HESI RN
HESI RN Exit Exam 2024 Quizlet Capstone
1. A client with a urinary tract infection is prescribed ciprofloxacin. What is the nurse's priority teaching?
- A. Take the medication with a full glass of water.
- B. Avoid direct sunlight while taking the medication.
- C. Take the medication with meals to prevent nausea.
- D. Discontinue the medication if you experience dizziness.
Correct answer: A
Rationale: The correct answer is A: 'Take the medication with a full glass of water.' It is crucial for the nurse to teach the client to take ciprofloxacin with a full glass of water to prevent crystalluria, a potential side effect of the medication. Choice B is incorrect because ciprofloxacin does not require avoiding direct sunlight. Choice C is incorrect as taking the medication with meals is not necessary to prevent nausea. Choice D is incorrect as dizziness is not a common reason to discontinue ciprofloxacin.
2. After a spider bite on the lower extremity, a client is admitted to treat an infection that is spreading up the leg. Which admission assessment findings should the nurse report to the healthcare provider?
- A. Swollen lymph nodes in the groin
- B. Core body temperature of 100.5°F
- C. All of the above
- D. Elevated white blood cell count
Correct answer: C
Rationale: All of the above findings should be reported to the healthcare provider for prompt evaluation and treatment. Swollen lymph nodes in the groin indicate regional lymphatic involvement, a core body temperature of 100.5°F suggests a mild fever response, and an elevated white blood cell count indicates an ongoing infection process. These findings collectively point towards the spread of infection and require immediate attention to prevent further complications.
3. A client with cirrhosis is experiencing ascites and peripheral edema. What is the nurse's priority intervention?
- A. Administer furosemide as prescribed.
- B. Administer albumin to increase oncotic pressure.
- C. Elevate the client's legs to reduce swelling.
- D. Administer a sodium-restricted diet.
Correct answer: A
Rationale: The correct answer is A: Administer furosemide as prescribed. Administering furosemide, a loop diuretic, is the priority intervention in a client with cirrhosis experiencing ascites and peripheral edema. Furosemide helps promote diuresis and reduce fluid buildup in the body. Choice B, administering albumin to increase oncotic pressure, may be beneficial in some cases but is not the priority intervention for immediate fluid removal. Elevating the client's legs (Choice C) and administering a sodium-restricted diet (Choice D) are important aspects of managing edema and ascites but are not the priority interventions in this situation.
4. 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.
5. A client with diabetes mellitus is scheduled for surgery. What is the nurse's priority action when preparing this client for surgery?
- A. Ensure the client is NPO before surgery
- B. Monitor the client's blood glucose levels
- C. Administer the client's insulin as scheduled
- D. Teach the client about postoperative care
Correct answer: B
Rationale: The correct answer is B: Monitor the client's blood glucose levels. Clients with diabetes are at risk for perioperative complications related to blood glucose fluctuations. Monitoring blood glucose levels is crucial to maintaining proper management before, during, and after surgery. Option A is not the priority action as ensuring NPO status is a standard preoperative procedure for all clients. Option C could be important but is secondary to monitoring blood glucose levels. Option D is important but not the priority during the preoperative phase.
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