HESI RN
HESI Exit Exam RN Capstone
1. 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.
2. The nurse is caring for a client who is post-op after a hip replacement. Which of the following nursing actions is most appropriate to prevent dislocation of the hip?
- A. Place an abduction pillow between the client's legs.
- B. Use an abduction pillow between the client's legs.
- C. Encourage the client to cross their legs while sitting.
- D. Encourage the client to sit upright for long periods.
Correct answer: B
Rationale: Using an abduction pillow between the client's legs is the most appropriate nursing action to prevent dislocation after hip replacement surgery. An abduction pillow helps maintain proper alignment and prevents the hip from dislocating. Placing the client in a high Fowler's position (Choice A) or encouraging them to sit upright for long periods (Choice D) may not provide the necessary support and stability needed to prevent hip dislocation. Encouraging the client to cross their legs while sitting (Choice C) can increase the risk of hip dislocation and should be avoided.
3. A male client with HIV on antiretroviral therapy complains of constant hunger and thirst while losing weight. What action should the nurse implement?
- A. Check the client's glucose level with a glucometer.
- B. Measure the client's weight accurately.
- C. Reassure the client that weight will stabilize as viral load decreases.
- D. Increase the dose of saquinavir.
Correct answer: A
Rationale: The correct action for the nurse to implement is to check the client's glucose level with a glucometer. Constant hunger and thirst along with weight loss can be indicative of hyperglycemia, a possible side effect of saquinavir. Monitoring the client's glucose levels is crucial in this situation. Measuring the client's weight accurately (Choice B) is important for monitoring purposes but does not address the immediate concern of hunger, thirst, and weight loss. Reassuring the client that weight will stabilize as viral load decreases (Choice C) is not appropriate in this scenario as the symptoms described need immediate attention. Increasing the dose of saquinavir (Choice D) without assessing the client's glucose level can worsen the hyperglycemia.
4. A client with multiple sclerosis is experiencing fatigue. What is the nurse's priority intervention?
- A. Encourage the client to increase physical activity.
- B. Encourage the client to take rest breaks during activities.
- C. Administer a stimulant medication to reduce fatigue.
- D. Advise the client to use energy conservation techniques.
Correct answer: D
Rationale: The correct answer is D: Advise the client to use energy conservation techniques. Energy conservation techniques are crucial in managing fatigue in multiple sclerosis. These techniques involve prioritizing activities, pacing oneself, and taking rest breaks to prevent overexertion, which can exacerbate fatigue. Encouraging the client to increase physical activity (choice A) may worsen fatigue if not done with proper energy conservation. Taking rest breaks during activities (choice B) is important but falls secondary to teaching energy conservation techniques. Administering a stimulant medication to reduce fatigue (choice C) should not be the priority as non-pharmacological interventions like energy conservation should be attempted first.
5. A client with hypothyroidism is prescribed levothyroxine. What assessment finding suggests the medication dosage is too high?
- A. Increased sensitivity to cold.
- B. Increased heart rate and palpitations.
- C. Improved energy levels.
- D. Improved tolerance to heat.
Correct answer: B
Rationale: The correct answer is B: Increased heart rate and palpitations. When a client with hypothyroidism is prescribed levothyroxine, these symptoms may indicate that the dosage is too high, causing the client to develop hyperthyroidism. Choices A, C, and D are incorrect. Increased sensitivity to cold is a symptom of hypothyroidism, improved energy levels are an expected outcome of levothyroxine therapy for hypothyroidism, and improved tolerance to heat is not a common sign of levothyroxine overdose.
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