After an older client receives treatment for drug toxicity, the healthcare provider prescribes a 24-hour creatinine clearance test. Before starting the urine collection, the nurse noted that the client's serum creatinine was 0.3 mg/dL. Which action should the nurse implement?

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HESI RN Exit Exam 2023 Capstone Questions

Question 1 of 5

After an older client receives treatment for drug toxicity, the healthcare provider prescribes a 24-hour creatinine clearance test. Before starting the urine collection, the nurse noted that the client's serum creatinine was 0.3 mg/dL. Which action should the nurse implement?

Correct Answer: C

Rationale: A serum creatinine level of 0.3 mg/dL is abnormally low, indicating potential issues with the interpretation of the creatinine clearance test. It is crucial for the nurse to notify the healthcare provider of this result before proceeding with the 24-hour urine collection. Checking urine output, instructing the client to increase fluid intake, or starting the urine collection without consulting the healthcare provider could lead to incorrect test results and misinterpretation of the client's renal function.

Question 2 of 5

Prior to surgery, written consent must be obtained. What is the nurse's legal responsibility with regard to obtaining written consent?

Correct Answer: D

Rationale: The nurse's legal responsibility is to ensure that informed consent has been obtained by verifying that the client has signed the form and that it is included in the record. Witnessing the consent and signing as a witness is not the nurse's role, as this is typically done by a neutral party. Informing the client of alternatives to the procedure and explaining the procedure in detail are responsibilities of the healthcare provider performing the surgery, not the nurse.

Question 3 of 5

A young male client is admitted to rehabilitation following a right AKA (above-the-knee amputation) for a severe traumatic injury. He is in the commons room and anxiously calls out to the nurse, stating that his 'right foot is aching.' The nurse offers reassurance and support. Which additional intervention is most important for the nurse to implement?

Correct Answer: D

Rationale: The client's report of pain in a missing limb is consistent with phantom limb pain, which can be distressing. Encouraging the client to discuss his feelings helps address the emotional and psychological aspects of the amputation and supports his overall recovery. Teaching distraction techniques (choice A) may provide temporary relief but does not address the underlying emotional distress. Providing a soft blanket (choice B) is not the priority when dealing with phantom limb pain. Administering pain medication (choice C) may not effectively manage phantom limb pain as it is more related to central nervous system changes rather than tissue damage.

Question 4 of 5

Which strategy should the nurse implement when teaching a client with low literacy about a new diagnosis of hypertension?

Correct Answer: B

Rationale: The correct strategy for teaching a client with low literacy about a new diagnosis of hypertension is to use simple language and visual aids. This approach helps ensure better understanding of the diagnosis and treatment plan by making the information clear and accessible. Providing a detailed handout with complex terms (Choice A) would not be suitable as it may confuse the client further. Encouraging the client to research the diagnosis online (Choice C) could lead to misinformation and overwhelm the client with information they may not understand. Incorporating medical jargon to explain the condition (Choice D) would not be helpful for a client with low literacy as it may complicate rather than clarify the information.

Question 5 of 5

The nurse is assessing a client with a history of schizophrenia who reports feeling sedated after starting a new antipsychotic medication. Which intervention is most appropriate?

Correct Answer: B

Rationale: Instructing the client to take the medication at bedtime is the most appropriate intervention. Taking antipsychotic medications at bedtime can help reduce the impact of sedation on the client's daily activities. This approach allows the client to sleep through the sedative effects. Choice A is incorrect because just reassuring the client may not address the immediate issue of sedation. Choice C is incorrect as taking the medication with food does not directly address the sedation concern. Choice D is not the first-line intervention; adjusting the dosage should be done by the healthcare provider after assessing the client's response to the medication.

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