a young male client is admitted to rehabilitation following a right above knee amputation aka and reports aching in his right foot which intervention
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Nursing Elites

HESI RN

HESI 799 RN Exit Exam Capstone

1. A young male client is admitted to rehabilitation following a right above-knee amputation (AKA) and reports aching in his right foot. Which intervention is most important for the nurse to implement?

Correct answer: B

Rationale: The correct answer is B: Administer a prescription for gabapentin. Gabapentin is used to treat phantom limb pain, which is common after amputations. Encouraging discussion about feelings of limb loss (choice A) is important for emotional support but does not address the physical pain. Teaching the client how to wrap the stump with an elastic bandage (choice C) is not indicated for aching in the 'right foot' as described. Offering assistance to move to a quiet room to relax (choice D) may provide comfort but does not address the underlying issue of phantom limb pain.

2. The nurse is assessing a client with rheumatoid arthritis who is taking a nonsteroidal anti-inflammatory drug (NSAID). Which laboratory value should the nurse monitor?

Correct answer: C

Rationale: When a client with rheumatoid arthritis is taking NSAIDs, the nurse should monitor serum creatinine levels. NSAIDs can potentially cause kidney damage, so monitoring creatinine levels helps assess for renal impairment. While monitoring hemoglobin, potassium, and white blood cell count may also be relevant in some cases, serum creatinine is the priority due to the risk of renal complications associated with NSAID use.

3. The client has been diagnosed with hypertension, and the nurse is providing education on dietary changes. Which food should the client be advised to avoid?

Correct answer: B

Rationale: Processed meats should be avoided by clients with hypertension as they are high in sodium, which can contribute to elevated blood pressure. It is essential to limit the intake of high-sodium foods to help manage hypertension. Bananas, low-fat yogurt, and whole grains are generally beneficial for heart health due to their nutrient content and should not be avoided in a heart-healthy diet.

4. A young woman with multiple sclerosis just received several immunizations in preparation for moving into a college dormitory. Two days later, she reports to the nurse that she is experiencing increasing fatigue and visual problems. What teaching should the nurse provide?

Correct answer: A

Rationale: Immunizations can sometimes trigger relapses in multiple sclerosis due to the activation of the immune system. Extra rest can help manage these symptoms. Choice B is incorrect because visual problems can be associated with the immune response triggered by immunizations in individuals with multiple sclerosis. While increasing fluid intake is generally good advice, in this case, the nurse should focus on explaining the possible connection between the immunizations and the symptoms experienced. Choice D is not the immediate course of action; educating the patient on the potential link between immunizations and symptom exacerbation is more appropriate at this stage.

5. A client with a history of asthma reports using an albuterol inhaler more frequently than prescribed. Which action should the nurse take first?

Correct answer: C

Rationale: Increased use of a rescue inhaler like albuterol may indicate worsening asthma symptoms. The nurse should first assess the client's respiratory status to determine the severity of the issue and the next steps in care. Option A is not the first action because assessing the client's condition should precede notifying the healthcare provider. Option B, scheduling a pulmonary function test, is not the priority as immediate assessment of the client's respiratory status is crucial. Instructing the client to decrease inhaler use should come after assessing the client's condition to ensure the appropriate intervention.

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