthcare provider. This is crucial in preventing the allergic reaction from worsening. Administering an antihistamine (choice A) may address the symptoms but does not address the primary concern of stopping the infusion. Slowing the infusion rate and monitoring the client (choice C) may not be sufficient if the reaction is severe. Administering epinephrine subcutaneously (choice D) is not the first-line intervention for this situation.
3. A client with a history of alcohol abuse presents with confusion and unsteady gait. The nurse suspects Wernicke's encephalopathy. Which treatment should the nurse anticipate?
- A. Thiamine supplementation
- B. Folic acid replacement
- C. Intravenous glucose
- D. Magnesium sulfate administration
Correct answer: A
Rationale: Wernicke's encephalopathy is a neurological condition commonly caused by a deficiency in thiamine, often seen in clients with chronic alcohol abuse. Thiamine supplementation is the primary treatment to prevent further neurological damage. Folic acid replacement (choice B) is not the correct treatment for Wernicke's encephalopathy. Intravenous glucose (choice C) may be necessary in some cases of Wernicke's encephalopathy, but thiamine supplementation takes precedence. Magnesium sulfate administration (choice D) is not indicated as the primary treatment for Wernicke's encephalopathy.
4. What does the nurse's signature on the client’s surgical consent form signify?
- A. The client voluntarily grants permission for the procedure to be done
- B. The client is competent to sign the consent without impairment of judgment
- C. The client understands the risks and benefits associated with the procedure
- D. The client has signed the form freely and voluntarily
Correct answer: A
Rationale: The nurse's signature on a surgical consent form signifies that the client voluntarily grants permission for the procedure to be done. This is the correct answer because the nurse's signature does not imply the client's competence, understanding of risks and benefits, or that the client signed the form freely and voluntarily. The nurse's role is to verify that the client has made an informed decision and is providing consent for the procedure.
5. A client with a urinary tract infection is prescribed ciprofloxacin. What is the most important teaching the nurse should provide?
- A. Take the medication with milk to prevent stomach upset.
- B. Increase fluid intake to 2-3 liters per day.
- C. Avoid taking the medication with dairy products.
- D. Continue taking the medication even if symptoms improve.
Correct answer: B
Rationale: Ciprofloxacin can cause crystalluria, so increasing fluid intake to 2-3 liters per day helps flush out the medication and prevent crystal formation in the kidneys. This also ensures adequate hydration, which supports the body's ability to fight the infection. Choice A is incorrect because ciprofloxacin should not be taken with dairy products as they can interfere with the absorption of the medication. Choice D is incorrect because although it's important to complete the full course of antibiotics, it's equally crucial to report any improvement in symptoms to the healthcare provider.
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