RN HESI Exit Exam Capstone

Correct Answer: B

Rationale: For a client with severe neutropenia, it is crucial to recommend a snack that is low in bacteria to reduce the risk of infection. Yogurt with fresh berries is an excellent choice as it is not only low in bacteria but also provides nutritional value. Baked apples with raisins (choice A) may not be ideal as the preparation process could introduce bacteria. Avocados and cheese (choice C) may not be the best option due to their potential bacterial content. Fresh fruit salad (choice D) may have a higher risk of bacterial contamination compared to yogurt with fresh berries.

Correct Answer: C

Rationale: The correct answer is to advise the client to apply ice to the breasts for comfort. Applying ice can help reduce swelling and discomfort associated with engorgement in a woman who is not breastfeeding. Expressing milk manually would stimulate further milk production, which is not desired in this case. Wearing a tight bra could increase discomfort by putting pressure on the engorged breasts. Warm showers may actually increase swelling due to the vasodilation effect of heat.

Correct Answer: A

Rationale: The correct first action for the nurse is to stop the transfusion and notify the healthcare provider. These symptoms suggest a transfusion reaction, and stopping the transfusion is crucial to prevent further complications. Notifying the healthcare provider ensures timely intervention and appropriate management for the client's condition. Monitoring vital signs, administering diphenhydramine, or preparing to administer an antihistamine can be considered after stopping the transfusion and seeking guidance from the healthcare provider. However, the immediate priority is to halt the transfusion and inform the provider.

Correct Answer: B

Rationale: Wheezing and stridor may indicate a severe allergic reaction to calcium gluconate, such as anaphylaxis, which requires immediate intervention. While hypocalcemia can present with decreased deep tendon reflexes and positive Chvostek's sign, these findings do not indicate an immediate life-threatening situation. Decreased bowel sounds are not directly related to a severe reaction to calcium gluconate and do not require immediate intervention.

Correct Answer: B

Rationale: Clients with peripheral artery disease often experience claudication (leg pain during walking) due to decreased blood flow. Encouraging rest breaks during walking helps to manage pain and improve circulation. Rest breaks allow the muscles to recover from ischemia caused by inadequate blood supply. Increasing physical activity without breaks may worsen the symptoms. Applying warm compresses can potentially lead to burns or skin damage in individuals with compromised circulation. Massaging the affected leg is contraindicated in peripheral artery disease as it can further compromise blood flow.