a client with end stage pulmonary disease requests no heroic measures if she stops breathing what should the nurse do next
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Nursing Elites

HESI RN

HESI Exit Exam RN Capstone

1. A client with end-stage pulmonary disease requests 'no heroic measures' if she stops breathing. What should the nurse do next?

Correct answer: B

Rationale: The correct next step for the nurse is to ask the client to discuss a 'do not resuscitate' (DNR) order with her healthcare provider. While the client's wishes should be respected, it is essential to ensure proper documentation and legal protection by involving the healthcare provider in this decision-making process. Documenting the request in the medical record (Choice A) is important but should follow the discussion with the healthcare provider. Consulting the ethics committee (Choice C) may not be necessary at this stage and could delay the necessary actions. Discharging the client (Choice D) without further discussion is not appropriate and disregards the importance of addressing the client's wishes in a respectful and professional manner.

2. While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse’s best response?

Correct answer: C

Rationale: Diuretics must be continued as long as the fluid problem persists to prevent heart failure symptoms.

3. The client with a below-the-knee amputation is being taught about proper care of the residual limb. The most important point to emphasize would be

Correct answer: B

Rationale: The correct answer is B: Keep the skin on the stump clean and dry. This is crucial for preventing infection and promoting healing of the residual limb. Wrapping the stump with an elastic bandage can constrict blood flow and cause issues. Using alcohol to cleanse the stump daily can be too harsh and drying for the skin, leading to irritation. Applying moisturizing lotion daily is not as essential as keeping the skin clean and dry to prevent complications.

4. A client with hypothyroidism is prescribed levothyroxine. What is the most important teaching point for the nurse to provide?

Correct answer: B

Rationale: The correct answer is B. Levothyroxine should be taken at the same time every day to maintain stable thyroid hormone levels and ensure effective management of hypothyroidism. Consistent dosing is critical for preventing fluctuations in hormone levels. Choice A is incorrect because levothyroxine is usually recommended to be taken on an empty stomach for optimal absorption. Choice C is incorrect because increased sensitivity to cold is not a common side effect of levothyroxine. Choice D is incorrect because adjusting the dosage without healthcare provider guidance can be dangerous and should not be done independently.

5. A client presents with three positive responses to the CAGE questionnaire. What interpretation should the nurse provide?

Correct answer: B

Rationale: Two positive responses on the CAGE questionnaire strongly suggest alcohol dependence. Choice A is incorrect as the CAGE questionnaire specifically targets alcohol abuse. Choice C is incorrect because one positive response is not enough to indicate alcohol addiction. Choice D is incorrect because alcohol dependence can be suggested with two positive responses, not all four.

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