what is the most important assessment for a nurse to conduct on a child diagnosed with intussusception
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HESI RN

HESI RN Exit Exam 2024 Capstone

1. What is the most important assessment for a nurse to conduct on a child diagnosed with intussusception?

Correct answer: C

Rationale: The correct answer is C: 'Check for bowel movement and changes in stool.' Intussusception can cause obstruction in the bowel, leading to symptoms like abdominal pain, vomiting, and 'currant jelly' stools. Monitoring for changes in bowel movement, especially the passage of 'currant jelly' stools, is crucial for early detection of worsening conditions. Choices A, B, and D are important assessments in pediatric care but are not as specific or crucial as checking for changes in bowel movement in a child diagnosed with intussusception.

2. A client is prescribed metformin for type 2 diabetes. What should the nurse emphasize in the client's teaching?

Correct answer: C

Rationale: The correct answer is to avoid alcohol consumption while taking metformin. Alcohol can increase the risk of lactic acidosis when combined with metformin. Choice A is incorrect because metformin is usually recommended to be taken with meals to reduce GI upset. Choice B is important but not the priority; muscle pain is more commonly associated with other diabetes medications. Choice D is incorrect because metformin typically does not cause hypoglycemia but rather helps control blood sugar levels in type 2 diabetes.

3. A client is receiving treatment for glaucoma. Which class of medications is commonly used to decrease intraocular pressure?

Correct answer: D

Rationale: Diuretics are commonly used to decrease intraocular pressure in clients with glaucoma. They work by reducing the production of aqueous humor in the eye or by increasing its outflow. Anticholinergics (Choice A) are not typically used in the treatment of glaucoma and can even increase intraocular pressure. Beta blockers (Choice B) are also commonly used in glaucoma treatment as they reduce aqueous humor production. Alpha blockers (Choice C) are not the first-line treatment for glaucoma and are not as commonly used as diuretics or beta blockers.

4. A client with Alzheimer's disease is prescribed donepezil. What is the most important teaching point?

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.

5. The nurse is providing discharge teaching to a client with gastroesophageal reflux disease (GERD). Which instruction should the nurse include in the teaching?

Correct answer: C

Rationale: The correct instruction for the nurse to include in the teaching for a client with GERD is to eat small, frequent meals throughout the day. This recommendation helps reduce symptoms by preventing the stomach from becoming overly full, which can increase pressure on the lower esophageal sphincter and lead to acid reflux. Choices A, B, and D are incorrect because increasing fluid intake with meals can exacerbate GERD symptoms, lying down after eating can worsen reflux, and consuming spicy foods can trigger acid reflux in individuals with GERD.

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