HESI RN
HESI 799 RN Exit Exam Capstone
1. The nurse is planning care for a client with a venous leg ulcer. Which intervention should the nurse include in the plan of care to promote healing?
- A. Apply compression therapy to the affected leg
- B. Keep the affected leg in a dependent position
- C. Massage the area surrounding the ulcer
- D. Encourage the client to elevate the leg for 2 hours daily
Correct answer: A
Rationale: Compression therapy is essential for managing venous leg ulcers as it helps improve venous return, reduces edema, and promotes healing. By applying compression therapy to the affected leg, the nurse can assist in enhancing circulation, reducing swelling, and aiding in the healing process. Keeping the affected leg in a dependent position can worsen venous insufficiency. Massaging the area surrounding the ulcer is contraindicated as it can cause further damage and delay healing. While encouraging the client to elevate the leg is beneficial, it is not as effective as compression therapy for promoting healing in venous leg ulcers.
2. Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls?
- A. Sensory perceptual alterations related to decreased vision
- B. Alteration in mobility related to fatigue
- C. Impaired gas exchange related to retained secretions
- D. Altered patterns of urinary elimination related to nocturia
Correct answer: D
Rationale: The correct answer is D: Altered patterns of urinary elimination related to nocturia. Nocturia increases the risk of falls in elderly clients due to frequent nighttime trips to the bathroom. Choice A is incorrect because while decreased vision can contribute to falls, nocturia poses a more direct risk. Choice B is incorrect as fatigue may affect mobility but is not as directly linked to falls as nocturia. Choice C is incorrect as impaired gas exchange is not typically associated with an increased risk of falls.
3. A client with postpartum depression receives a prescription for sertraline (Zoloft). What information is most important to include in client teaching?
- A. Avoid foods high in tyramine, such as processed meats, red wine, and Swiss cheese.
- B. Contact the healthcare provider immediately if suicidal thoughts occur.
- C. Increase activity level to include regular exercise.
- D. Contact the healthcare provider immediately if muscle stiffness occurs.
Correct answer: B
Rationale: The most critical information to include in client teaching for a client with postpartum depression starting sertraline (Zoloft) is to contact the healthcare provider immediately if suicidal thoughts occur. This is vital for the client's safety as antidepressants, including sertraline, can sometimes increase the risk of suicidal thoughts, especially at the start of treatment. Choices A, C, and D are not the most crucial information in this scenario. Choice A about avoiding foods high in tyramine is not directly related to sertraline use. Choice C about increasing activity level is important but not as critical as addressing suicidal ideation. Choice D about muscle stiffness is a potential side effect of sertraline but is not as urgent as monitoring for suicidal thoughts.
4. A woman at 36-weeks' gestation who is Rh negative is admitted to labor and delivery reporting abdominal cramping. She is placed on strict bedrest, and the fetal heart rate and contraction pattern are monitored with an external fetal monitor. The nurse notes a large amount of bright red vaginal bleeding. Which nursing intervention has the highest priority?
- A. Perform a sterile vaginal examination to determine dilatation.
- B. Determine fetal position by performing Leopold maneuvers.
- C. Assess the fetal heart rate and client's contraction pattern.
- D. Confirm Rh and Coombs status for Rho(D) immunoglobulin administration.
Correct answer: C
Rationale: The highest priority nursing intervention in this scenario is to assess the fetal heart rate and the client's contraction pattern. The presence of a large amount of bright red vaginal bleeding in a woman at 36-weeks' gestation who is Rh negative raises concerns about the well-being of the fetus. Monitoring the fetal heart rate and contraction pattern will provide crucial information about fetal status and help determine the appropriate course of action to ensure the safety and health of both the mother and the baby.
5. A client is hospitalized with heart failure (HF). Which intervention should the nurse implement to improve ventilation and reduce venous return?
- A. Perform passive range of motion exercises
- B. Place the client in high Fowler's position
- C. Administer oxygen via nasal cannula
- D. Increase the client's activity level
Correct answer: B
Rationale: In clients with heart failure, placing them in high Fowler's position is beneficial as it helps reduce venous return and improve ventilation. This position aids in decreasing the workload on the heart by promoting better lung expansion and oxygenation. Passive range of motion exercises (Choice A) are not directly related to improving ventilation or reducing venous return. Administering oxygen via nasal cannula (Choice C) may help with oxygenation but does not directly address reducing venous return. Increasing the client's activity level (Choice D) may worsen heart failure symptoms by increasing the workload on the heart.