HESI RN
HESI RN Exit Exam Capstone
1. A client with a seizure disorder is prescribed phenytoin. What is the most important teaching the nurse should provide?
- A. Take phenytoin with antacids to reduce stomach upset.
- B. Maintain a consistent dosing schedule to prevent seizures.
- C. Monitor for excessive drowsiness and dizziness.
- D. Take the medication at bedtime to reduce seizure risk.
Correct answer: B
Rationale: The most important teaching the nurse should provide to a client prescribed phenytoin is to maintain a consistent dosing schedule to prevent seizures. Phenytoin is an antiepileptic drug, and missing doses can increase the risk of seizures. Option A is incorrect because antacids can interact with phenytoin and reduce its absorption. Option C is important but not the most critical teaching as compared to maintaining a consistent dosing schedule. Option D is incorrect because the timing of phenytoin administration should be consistent rather than specifically at bedtime.
2. 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.
3. A client is scheduled for a colonoscopy. Which preparation is the most important for the nurse to implement?
- A. Administer an enema before the procedure.
- B. Ensure the client is NPO after midnight.
- C. Encourage the client to drink clear liquids.
- D. Verify the client has completed the bowel preparation.
Correct answer: D
Rationale: The correct answer is to verify that the client has completed the bowel preparation. This step is crucial to ensure the colon is clear for accurate visualization during the procedure. Administering an enema before the procedure may not always be necessary and can be uncomfortable for the client. Ensuring the client is NPO after midnight is important, but verifying bowel preparation takes precedence. Encouraging the client to drink clear liquids is a part of the preparation process but not the most critical step compared to verifying completion of bowel preparation.
4. A 66-year-old woman is retiring and needs health insurance. To which agency should the employee health nurse refer her?
- A. Medicaid
- B. Medicare
- C. COBRA
- D. Private insurance
Correct answer: B
Rationale: The correct answer is B: Medicare. Medicare is the federal health insurance program for individuals aged 65 and older, so it is the most suitable option for the 66-year-old woman retiring. Medicaid (choice A) is a state and federally funded program for low-income individuals and families, not specifically for retirees. COBRA (choice C) allows employees to continue their employer-sponsored health insurance for a limited time after leaving employment. Private insurance (choice D) refers to health insurance plans purchased directly from private insurance companies.
5. The nurse is caring for a client with a chest tube following surgery. The nurse should intervene if which of the following is observed?
- A. The chest tube is securely taped at the insertion site.
- B. The water seal chamber is filled to the correct level.
- C. The chest drainage system is below chest level.
- D. There are no air leaks in the system.
Correct answer: C
Rationale: The correct answer is C. The chest drainage system should always be kept below chest level to ensure proper drainage. Having the system above chest level can result in ineffective drainage. Choices A, B, and D are all correct actions to maintain the integrity and functionality of the chest tube system. Securing the chest tube at the insertion site, maintaining the water seal chamber at the correct level, and ensuring there are no air leaks are all essential components of caring for a client with a chest tube post-surgery.
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