HESI RN
HESI 799 RN Exit Exam
1. Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis?
- A. Egg whites, toast, and coffee.
- B. Bran muffin, mixed fruits, and orange juice.
- C. Granola and grapefruit juice.
- D. Bagel with jelly and skim milk.
Correct answer: D
Rationale: The correct answer is D, 'Bagel with jelly and skim milk.' This choice includes skim milk, a good source of calcium, which is important for osteoporosis management. It also avoids foods that inhibit calcium absorption. Osteoporosis dietary management emphasizes increased calcium intake and reducing foods that hinder calcium absorption. Choice A only provides proteins but lacks calcium. Choice B offers fruits and a bran muffin, but it lacks a good source of calcium. Choice C has granola but misses a significant source of calcium.
2. The nurse is caring for a client with chronic renal failure who is receiving dialysis. The client reports muscle cramps and tingling in the hands. Which laboratory result should the nurse monitor to identify the cause of these symptoms?
- A. Sodium
- B. Calcium
- C. Phosphate
- D. Potassium
Correct answer: B
Rationale: Muscle cramps and tingling in clients with chronic renal failure are often associated with hypocalcemia. Monitoring calcium levels is crucial to identify imbalances and manage symptoms appropriately. Sodium, phosphate, and potassium levels are important in renal failure but are not directly related to the symptoms of muscle cramps and tingling reported by the client.
3. A client has been prescribed cyclosporine (Sandimmune). Which food item should the client avoid based on the medication's interaction?
- A. Red meats
- B. Orange juice
- C. Grapefruit juice
- D. Green, leafy vegetables
Correct answer: C
Rationale: Grapefruit juice should be avoided when taking cyclosporine because it inhibits the metabolism of the medication, leading to increased blood levels and a higher risk of toxicity. It is important for the client to follow this dietary instruction to ensure the safe and effective use of cyclosporine.
4. One day after abdominal surgery, an obese client complains of pain and heaviness in the right calf. What action should the nurse implement?
- A. Observe for unilateral swelling
- B. Administer pain medication
- C. Elevate the leg and apply a warm compress
- D. Notify the healthcare provider
Correct answer: A
Rationale: The correct action for the nurse to implement is to observe for unilateral swelling. Unilateral swelling could indicate a deep vein thrombosis (DVT), which is a serious complication that requires immediate assessment. Administering pain medication or applying warm compress may not address the underlying cause of the symptoms. Notifying the healthcare provider should be done after assessing and identifying the issue of unilateral swelling.
5. The nurse is caring for a preterm newborn with nasal flaring, grunting, and sternal retractions. After administering surfactant, which assessment is most important for the nurse to monitor?
- A. Bowel sounds
- B. Heart rate
- C. Arterial blood gases
- D. Apnea episodes
Correct answer: C
Rationale: Corrected Rationale: Surfactant therapy is used to improve lung function and gas exchange in premature infants with respiratory distress. Monitoring arterial blood gases is essential to assess the effectiveness of the treatment and ensure adequate oxygenation. While monitoring heart rate is important in neonatal care, assessing arterial blood gases will provide direct information regarding the infant's oxygenation status post-surfactant administration. Bowel sounds are not directly related to the respiratory distress symptoms described, and monitoring apnea episodes, although important in preterm infants, is not the most crucial assessment immediately following surfactant administration.