Questions 79

HESI RN

HESI RN Test Bank

RN HESI Exit Exam Capstone Questions

Question 1 of 5

The nurse is preparing a discharge teaching plan for a liver transplant client. Which instruction is most important to include in this plan?

Correct Answer: B

Rationale: The most critical instruction to include in the discharge teaching plan for a liver transplant client is to take immunosuppressant medications as prescribed. This is vital to prevent organ rejection and ensure the success of the transplant. While ensuring daily follow-up with the healthcare provider is important for monitoring progress, avoiding crowds for the first two months after surgery helps reduce the risk of infections but is not as crucial as medication adherence. Returning to work in three months is a consideration but not the most important aspect immediately post-transplant.

Question 2 of 5

A client in the third trimester of pregnancy reports that she feels some 'lumpy places' in her breasts and that her nipples sometimes leak a yellowish fluid. She has an appointment with her healthcare provider in two weeks. What action should the nurse take?

Correct Answer: C

Rationale: The yellowish fluid is likely colostrum, a normal finding in late pregnancy as the breasts prepare for lactation. It is common for women in the third trimester to experience 'lumpy places' in the breasts due to increased milk duct development. In this situation, the nurse should educate the client that these findings are normal physiological changes associated with pregnancy. Since the client has an upcoming appointment with her healthcare provider in two weeks, it is appropriate to reassure her that this can be further assessed during that visit. Instructing the client to immediately see her provider (
Choice
A) is unnecessary as this is a common finding in late pregnancy. Assessing the fluid for signs of infection (
Choice
B) is not warranted as colostrum leakage is a normal occurrence. Recommending a breast ultrasound (
Choice
D) is premature without further assessment by the healthcare provider.

Question 3 of 5

A client reports dizziness when standing up quickly. What advice should the nurse give?

Correct Answer: B

Rationale: The correct advice for a client experiencing dizziness when standing up quickly is to change positions slowly to prevent dizziness. This symptom is suggestive of postural hypotension, where a sudden change in position can lead to a drop in blood pressure, causing dizziness. Encouraging the client to drink more fluids (
Choice
A) may be beneficial for other conditions but is not directly related to the prevention of dizziness in this case. Reporting the symptom to the healthcare provider immediately (
Choice
C) is important if the dizziness is persistent or severe, but the immediate action to prevent it is to change positions slowly. Limiting physical activity (
Choice
D) may not necessarily address the underlying cause of dizziness in this context.

Question 4 of 5

A client with peripheral artery disease reports pain while walking. What intervention should the nurse recommend?

Correct Answer: B

Rationale: Clients with peripheral artery disease often experience claudication (leg pain during walking) due to decreased blood flow. Encouraging rest breaks during walking helps to manage pain and improve circulation. Rest breaks allow the muscles to recover from ischemia caused by inadequate blood supply. Increasing physical activity without breaks may worsen the symptoms. Applying warm compresses can potentially lead to burns or skin damage in individuals with compromised circulation. Massaging the affected leg is contraindicated in peripheral artery disease as it can further compromise blood flow.

Question 5 of 5

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.

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