the father of a 4 year old has been battling metastatic lung cancer for the past 2 years after discussing the remaining options with his healthcare pr
Logo

Nursing Elites

HESI RN

HESI RN Exit Exam 2024 Capstone

1. The father of a 4-year-old has been battling metastatic lung cancer for the past 2 years. After discussing the remaining options with his healthcare provider, the client requests that all treatment stop and that no heroic measures be taken to save his life. When the client is transferred to the palliative care unit, which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care?

Correct answer: C

Rationale: Obtaining a detailed report from the previous nurse ensures continuity of care and that all relevant information is passed on. This is critical in palliative care, where comfort measures and symptom management are key components of care. Choice A is not the most important action in this scenario, as the question focuses on continuity of care within the healthcare team. Beginning comfort measures immediately, as in choice B, is essential but obtaining a detailed report takes precedence to ensure a smooth transition of care. Confirming that the client understands the treatment plan, as in choice D, is important but does not directly address the need for continuity of care through a detailed report.

2. A client with cirrhosis is receiving spironolactone. What electrolyte level should the nurse monitor closely?

Correct answer: A

Rationale: The correct answer is to monitor potassium levels. Spironolactone is a potassium-sparing diuretic, which means it helps the body retain potassium and excrete sodium. Monitoring potassium levels closely is essential because spironolactone can cause hyperkalemia (high potassium levels). Sodium levels are not typically affected by spironolactone. Calcium and magnesium levels are also not directly impacted by spironolactone, making choices B, C, and D incorrect.

3. The nurse has received funding to design a health promotion project for African American women who are at risk for developing breast cancer. Which resource is most important in designing this program?

Correct answer: A

Rationale: The most important resource in designing a health promotion project for African American women at risk for breast cancer is the participation of community leaders in planning the program. Involving community leaders helps ensure that the program is culturally relevant, addresses the specific needs of the target population, and fosters trust and engagement. While the latest research on breast cancer risk factors, partnership with local healthcare providers, and health surveys of African American women are valuable resources, they are not as crucial as community involvement for tailoring the program effectively.

4. The healthcare provider is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the healthcare provider?

Correct answer: C

Rationale: A pulse oximetry reading of 88 indicates hypoxia, which is a serious condition requiring immediate intervention. Adequate oxygenation is crucial for the client's well-being. Choices A and B are normal findings after endotracheal intubation. Hearing bilateral breath sounds and seeing mist in the T-piece indicate proper functioning of the endotracheal tube. While choice D may indicate an issue with speaking due to the endotracheal tube, it is not as critical as the hypoxia indicated by the low pulse oximetry reading.

5. A client with pheochromocytoma is admitted to the hospital. Which intervention has the highest priority?

Correct answer: B

Rationale: The correct answer is B: Start intravenous fluids at a fast rate. In a client with pheochromocytoma, the highest priority intervention is to ensure adequate intravascular volume before initiating any other treatment. This helps prevent a sudden drop in blood pressure that can occur due to the release of catecholamines during tumor manipulation. While monitoring blood pressure frequently is essential, ensuring adequate intravascular volume takes precedence. Administering pain medication and antihypertensive medications are important but are not the highest priority in the initial management of pheochromocytoma.

Similar Questions

A client is receiving lactulose for signs of hepatic encephalopathy. To evaluate the therapeutic response, which assessment should the nurse obtain?
The nurse is caring for a client with pancreatitis who is receiving total parenteral nutrition (TPN). Which assessment finding requires immediate intervention by the nurse?
A client with chronic renal failure has a potassium level of 6.5 mEq/L. What is the nurse's priority action?
After completing her first chemotherapy treatment, what behavior indicates that a female client with breast cancer understands her discharge care needs?
In the critical care unit, which client should receive the most care hours by a registered nurse (RN)?

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