HESI RN
HESI 799 RN Exit Exam Capstone
1. A client with deep vein thrombosis (DVT) is prescribed heparin therapy. What laboratory value should the nurse monitor?
- A. Monitor the client’s liver function tests.
- B. Monitor the client’s prothrombin time (PT).
- C. Monitor the client’s partial thromboplastin time (PTT).
- D. Monitor the client’s red blood cell count.
Correct answer: C
Rationale: The correct answer is C: Monitor the client’s partial thromboplastin time (PTT). During heparin therapy for DVT, it is essential to monitor the PTT to assess the effectiveness of the medication in preventing clot formation. Monitoring the PTT helps ensure that the client is within the therapeutic range for anticoagulation. Choices A, B, and D are incorrect because liver function tests, prothrombin time (PT), and red blood cell count are not specifically monitored to assess the effectiveness of heparin therapy in preventing clot formation.
2. A client with chronic kidney disease has a potassium level of 6.2 mEq/L. Which intervention should the nurse implement?
- A. Encourage the client to eat foods rich in potassium
- B. Administer a potassium-sparing diuretic
- C. Administer a potassium-binding medication
- D. Hold all medications containing potassium
Correct answer: C
Rationale: A potassium level of 6.2 mEq/L indicates hyperkalemia, which is dangerous and requires immediate treatment. Administering a potassium-binding medication will help lower potassium levels and prevent life-threatening complications.
3. A client asks the nurse for information about reducing risk factors for BPH. Which information should the nurse provide?
- A. Increase physical activity
- B. Decrease alcohol consumption
- C. Reduce intake of dairy products
- D. Avoid caffeine and spicy foods
Correct answer: A
Rationale: The correct answer is A: Increase physical activity. Physical activity can help reduce the risk of benign prostatic hyperplasia (BPH) by improving overall circulation and reducing inflammation. While decreasing alcohol consumption and avoiding caffeine and spicy foods may help with symptom management, increasing physical activity is more strongly linked to the prevention of BPH.
4. A client with a history of hypertension and hyperlipidemia is admitted with chest pain. What is the nurse's priority action?
- A. Administer prescribed nitroglycerin.
- B. Obtain a 12-lead electrocardiogram (ECG).
- C. Check the client's vital signs.
- D. Place the client on continuous telemetry.
Correct answer: B
Rationale: The correct answer is to obtain a 12-lead electrocardiogram (ECG). This action is crucial in assessing the heart's electrical activity and helps in the evaluation of chest pain. Administering nitroglycerin (Choice A) may be necessary but should come after obtaining the ECG to confirm the diagnosis. Checking vital signs (Choice C) is important but does not provide direct information about the heart's electrical status. Placing the client on continuous telemetry (Choice D) may be appropriate later but does not provide immediate information on the heart's electrical activity as an ECG does.
5. The nurse is providing discharge instructions to a client with chronic venous insufficiency. Which recommendation should the nurse include to help prevent complications?
- A. Use a heating pad on the legs
- B. Wear compression stockings
- C. Massage the legs daily
- D. Elevate legs for 10 minutes every hour
Correct answer: B
Rationale: The correct recommendation for a client with chronic venous insufficiency to prevent complications is to wear compression stockings. Compression stockings help improve venous circulation and prevent the worsening of symptoms. While elevating the legs is also beneficial, the priority intervention in preventing complications is wearing compression stockings. Using a heating pad on the legs can actually worsen the condition by dilating blood vessels, and massaging the legs daily can potentially damage fragile skin in clients with chronic venous insufficiency.
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