a client with heart failure reports nausea vomiting yellow vision and palpitations what should the nurse assess first
Logo

Nursing Elites

HESI RN

HESI RN Exit Exam 2024 Capstone

1. A client with heart failure reports nausea, vomiting, yellow vision, and palpitations. What should the nurse assess first?

Correct answer: B

Rationale: The combination of nausea, vomiting, yellow vision, and palpitations in a heart failure patient is indicative of digoxin toxicity. The nurse should first obtain a list of the client's medications to verify if they are taking digoxin.

2. A client with a history of deep vein thrombosis (DVT) is prescribed warfarin. Which laboratory value should the nurse monitor to assess the therapeutic effect of this medication?

Correct answer: B

Rationale: Prothrombin time (PT) is the correct laboratory value to monitor to assess the therapeutic effect of warfarin. Warfarin works by inhibiting clotting factors, and PT measures the time it takes for blood to clot. Monitoring PT helps ensure that the medication is working effectively to prevent clot formation without causing excessive bleeding. Platelet count (Choice A) is not specific to warfarin therapy and assesses the number of platelets in the blood. White blood cell count (Choice C) and hemoglobin level (Choice D) are not directly related to monitoring the therapeutic effect of warfarin.

3. A 60-year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void?

Correct answer: C

Rationale: Assisting the client to stand by the side of the bed to void is the most appropriate action in this situation. Standing to void often helps relieve the bladder, especially after surgery. Option A, having him drink several glasses of water, may not be as effective as the client might already be adequately hydrated. Option B, Crede maneuver, is a technique for emptying the bladder by applying manual pressure and is not the first-line intervention for a client who cannot void post-surgery. Option D, waiting 2 hours before trying to void again, may delay necessary intervention if the client is experiencing urinary retention.

4. A client receiving radiation therapy for breast cancer reports dry, peeling skin at the treatment site. What action should the nurse recommend?

Correct answer: B

Rationale: The correct recommendation for a client with dry, peeling skin at a radiation therapy treatment site is to use mild soap and water to cleanse the area. This approach helps in preventing skin irritation and reduces the risk of infection. Applying lotion (Choice A) may further irritate the skin due to the chemicals present in the lotion. Covering the area with a sterile dressing (Choice C) is not necessary unless there is an open wound that needs protection. Allowing the skin to air dry after washing (Choice D) may lead to further dryness and peeling.

5. A client receiving chemotherapy has severe neutropenia. What snack is best for the nurse to recommend?

Correct answer: B

Rationale: For a client with severe neutropenia, it is crucial to recommend a snack that is low in bacteria to reduce the risk of infection. Yogurt with fresh berries is an excellent choice as it is not only low in bacteria but also provides nutritional value. Baked apples with raisins (choice A) may not be ideal as the preparation process could introduce bacteria. Avocados and cheese (choice C) may not be the best option due to their potential bacterial content. Fresh fruit salad (choice D) may have a higher risk of bacterial contamination compared to yogurt with fresh berries.

Similar Questions

A client on mechanical ventilation is experiencing high-pressure alarms. What action should the nurse implement first?
A client with cirrhosis is receiving lactulose. What is the most important assessment for the nurse to monitor?
A client with diabetic ketoacidosis (DKA) is receiving an insulin infusion. Which finding indicates that the treatment is effective?
A client recovering from a stroke is demonstrating slurred speech. What action should the nurse take?
A client with atrial fibrillation is prescribed warfarin. Which instruction should the nurse include in the teaching?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses