HESI RN
HESI RN Exit Exam 2024 Quizlet Capstone
1. The nurse is caring for a client with a history of congestive heart failure (CHF) who is receiving digoxin therapy. The client reports seeing halos around lights. Which action should the nurse take?
- A. Assess the client's digoxin level
- B. Increase the client's fluid intake
- C. Check the client's blood pressure
- D. Administer a dose of potassium
Correct answer: A
Rationale: Seeing halos around lights is a classic symptom of digoxin toxicity. The nurse should assess the client's digoxin level to determine if the dose needs to be adjusted or if the medication should be held. Increasing fluid intake or checking blood pressure would not directly address the symptom of halos around lights. Administering a dose of potassium is not indicated without knowing the digoxin level and could potentially worsen the toxicity.
2. To prevent unnecessary hypoxia during suctioning of a tracheostomy, what must the nurse do?
- A. Apply suction for no more than 10 seconds
- B. Maintain sterile technique
- C. Lubricate 3 to 4 inches of the catheter tip
- D. Withdraw catheter in a circular motion
Correct answer: A
Rationale: The correct answer is to apply suction for no more than 10 seconds. Prolonged suctioning can lead to hypoxia, so it is essential to limit the suctioning time. Maintaining sterile technique (choice B) is important to prevent infections but is not directly related to preventing hypoxia during suctioning. Lubricating the catheter tip (choice C) helps with insertion but does not specifically address hypoxia prevention. Withdrawing the catheter in a circular motion (choice D) is not a standard practice during tracheostomy suctioning and does not help prevent hypoxia.
3. A client with Crohn's disease reports diarrhea. What intervention should the nurse implement?
- A. Instruct the client to drink clear fluids and avoid solid foods.
- B. Administer antidiarrheal medication as prescribed.
- C. Encourage a high-fiber diet and regular physical activity.
- D. Restrict fluid intake and monitor electrolytes.
Correct answer: C
Rationale: The correct intervention for a client with Crohn's disease reporting diarrhea is to encourage a high-fiber diet and regular physical activity. A high-fiber diet helps manage diarrhea in Crohn's disease by adding bulk to the stool and promoting more regular bowel movements. Instructing the client to drink clear fluids and avoid solid foods (Choice A) may not be appropriate as it can further exacerbate diarrhea. Administering antidiarrheal medication (Choice B) without addressing the underlying cause may not be the best initial approach. Encouraging a high-fiber diet and physical activity (Choice C) is beneficial for managing symptoms. Restricting fluid intake and monitoring electrolytes (Choice D) is not recommended as it can lead to dehydration, which is a concern in clients with diarrhea.
4. The nurse is providing care for a client with severe peripheral arterial disease (PAD). The client reports a history of rest ischemia, with leg pain that occurs during the night. Which action should the nurse take in response to this finding?
- A. Elevate the legs on pillows
- B. Encourage ambulation and leg exercises
- C. Provide a heating pad for warmth
- D. Offer cold packs when the pain occurs
Correct answer: C
Rationale: Providing warmth can help dilate peripheral vessels and increase blood flow, relieving ischemic pain. In PAD, where there is already compromised blood flow, elevating the legs or applying cold therapy could worsen ischemic pain by further reducing blood flow to the extremities. Encouraging ambulation and leg exercises may be beneficial in other conditions but not suitable for clients with severe PAD experiencing rest ischemia.
5. A client receiving continuous ambulatory peritoneal dialysis (CAPD) has lost weight and exhibits increasing edema. What should the nurse prioritize?
- A. Evaluate the patency of the arteriovenous (AV) graft.
- B. Instruct the client to continue a fluid-restricted diet.
- C. Recommend support stockings for venous return.
- D. Monitor the client's serum albumin levels.
Correct answer: A
Rationale: In a client receiving continuous ambulatory peritoneal dialysis (CAPD) who has lost weight and exhibits increasing edema, the nurse should prioritize evaluating the patency of the arteriovenous (AV) graft. This assessment is crucial to determine if hemodialysis can be resumed, addressing the client's presenting issues effectively. Instructing the client to continue a fluid-restricted diet (choice B) may not address the underlying issue related to the CAPD. Recommending support stockings for venous return (choice C) is not directly relevant to the situation described. Monitoring the client's serum albumin levels (choice D) may be important but does not directly address the immediate concern of weight loss and increasing edema in a CAPD client.