HESI RN Exit Exam

Correct Answer:

C. Participation of community leaders in planning the program.

Explanation of Correct Answer

C. Participation of community leaders in planning the program

Community leaders provide cultural insight, credibility, and influence that encourage participation and trust among African-American women. Their involvement ensures the program is tailored to the community’s needs, values, and preferences, which is essential for the program’s acceptance, success, and sustainability.

Correct Answer C: Minimal drainage into the urinary collection bag

Explanation:

After a TURP, continuous bladder irrigation (CBI) is used to prevent clot formation and keep the catheter patent. The nurse should expect light pink urine and sometimes mild suprapubic cramping due to bladder spasms, which are common in the first 24 hours. A sensation of pulling on the catheter is also not unusual if the catheter is taped or secured. However, minimal drainage in the collection bag indicates an obstruction (often due to blood clots blocking the catheter), which can cause acute urinary retention, bladder distension, and increased risk of hemorrhage. This is the most urgent and must be reported immediately.

Why Other Options Are Wrong:

A) Light, pink urine

This is an expected finding after TURP. Bleeding should gradually decrease, and urine should remain light pink in the first 24–48 hours.

B) Occasional suprapubic cramping

This is commonly due to bladder spasms from catheter irritation or irrigation fluid. Antispasmodics (like oxybutynin) may be prescribed. It is not an urgent reportable finding.

D) Complaints of the feeling of pulling on the urinary catheter

This can occur if the catheter is not secured properly, but it is not a sign of complication. Adjusting the tape or securing device usually resolves the issue.

Correct Answer:

D. I should take the medication with antacids.

Explanation of Correct Answer

D. I should take the medication with antacids.

Itraconazole requires gastric acidity for optimal absorption. Taking antacids reduces stomach acid and impairs absorption, making the drug less effective. If an antacid must be used, it should be taken at least 2 hours before or after itraconazole. This statement shows the client needs further instruction to avoid decreased therapeutic benefit.

Why Other Options Are Incorrect

A. If I experience any difficulty with breathing I will report it.

This is a correct statement. Itraconazole can cause rare but serious side effects such as heart failure and pulmonary symptoms. Reporting breathing difficulties allows for early detection of adverse reactions.

B. Drinking grapefruit juice will increase the effects of the medication.

This is accurate. Grapefruit juice inhibits CYP3A4 enzymes in the liver, increasing itraconazole blood levels and effects. Clients should be aware of this interaction to avoid excessive drug accumulation and toxicity.

C. Monitoring for changes in stool color is important.

This is correct. Dark urine or clay-colored stools may indicate hepatotoxicity, a serious adverse effect of itraconazole. Monitoring stool color and reporting changes helps with early detection of liver injury.

Correct Answer B. Increase ventilator rate.

Explanation:

The ABG results indicate respiratory acidosis (pH 7.31, PaCO₂ 60 mmHg) caused by hypoventilation, where carbon dioxide is being retained. Oxygenation is adequate (PaO₂ 104, SpO₂ 98%), so the issue is not with oxygen delivery but insufficient ventilation. The most appropriate intervention is to increase the ventilator rate, which will enhance CO₂ elimination and help normalize the pH.

Why Other Options Are Wrong:

A. Report the results to the healthcare provider.

While reporting ABG results is necessary, immediate corrective action is required first to address hypoventilation and CO₂ retention. Simply reporting does not treat the underlying problem.

C. Administer a dose of sodium carbonate.

This is incorrect because sodium bicarbonate is used to treat metabolic acidosis, not respiratory acidosis. The problem here is CO₂ retention, which requires ventilatory adjustment.

D. Decrease the flow rate of oxygen.

This is incorrect because the client’s oxygenation is already adequate. Lowering FiO₂ will not address the elevated PaCO₂ and could even reduce oxygen levels unnecessarily.

Correct Answer C. Muscle pain

Explanation of Correct Option:

Muscle pain is the most critical symptom because it can indicate rhabdomyolysis, a rare but life-threatening adverse effect of statins like lovastatin. Rhabdomyolysis involves muscle breakdown that releases myoglobin into the bloodstream, potentially leading to acute kidney failure. Prompt recognition and intervention are essential to prevent severe complications.

Why Other Options Are Wrong:

A. Diarrhea and flatulence

These are mild gastrointestinal side effects of lovastatin and are relatively common. While they may cause discomfort, they are not life-threatening and do not require immediate intervention compared to muscle pain.

B. Abdominal cramps

Though uncomfortable, abdominal cramps are a less severe gastrointestinal effect of statins. Monitoring and supportive care, such as taking the medication with food, can usually manage this problem without urgent action.

D. Altered taste

Changes in taste perception are an uncommon but non-serious adverse effect. This does not pose immediate risk to the client’s health and is less concerning than symptoms that suggest rhabdomyolysis.

Correct Answer B. Administer the Zofran after flushing the saline lock with saline

Explanation:

Ondansetron (Zofran) is an antiemetic, not a chemotherapy drug, and therefore does not require chemotherapy certification to administer. The nurse can safely give the IV medication through the saline lock after flushing with normal saline, following standard IV medication administration protocols. Scheduled doses should be administered as ordered to maintain effectiveness in preventing nausea and vomiting related to chemotherapy.

Why Other Options Are Wrong:

A. Ask a chemotherapy-certified nurse to administer the Zofran

Unnecessary, since ondansetron is not chemotherapy and can be administered by any nurse trained in IV therapy.

C. Hold the scheduled dose of Zofran until the client awakens

This risks reducing the drug’s effectiveness, since ondansetron works best when given on schedule to prevent nausea rather than after it begins.

D. Awaken the client to assess the need for administration of the Zofran

Zofran is ordered on a scheduled basis, not PRN (as needed). Its effectiveness depends on timely dosing, not waiting for symptoms.

Correct Answer C. Mild vomiting that progressed to vomiting shooting across the room.

Explanation:

C. Mild vomiting that progressed to vomiting shooting across the room.

Projectile vomiting after feeding is the hallmark and earliest classic sign of pyloric stenosis in infants. It typically begins as mild regurgitation or spitting up and rapidly progresses to forceful, projectile vomiting due to hypertrophy of the pyloric sphincter, which obstructs gastric emptying. Despite vomiting, infants often remain hungry and eager to feed again, which further supports the diagnosis.

Why Other Options Are Incorrect:

A. I noticed a little lump a little above the belly button.

This could describe an umbilical hernia rather than pyloric stenosis. The palpable “olive-shaped” mass of pyloric stenosis is usually felt in the right upper quadrant or epigastric area, not above the umbilicus.

B. The baby seems hungry all the time.

Infants with pyloric stenosis may indeed remain hungry after vomiting, but this symptom alone is nonspecific. Increased appetite can result from many conditions and does not directly confirm the diagnosis.

D. Irritation and spitting up immediately after feedings.

Simple spitting up or reflux is common in many healthy infants and does not necessarily indicate pyloric stenosis. The key distinguishing feature is projectile vomiting that worsens over time, not mild post-feeding regurgitation.

Correct Answer D. Avoid all isometric exercises, but walk regularly.

Explanation:

Clients with angina should be taught to avoid isometric exercises (like heavy lifting or straining), which significantly increase myocardial oxygen demand and can trigger angina attacks. Instead, regular walking and moderate aerobic exercise are recommended to improve circulation, reduce cardiac workload, and promote cardiovascular health. Exercise should be done in moderation, and activity should be stopped if chest pain occurs.

Why Other Options Are Wrong:

A. Engage in physical exercise immediately after eating to help decrease cholesterol levels

Exercising right after meals increases cardiac workload during digestion and can precipitate angina. Cholesterol management should be addressed through diet and safe, planned exercise.

B. Walk briskly in cold weather to increase cardiac output

Cold weather is a known trigger for angina because it causes vasoconstriction, increasing cardiac workload and oxygen demand. This advice would increase the risk of angina.

C. Keep nitroglycerin in a light-colored plastic bottle and readily available.

Nitroglycerin should be stored in its original dark glass container, tightly closed, to protect it from light and moisture. A plastic bottle degrades its potency. While keeping it available is correct, the storage instruction here is unsafe.

Correct Answer C: Precautions with position changes

Explanation:

Late-stage multiple myeloma leads to bone destruction, osteoporosis, and pathological fractures due to malignant plasma cells infiltrating bone marrow. Clients are at very high risk of fractures, even with minimal movement, so the plan of care should emphasize careful and supported position changes. Protecting bone integrity and minimizing injury is a priority.

Why Other Options Are Wrong:

A) Monitor for hyperkalemia

Multiple myeloma is more commonly associated with hypercalcemia due to bone breakdown, not hyperkalemia.

B) Place in protective isolation

Protective isolation is not typically required unless the client is neutropenic. The priority in late-stage disease is bone safety.

D) Administer diuretics as ordered

Diuretics may be used in hypercalcemia management but are not a standard late-stage priority in all patients. The main focus remains on fracture prevention.