HESI RN Exit Exam Capstone

Correct Answer: B

Rationale: Before administering nitroglycerin, which can lower blood pressure and heart rate, it is important to assess both to avoid exacerbating hypotension or bradycardia. Nitroglycerin helps relieve chest pain by dilating coronary arteries, but its vasodilating effect can also cause a significant drop in blood pressure, which can be dangerous for some clients.

Correct Answer: A

Rationale: Stopping the transfusion prevents further reactions, and notifying the healthcare provider ensures timely intervention.

Correct Answer: D

Rationale: Clients prescribed nitroglycerin should be instructed to limit its use to no more than three doses in 15 minutes. This prevents excessive use, which can lead to severe hypotension and other complications.

Correct Answer: B

Rationale: Muscle weakness in a client receiving furosemide (a diuretic) is often a sign of hypokalemia, as furosemide increases potassium loss. Monitoring potassium levels is essential to identify and address any imbalances and prevent complications such as arrhythmias.

Correct Answer: C

Rationale: Acknowledging the UAP's feelings while exploring the client's behavior provides a supportive and collaborative approach. This helps maintain a therapeutic environment for both the UAP and the client.