HESI RN
HESI RN Exit Exam Capstone
1. A client with heart failure receiving furosemide develops muscle weakness. What is the nurse's priority action?
- A. Administer potassium supplements as prescribed.
- B. Monitor the client’s potassium levels.
- C. Instruct the client to increase their salt intake.
- D. Discontinue the furosemide.
Correct answer: B
Rationale: Muscle weakness in a client receiving furosemide (a diuretic) is often a sign of hypokalemia, as furosemide increases potassium loss. Monitoring potassium levels is essential to identify and address any imbalances and prevent complications such as arrhythmias. Administering potassium supplements without monitoring the levels can lead to hyperkalemia, which has its own set of serious complications. Instructing the client to increase salt intake is not appropriate in this situation as it does not address the underlying electrolyte imbalance. Discontinuing furosemide abruptly can worsen heart failure symptoms; therefore, monitoring potassium levels and adjusting the treatment accordingly is the most appropriate action.
2. While changing a client's chest tube dressing, the nurse notes a cracking sensation when gentle pressure is applied to the skin at the insertion site. What should the nurse do next?
- A. Apply a pressure dressing at the chest tube site.
- B. Administer an oral antihistamine per PRN order.
- C. Assess the client for allergies to topical cleaning agents.
- D. Measure the area of crackling and swelling.
Correct answer: D
Rationale: Measuring the area of crackling and swelling is essential in monitoring the progression of subcutaneous emphysema, which can result from air leaking into the tissues around the chest tube insertion site. This technique helps evaluate the extent of the issue and guides further interventions. Applying a pressure dressing (choice A) might exacerbate the condition by trapping more air. Administering an oral antihistamine (choice B) is not indicated for subcutaneous emphysema. Assessing for allergies to topical cleaning agents (choice C) is not the priority in this situation compared to evaluating and managing the subcutaneous emphysema.
3. A client with diabetes insipidus is admitted due to a pituitary tumor. What complication should the nurse monitor closely?
- A. Monitor for elevated blood pressure.
- B. Monitor for ketonuria.
- C. Monitor for peripheral edema.
- D. Monitor for hypokalemia.
Correct answer: D
Rationale: The correct answer is to monitor for hypokalemia. In diabetes insipidus, excessive urination can lead to electrolyte imbalances, particularly low potassium levels (hypokalemia). The loss of potassium through increased urination can result in muscle weakness, cardiac dysrhythmias, and other serious complications. Elevated blood pressure (Choice A) is not a typical complication of diabetes insipidus due to pituitary tumors. Ketonuria (Choice B) is more commonly associated with diabetes mellitus due to inadequate insulin levels. Peripheral edema (Choice C) is not a direct complication of diabetes insipidus.
4. During an assessment of a client with congestive heart failure, the nurse is most likely to hear which of the following upon auscultation of the heart?
- A. S3 ventricular gallop
- B. Apical click
- C. Systolic murmur
- D. Split S2
Correct answer: A
Rationale: Correct Answer: An S3 ventricular gallop is an abnormal heart sound commonly heard in clients with congestive heart failure. This sound is indicative of fluid overload or volume expansion in the ventricles, which is often present in heart failure. <br> Incorrect Answers: <br> B: An apical click is not typically associated with congestive heart failure. <br> C: A systolic murmur may be heard in various cardiac conditions but is not specific to congestive heart failure. <br> D: A split S2 refers to a normal heart sound caused by the closure of the aortic and pulmonic valves at slightly different times during inspiration, not directly related to congestive heart failure.
5. A client with psoriasis is prescribed topical corticosteroids. What side effect should the nurse monitor for?
- A. Monitor for weight gain and skin thinning.
- B. Assess for increased sensitivity to sunlight.
- C. Monitor for hair loss and excessive bruising.
- D. Report any signs of increased redness or itching.
Correct answer: D
Rationale: The correct answer is D. When a client with psoriasis is prescribed topical corticosteroids, the nurse should monitor for signs of increased redness or itching. This is because topical corticosteroids can cause skin thinning and increased redness if overused. Choices A, B, and C are incorrect because weight gain, sensitivity to sunlight, hair loss, and excessive bruising are not typically associated with the use of topical corticosteroids.
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