a client with heart failure is experiencing shortness of breath and swelling in the legs what is the nurses priority intervention
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Nursing Elites

HESI RN

HESI RN Exit Exam Capstone

1. A client with heart failure is experiencing shortness of breath and swelling in the legs. What is the nurse's priority intervention?

Correct answer: A

Rationale: The correct answer is A: Administer prescribed diuretics. Diuretics are prescribed to reduce fluid overload in clients with heart failure. By promoting urine output, diuretics help alleviate symptoms like shortness of breath and swelling. While placing the client in a supine position can help with breathing and fluid redistribution, administering diuretics takes precedence as it directly addresses fluid overload. Restricting fluid intake immediately may be necessary in some cases, but the immediate priority is to administer diuretics. Increasing the client's sodium intake would worsen fluid retention and is contraindicated in heart failure.

2. A client asks the nurse to call the police and states: 'I need to report that I am being abused by a nurse.' The nurse should first

Correct answer: C

Rationale: The correct initial action for the nurse is to obtain more details about the client's claim of abuse. This will help the nurse better understand the situation before proceeding with any further actions. Option A is incorrect as reality orientation is not the priority in this situation. Option B is premature as more details are needed first. Option D is not the immediate step as gathering information should come before documentation and reporting.

3. Prolonged exposure to high concentrations of supplemental oxygen over several days can cause which pathophysiological effect?

Correct answer: B

Rationale: Corrected Rationale: Prolonged exposure to high oxygen concentrations can disrupt the production of surfactant in the lungs, leading to atelectasis and other lung complications. Surfactant is essential for maintaining lung compliance and preventing alveolar collapse. Reduced cardiac output (Choice A) is not directly associated with prolonged oxygen exposure. Hyperactivity of alveoli (Choice C) is not a recognized consequence of high oxygen levels. Increased oxygen carrying capacity (Choice D) is not a pathophysiological effect of prolonged high oxygen exposure.

4. The charge nurse is planning assignments on a medical unit. Which client should be assigned to the PN?

Correct answer: C

Rationale: Irrigating and redressing a leg wound is a common task within the PN's scope of practice, making this assignment appropriate. Tasks like testing stool specimens for occult blood and assisting with ambulation of a client with a chest tube may require a higher level of training and assessment, typically performed by RNs. Admitting a client from the emergency room involves a comprehensive assessment and decision-making process, which is usually within the RN's responsibility.

5. A client with atrial fibrillation is prescribed warfarin, and their INR is elevated. What is the nurse's priority action?

Correct answer: D

Rationale: An elevated INR in clients taking warfarin increases the risk of bleeding, indicating the dose may be too high. The nurse's priority action is to notify the healthcare provider immediately and hold the next dose of warfarin to prevent bleeding complications. Administering vitamin K is not the first-line intervention for an elevated INR. Monitoring for signs of bleeding is important but not the priority over contacting the healthcare provider. Increasing the warfarin dosage can exacerbate the risk of bleeding and is contraindicated.

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