HESI RN
HESI RN Exit Exam 2024 Capstone
1. A client receiving full-strength continuous enteral tube feeding develops diarrhea. What intervention should the nurse take?
- A. Stop the feeding and provide IV fluids.
- B. Dilute the feeding to half strength and continue at the same rate.
- C. Reduce the feeding rate and monitor for improvement.
- D. Add fiber to the client's diet to resolve diarrhea.
Correct answer: B
Rationale: When a client develops diarrhea from continuous enteral tube feeding, diluting the feeding to half strength and continuing at the same rate is the appropriate intervention. This helps reduce the strength of the feeding, minimizing gastrointestinal upset while still providing necessary nutrition. Stopping the feeding abruptly (Choice A) may lead to nutritional deficits. Simply reducing the feeding rate (Choice C) may not effectively address the issue of diarrhea. Adding fiber (Choice D) could potentially worsen the diarrhea in this scenario instead of resolving it.
2. A client has been given a prescription for tetracycline HCL (Sumycin). The nurse should emphasize the client to
- A. Take the medication with food or milk
- B. Avoid prolonged sun exposure
- C. Monitor for signs of yellowing skin or eyes
- D. Expect a yellow-brown discoloration of the teeth
Correct answer: C
Rationale: The correct answer is C: 'Monitor for signs of yellowing skin or eyes.' Tetracycline can cause hepatotoxicity, leading to jaundice which may present as yellowing of the skin or eyes. This is a serious side effect that the nurse should emphasize to the client. Choice A is incorrect because tetracycline should generally be taken on an empty stomach, not with food or milk. Choice B is also incorrect as tetracycline can cause photosensitivity, but it is not directly related to yellowing skin or eyes. Choice D is incorrect because tetracycline can cause yellow-brown discoloration of the teeth, but this is usually seen in children under 8 years of age, not a common concern for adult clients.
3. A client with Alzheimer's disease is prescribed donepezil. What is the most important teaching point?
- A. Take the medication as directed for best results.
- B. Report any unusual changes in behavior.
- C. This medication helps improve cognitive function.
- D. This medication is not a cure for Alzheimer's disease.
Correct answer: C
Rationale: The most important teaching point for a client prescribed donepezil is that it helps improve cognitive function. While it is important to take the medication as directed for best results (choice A) and report any unusual changes in behavior (choice B), the key point is that donepezil is not a cure for Alzheimer's disease (choice D). Therefore, the correct answer is C.
4. A client with chronic kidney disease is prescribed a low-potassium diet. Which food should the nurse instruct the client to avoid?
- A. Carrots
- B. White bread
- C. Bananas
- D. Apples
Correct answer: C
Rationale: The correct answer is C: Bananas. Bananas are high in potassium and should be avoided in clients who are on a low-potassium diet due to chronic kidney disease. Foods like apples and white bread are low in potassium and are safer choices. Carrots are also low in potassium and do not need to be avoided in this case.
5. A client with rheumatoid arthritis is prescribed methotrexate. What is the most important teaching point for the nurse to provide?
- A. Take the medication with food to avoid gastrointestinal upset.
- B. Monitor for signs of infection, such as a sore throat.
- C. Increase fluid intake to prevent dehydration.
- D. Avoid direct sunlight to prevent photosensitivity.
Correct answer: D
Rationale: The most important teaching point for a client prescribed methotrexate is to avoid direct sunlight to prevent photosensitivity. Methotrexate can make the skin more sensitive to sunlight, increasing the risk of sunburn and skin damage. Choices A, B, and C are important aspects of client care but are not specifically related to the side effect of photosensitivity caused by methotrexate.
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