HESI RN
HESI 799 RN Exit Exam Capstone
1. A client with a history of atrial fibrillation is prescribed warfarin. What is the nurse's priority teaching?
- A. Avoid eating foods high in potassium.
- B. Avoid foods high in vitamin K.
- C. Take the medication on an empty stomach.
- D. Take the medication at bedtime for best results.
Correct answer: B
Rationale: The correct answer is B: 'Avoid foods high in vitamin K.' Warfarin is an anticoagulant medication that works by interfering with vitamin K-dependent clotting factors. Therefore, consuming foods high in vitamin K can affect the medication's effectiveness. Choices A, C, and D are incorrect because: A) Warfarin is not affected by foods high in potassium; C) Warfarin should be taken with food to minimize gastrointestinal side effects; D) There is no specific requirement for taking warfarin at bedtime for best results.
2. The nurse is providing education to a client who experiences recurrent levels of moderate anxiety in response to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?
- A. Practice using muscle relaxation techniques
- B. Take medication only when anxiety is at its worst
- C. Avoid interactions that trigger stress
- D. Engage in exercise during anxious periods
Correct answer: A
Rationale: Teaching relaxation techniques, such as muscle relaxation, helps the client manage anxiety more effectively. These techniques can be practiced regularly to reduce overall anxiety and can complement prescribed medications. Choice B is incorrect because medication should be taken as prescribed, not only when anxiety is at its worst. Choice C is incorrect as avoiding interactions that trigger stress may not always be feasible and does not teach the client coping mechanisms. Choice D is incorrect as engaging in exercise during anxious periods may not be the most effective strategy for managing moderate anxiety levels.
3. A client with Cushing's syndrome presents with excessive bruising and elevated blood glucose. What action should the nurse take first?
- A. Check the client's blood glucose level.
- B. Administer insulin per sliding scale protocol.
- C. Administer intravenous fluids.
- D. Check the client's skin for signs of bruising.
Correct answer: A
Rationale: Excessive bruising and elevated blood glucose are common symptoms of Cushing's syndrome. The nurse should first check the client's blood glucose level to assess and address the hyperglycemia promptly. Administering insulin or IV fluids would be premature without knowing the current blood glucose level. Checking the skin for bruising, although important for overall assessment, does not address the immediate concern of elevated blood glucose.
4. A client with type 1 diabetes reports blurry vision. What is the most important assessment the nurse should perform?
- A. Assess the client’s most recent blood glucose levels.
- B. Check the client’s hemoglobin A1C level.
- C. Check the client’s blood pressure for signs of hypertension.
- D. Examine the client’s feet for signs of neuropathy.
Correct answer: A
Rationale: Blurry vision in clients with type 1 diabetes may indicate hyperglycemia, which requires prompt assessment of recent blood glucose levels to determine the cause and appropriate intervention. Checking the client’s hemoglobin A1C level (Choice B) is useful for assessing long-term glucose control, not for immediate management of blurry vision. Monitoring blood pressure (Choice C) is important in diabetes care but is not the most crucial assessment when blurry vision is reported. Examining the client’s feet for signs of neuropathy (Choice D) is important in diabetic foot care but is not the priority when dealing with blurry vision.
5. A client asks the nurse for information about reducing risk factors for BPH. Which information should the nurse provide?
- A. Increase physical activity
- B. Decrease alcohol consumption
- C. Reduce intake of dairy products
- D. Avoid caffeine and spicy foods
Correct answer: A
Rationale: The correct answer is A: Increase physical activity. Physical activity can help reduce the risk of benign prostatic hyperplasia (BPH) by improving overall circulation and reducing inflammation. While decreasing alcohol consumption and avoiding caffeine and spicy foods may help with symptom management, increasing physical activity is more strongly linked to the prevention of BPH.
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