HESI RN
HESI RN Exit Exam 2024 Capstone
1. When conducting diet teaching for a client on a postoperative full liquid diet, which foods should the nurse encourage the client to eat?
- A. Yogurt, milk, and pudding
- B. Tea, lentils, and potato soup
- C. Ice cream, broth, and fruit smoothies
- D. Orange juice, mashed potatoes, and soft cheese
Correct answer: A
Rationale: A full liquid diet includes foods that are liquid or will turn liquid at room temperature. Yogurt, milk, and pudding are appropriate choices as they align with the consistency requirements of a full liquid diet. Choices B, C, and D are incorrect. Tea, lentils, potato soup, ice cream, fruit smoothies, orange juice, mashed potatoes, and soft cheese are not typically part of a full liquid diet. These options either contain solid elements or are not in liquid form, which makes them unsuitable for a postoperative full liquid diet.
2. The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the UAP?
- A. Report any client complaint of pain or discomfort
- B. Weigh the client and report any weight gain
- C. Note and report the client's food and liquid intake during meals and snacks
- D. All of the above
Correct answer: D
Rationale: The UAP can be tasked with reporting complaints, monitoring weight gain, and tracking food and fluid intake, all of which are important in managing a client with Cushing's syndrome. These tasks fall within the UAP's scope of practice. Reporting client complaints helps in early identification of complications, monitoring weight is crucial due to fluid retention in Cushing's syndrome, and tracking food and fluid intake assists in dietary management. Choices A, B, and C are all necessary components of care for a client with Cushing's syndrome, making option D the correct answer.
3. Which meal option should the nurse recommend for a client with renal disease who is following a low-protein diet?
- A. Grilled chicken with steamed vegetables
- B. Tofu stir-fry with rice
- C. Pasta with marinara sauce
- D. Baked salmon with quinoa
Correct answer: C
Rationale: The correct answer is C: Pasta with marinara sauce. Clients with renal disease following a low-protein diet should opt for lower-protein options. Pasta with marinara sauce is a suitable choice as it is lower in protein compared to grilled chicken, tofu, or salmon. Grilled chicken, tofu, and salmon are higher in protein content and are not ideal for individuals following a low-protein diet for renal disease as they may strain the kidneys.
4. What instruction should the nurse include for a client prescribed nitroglycerin for a myocardial infarction?
- A. Take the medication only when experiencing severe chest pain.
- B. Store the medication in a dark container to protect it from light.
- C. Take the medication before engaging in physical activity that may trigger chest pain.
- D. Limit nitroglycerin use to no more than three doses in 15 minutes.
Correct answer: D
Rationale: The correct answer is D: 'Limit nitroglycerin use to no more than three doses in 15 minutes.' This instruction is crucial to prevent excessive use, which can lead to severe hypotension and other complications. Choice A is incorrect because nitroglycerin should also be used preventatively, not only during severe chest pain. Choice B is irrelevant and not a necessary instruction for nitroglycerin use. Choice C is incorrect as nitroglycerin is typically taken to prevent chest pain rather than waiting for an activity that may trigger it.
5. A male client with heart failure presents with shortness of breath, audible wheezing, and pink frothy sputum. What action should the nurse take?
- A. Consult with the charge nurse regarding morphine prescription.
- B. Administer the dose of morphine sulfate as prescribed.
- C. Withhold morphine until dyspnea resolves.
- D. Review the need for the prescription with the healthcare provider.
Correct answer: B
Rationale: The correct answer is B: Administer the dose of morphine sulfate as prescribed. In heart failure, morphine helps reduce anxiety, preload, and afterload on the heart, improving oxygenation. The client's symptoms indicate acute decompensated heart failure, and morphine should be administered promptly to relieve distress. Consulting the charge nurse (Choice A) or withholding morphine (Choice C) would delay necessary treatment. Reviewing the prescription with the healthcare provider (Choice D) is not needed in this acute situation.
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