RN HESI Exit Exam Capstone

Correct Answer: A

Rationale: The correct answer is A: 'Limit the effects of tissue damage.' After a myocardial infarction, the primary goal of care is to limit the damage to the heart muscle. This includes interventions to improve blood flow, oxygenation, and prevent further complications. Choice B ('Relieve pain and anxiety') is important but secondary to addressing tissue damage. Choice C ('Prevent arrhythmias') is also crucial but falls under the broader goal of limiting tissue damage. Choice D ('Reduce anxiety') is essential for holistic care but is not the primary goal immediately after a myocardial infarction.

Correct Answer: B

Rationale: The correct answer is B: Assess for signs of hypocalcemia. After a thyroidectomy, monitoring for hypocalcemia is crucial because damage to the parathyroid glands during surgery can result in low calcium levels, which may cause life-threatening complications. Monitoring respiratory rate and rhythm (choice A) is important but not the most critical in this situation. Monitoring for elevated body temperature (choice C) is less of a priority post-thyroidectomy. Checking blood pressure every 30 minutes (choice D) is not as vital as monitoring for hypocalcemia in this context.

Correct Answer: A

Rationale: The correct instruction for the nurse to provide after cataract extraction is to advise the client to avoid straining, bending, or lifting heavy objects. These activities can increase intraocular pressure, which should be minimized post-surgery to promote healing and prevent complications. Choices B, C, and D are incorrect because limiting sunlight exposure, irrigating the conjunctiva with saline, and reading without direct lighting are not primary instructions following cataract extraction.

Correct Answer: C

Rationale: The correct answer is C: 'Monitor for signs of yellowing skin or eyes.' Tetracycline can cause hepatotoxicity, leading to jaundice which may present as yellowing of the skin or eyes. This is a serious side effect that the nurse should emphasize to the client. Choice A is incorrect because tetracycline should generally be taken on an empty stomach, not with food or milk. Choice B is also incorrect as tetracycline can cause photosensitivity, but it is not directly related to yellowing skin or eyes. Choice D is incorrect because tetracycline can cause yellow-brown discoloration of the teeth, but this is usually seen in children under 8 years of age, not a common concern for adult clients.

Correct Answer: D

Rationale: The correct action for the nurse to implement while awaiting surgery for a client with muscle spasms due to a broken femur is to encourage oral fluid intake to relieve muscle tension. Dehydration can exacerbate muscle spasms, so increasing fluid intake can help alleviate them. Checking electrolyte levels may not directly address muscle spasms in this situation. Administering a muscle relaxant should be based on a healthcare provider's prescription, and traction weight adjustments should only be made by the provider overseeing the client's care.