the nurse is caring for a client with an acute myocardial infarction which symptom requires immediate intervention
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Nursing Elites

HESI RN

RN HESI Exit Exam Capstone

1. The nurse is caring for a client with an acute myocardial infarction. Which symptom requires immediate intervention?

Correct answer: C

Rationale: Severe chest pain is the hallmark symptom of an acute myocardial infarction (heart attack) and requires immediate intervention to prevent further damage to the heart muscle. Chest pain in this context is often described as crushing, pressure, tightness, or heaviness. It can radiate to the arms, neck, jaw, back, or upper abdomen. Other symptoms like dizziness, shortness of breath, nausea, and vomiting may also occur in acute myocardial infarction, but chest pain is the most critical sign requiring prompt action as it signifies inadequate blood flow to the heart muscle. Shortness of breath may indicate heart failure, while nausea and vomiting can be associated with the sympathetic response to myocardial infarction. Dizziness could result from decreased cardiac output but is not as specific to myocardial infarction as severe chest pain.

2. A client in heart failure (HF) presents with weakness and poor urine output. Which assessment finding requires immediate action?

Correct answer: C

Rationale: An elevated temperature may indicate infection and should be treated immediately in a client with heart failure.

3. During a thyroid storm, what is the nurse's priority intervention for a client experiencing increased heart rate and tremors?

Correct answer: A

Rationale: The correct answer is to administer antithyroid medications as prescribed during a thyroid storm. Antithyroid medications help control the overproduction of thyroid hormones, which is crucial in managing symptoms such as increased heart rate and tremors. These symptoms can be life-threatening if not promptly addressed. Administering a beta-blocker (Choice B) may help control the heart rate, but addressing the underlying cause with antithyroid medications is the priority. Monitoring the client's temperature (Choice C) is important but not the priority intervention during a thyroid storm. Lastly, preparing the client for an emergency thyroidectomy (Choice D) is not the initial intervention for managing symptoms of a thyroid storm.

4. A client with advanced chronic kidney disease (CKD) is scheduled for hemodialysis. Which dietary instruction should the nurse provide to the client?

Correct answer: A

Rationale: The correct answer is A: 'Limit fluid intake to prevent fluid overload.' Clients with advanced chronic kidney disease are at risk of fluid retention, which can lead to complications like fluid overload and hypertension. Therefore, it is crucial to instruct the client to limit fluid intake. Choice B is incorrect because increasing sodium intake can exacerbate fluid retention and hypertension in clients with CKD. Choice C is incorrect as increasing potassium intake can be dangerous for clients with CKD who may already have elevated potassium levels. Choice D is incorrect because while protein intake may need to be adjusted for clients on hemodialysis, the priority in this case is managing fluid intake.

5. A female client taking prednisone reports feeling tired after stopping the corticosteroid abruptly. What is the priority nursing intervention?

Correct answer: C

Rationale: The correct answer is to palpate the abdomen. When a client abruptly stops taking prednisone, there is a risk of adrenal insufficiency, which can present with symptoms like fatigue. Palpating the abdomen is crucial to assess for signs of adrenal crisis, such as abdominal pain, which can indicate severe adrenal insufficiency. Auscultating breath sounds (Choice A) and observing the skin for bruising (Choice D) are not the priority interventions in this situation. While measuring vital signs (Choice B) is important, palpating the abdomen takes precedence in this case to assess for potential adrenal insufficiency.

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