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Bsn 366 Rn Hesi Exit (Nightingale) Proctored Exam
Total Questions : 125
Showing 10 questions, Sign in for moreA client with leukemia who is receiving a myelosuppressive chemotherapy has a platelet count of 25,000/mm3 (25 x 109/L). Which intervention is most important for the nurse to include in this client's plan of care?
Reference Range:
Platelet count [150,000 to 400,000/mm3 (150 to 400 x 109/L)]
A client reports that the 30 mg extended release form of cyclobenzaprine has been the only medication that provided relief from lower back pain in the past. The client asks the nurse if the medication for chronic back pain could be prescribed on a monthly basis. Which is the best response from the nurse?
Following a total knee arthroplasty, the client is discharged from the hospital with a prescription for warfarin. In reviewing discharge teaching, the client recounts to the nurse the need to avoid eating foods high in potassium, such as bananas and melon. How should the nurse respond?
The nurse is caring for a client who is receiving continuous ambulatory peritoneal dialysis (CAPD) and notes that the output flow is 100 mL less than the input flow. Which actions should the nurse implement first?
The licensed nurse is unable to complete medication administration within the accepted time limits. The licensed nurse reviews time management strategies with the lead nurse and reports difficulty with interruptions and call-lights. Which strategy should the lead nurse recommend to improve on-time medication administration?
A 57-year-old male client is brought to the emergency department (ED) by emergency medical services (EMS) with reports of chest pain. Client was mowing his lawn and noticed chest pain presenting as tightness and pressure. The pain continued to increase over about 30 minutes when the client decided to rest. The client's wife called emergency medical services (EMS) when the pain was unrelieved after 20 minutes of rest. Client reports no other incidents of experiencing this pain. His medical history includes hypertension, obesity, and a 20 year history of smoking, having quit about 5 years ago. Takes metoprolol succinate ER 25 mg PO daily.
1230
The client presents to the emergency department (ED) after arrival via emergency medical services (EMS) with reports on increasing chest pain.
Neurological: Alert and oriented to person, place, time, and situation. Agitated. Denies headaches.
Cardiovascular: Reported chest pain described as pressure and tightness that is unrelieved with rest. Rapid regular rhythm. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.
Respiratory: Rapid and shallow breaths. Clear breath sounds throughout bilateral lungs.
Gastrointestinal: Within normal limits (WNL).
Genitourinary: WNL..
Musculoskeletal :WNL.
Pain: Reported 7 on a 0 to 10 scale, tightness and pressure in chest. Started approximately 2 hours ago and got progressively worse, unrelieved by rest.
1230
Vital signs
- Temperature: 98.1° F (36.7° C) orally
- Heart rate: 121 beats/minute
- Respirations: 21 breaths/minute
- Blood pressure: 162/98 mm Hg
- Oxygen saturation: 92% on room air
- Body mass index [BMI): 32 kg/m2 (normal 18 to 24.9 kg/m2)
A history is completed by the healthcare provider (HCP) with a rapid assessment, and vital signs completed by the nurse
Click to highlight the findings that require follow up.
- Neurological: Alert and oriented person, place, time, and situation. Agitated. Denies headaches.
- Cardiovascular: Reported chest pain described as pressure and tightness that is unrelieved with rest. Rapid regular rhythm. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.
- Respiratory: Rapid and shallow breaths. Clear breath sounds throughout bilateral lungs.
- Gastrointestinal: Within normal limits (WNL).
- Genitourinary: WNL
- Musculoskeletal: WNL
- Pain: Reported 7 on a 0 to 10 scale, tightness and pressure in chest. Started approximately 2 hours ago and got progressively worse, unrelieved by rest.
Explanation
Rationale for correct answers:
- Agitated: In the context of chest pain, agitation or a "sense of impending doom" is a clinical indicator of decreased cerebral perfusion or a sympathetic nervous system surge related to a myocardial infarction.
- Reported chest pain described as pressure and tightness that is unrelieved with rest: Stable angina usually resolves with rest. Pain that is "unrelieved by rest" and has lasted longer than 20 minutes is a classic hallmark of unstable angina or an acute myocardial infarction.
- Rapid and shallow breaths: A respiratory rate of 21 and a shallow pattern indicate respiratory distress. This may be a compensatory mechanism for low oxygen saturation (92%) or a result of the pain and anxiety associated with a cardiac event.
- Pain: Reported 7 on a 0 to 10 scale, tightness and pressure in chest: Any chest pain rated as severe (7/10) requires a STAT ECG and cardiac enzyme markers (Troponin) to rule out heart muscle damage.
Rationale of incorrect answers:
- Alert and oriented person, place, time, and situation: This is a normal finding (A&O x4), showing that the client currently has enough cardiac output to perfuse the brain.
- Radial and pedal pulses 2+: This is a normal finding, indicating that peripheral circulation is currently adequate and equal in all extremities.
- Clear breath sounds throughout bilateral lungs: This is a "normal" finding in this context. While it’s good the lungs are clear (suggesting no immediate heart failure/pulmonary edema), it is not an abnormal cue that needs a change in the plan of care.
A 57-year-old male client is brought to the emergency department (ED) by emergency medical services (EMS) with reports of chest pain. Client was mowing his lawn and noticed chest pain presenting as tightness and pressure. The pain continued to increase over about 30 minutes when the client decided to rest. The client's wife called emergency medical services (EMS) when the pain was unrelieved after 20 minutes of rest. Client reports no other incidents of experiencing this pain. His medical history includes hypertension, obesity, and a 20 year history of smoking, having quit about 5 years ago. Takes metoprolol succinate ER 25 mg PO daily.
1230
The client presents to the emergency department (ED) after arrival via emergency medical services (EMS) with reports on increasing chest pain.
Assessment
Neurological: Alert and oriented to person, place, time, and situation. Agitated. Denies headaches.
Cardiovascular: Reported chest pain described as pressure and tightness that is unrelieved with rest. Rapid regular rhythm. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.
Respiratory: Rapid and shallow breaths. Clear breath sounds throughout bilateral lungs.
Gastrointestinal: Within normal limits (WNL).
Genitourinary: WNL
Musculoskeletal: WNL.
Pain: Reported 7 on a 0 to 10 scale, tightness and pressure in chest. Started approximately 2 hours ago and got progressively worse, unrelieved by rest.
- Temperature: 98.1° F (36.7° C) orally
- Heart rate: 121 beats/minute
- Respirations: 21 breaths/minute
- Blood pressure: 162/98 mm Hg
- Oxygen saturation: 92% on room air
- Body mass index [BMI]: 32 kg/m
- 2 (normal 18 to 24.9 kg/m2)
- Pain: 7 on a 0 to 10 scale, tightness and pressure in chest
1245
12-lead electrocardiogram (ECG)
Prothrombin time (PT), International normalized ratio (INR), troponin T, troponin I, C-reactive protein, cholesterol, triglycerides, high-density lipoproteins (HDL), low-density lipoproteins (LDL)
Titrate oxygen via nasal cannula to maintain oxygen saturation greater than 94%
Insert peripheral IV (PIV) access device and maintain per unit protocol
Click to indicate if the listed symptoms are consistent with angina, myocardial infarction, or both. Each column must have at least one response option selected
Explanation
- Pain relieved by nitroglycerin (Angina): Nitroglycerin works by dilating coronary arteries and reducing myocardial oxygen demand. In stable angina, the underlying problem is temporary myocardial ischemia (reduced blood flow without tissue death). Because the myocardium is still viable, improving blood flow quickly relieves the pain. In contrast, during a myocardial infarction (MI), there is prolonged ischemia with myocardial cell death, so nitroglycerin may provide little or only partial relief.
- Epigastric distress (Both): Both angina and MI can present with atypical symptoms, especially involving the gastrointestinal system. Reduced oxygen supply to the heart can stimulate the vagus nerve, leading to symptoms such as epigastric pain, nausea, or indigestion-like discomfort. This overlap makes it important not to dismiss GI symptoms, particularly in cardiac-risk clients.
- Pain only relieved by opioids (Myocardial Infarction): In MI, the pain is typically severe, persistent, and unrelenting, due to actual myocardial tissue injury and necrosis. Nitroglycerin is often insufficient. Opioids (e.g., morphine) are required because they reduce pain, decrease anxiety, and lower sympathetic workload, helping reduce cardiac oxygen demand.
- Chest pain radiating down arm (Myocardial Infarction): MI pain commonly radiates to the left arm, jaw, neck, or back due to shared nerve pathways (referred pain). While angina can occasionally radiate, this classic radiation pattern—especially when severe and prolonged—is more strongly associated with MI.
- Occurring without cause: Unstable angina and MI can both occur at rest or without clear exertional triggers. Stable angina usually occurs with exertion.
- Feelings of fear (Myocardial Infarction): Clients experiencing MI often report a sense of impending doom. This is caused by a strong sympathetic nervous system response (release of catecholamines like epinephrine), along with severe pain and decreased cardiac output. This psychological and physiological response is much more intense than what is typically seen in angina.
A 57-year-old male client is brought to the emergency department (ED) by emergency medical services (EMS) with reports of chest pain. Client was mowing his lawn and noticed chest pain presenting as tightness and pressure. The pain continued to increase over about 30 minutes when the client decided to rest. The client's wife called emergency medical services (EMS) when the pain was unrelieved after 20 minutes of rest. Client reports no other incidents of experiencing this pain. His medical history includes hypertension, obesity, and a 20 year history of smoking, having quit about 5 years ago. Takes metoprolol succinate ER 25 mg PO daily.
1230
The client presents to the emergency department (ED) after arrival via emergency medical services (EMS) with reports on increasing chest pain.
Assessment
Neurological: Alert and oriented to person, place, time, and situation. Agitated. Denies headaches.
Cardiovascular: Reported chest pain described as pressure and tightness that is unrelieved with rest. Rapid regular rhythm. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.
Respiratory: Rapid and shallow breaths. Clear breath sounds throughout bilateral lungs.
Gastrointestinal: Within normal limits (WNL).
Genitourinary: WNL
Musculoskeletal: WNL
Pain: Reported 7 on a 0 to 10 scale, tightness and pressure in chest. Started approximately 2 hours ago and got progressively worse, unrelieved by rest.
|
Laboratory Test |
Result |
Range |
|
Cholesterol |
240 mg/dL (6.2 mmol/L) |
Less than 200 mg/dL (Less than 5.2 mmol/L) |
|
Triglycerides |
186 mg/dL (2.1 mmol/L) |
40 to 160 mg/dL (0.45 to 1.81 mmol/L) |
|
High-density lipoproteins (HDLs) |
27 mg/dL (0.62 mmol/L) |
Greater than 45 mg/dL (Greater than 1.16 mmol/L) |
|
Low-density lipoproteins (LDLs) |
150.8 mg/dL (3.9 mmol/L) |
Less than 130 mg/dL (Less than 3.4 mmol/L) |
|
Laboratory Test |
Result |
Range |
|
Prothrombin time |
12 seconds |
11 to 12.5 seconds |
|
International normalized ratio |
1.0 |
0.8 to 1.1 |
|
Troponin T |
0.01 ng/mL (0.01 μg/L) |
Less than 0.1 ng/mL (Less than 0.1 μg/L) |
|
Troponin I |
0.02 ng/mL (0.02 μg/L) |
Less than 0.03 ng/mL (Less than 0.03 μg/L) |
|
C-reactive protein |
2.2 mg/dL (22 mg/L) |
Less than 1.0 mg/dL (Less than 10 mg/L) |
- Temperature: 98.1° F (36.7° C) orally
- Heart rate: 121 beats/minute
- Respirations: 21 breaths/minute
- Blood pressure: 162/98 mm Hg
- Oxygen saturation: 92% on room air
- Body mass index (BMI): 32 kg/m2 (normal 18 to 24.9 kg/m2)
- Pain: 7 on a 0 to 10 scale, tightness and pressure in chest
1245
12-lead electrocardiogram (ECG)
Prothrombin time (PT), International normalized ratio (INR), troponin T, troponin I, C-reactive protein, cholesterol, triglycerides, high-density lipoproteins (HDL), low-density lipoproteins (LDL)
Titrate oxygen via nasal cannula to maintain oxygen saturation greater than 94%
Insert peripheral IV (PIV) access device and maintain per unit protocol
1300
12-lead electrocardiogram (ECG): Sinus tachycardia (ST) with a 1st degree heart block PR interval (PRI) 0.22 seconds, ST depression.
Initial testing is complete, and the nurse is reviewing the results.
Choose the most likely options for the information missing from the statement by selecting from the lists of options provided.
The nurse determines that the client has
Explanation
Rationale for correct choices:
- New onset angina: The client presents with chest pain described as pressure and tightness that started during activity (mowing the lawn) and worsened despite rest, which is consistent with unstable or new-onset angina. The ECG shows ST depression, indicating myocardial ischemia without infarction. Normal troponin levels confirm that no myocardial cell death has occurred, differentiating angina from myocardial infarction.
- Troponin: Troponin T and I are specific biomarkers for myocardial injury. In this client, troponin levels are within normal limits, indicating that myocardial necrosis has not occurred. This supports the diagnosis of angina rather than myocardial infarction.
Rationale for incorrect choices:
- Myocardial infarction: MI typically presents with prolonged chest pain and ST-segment changes on ECG plus elevated troponin, indicating cardiac muscle damage. This client’s troponin levels are normal, making MI unlikely at this time.
- Aortic aneurysm: Usually presents with sudden, severe, tearing chest or back pain, often radiating to the back. ST depression on ECG is not associated with aortic aneurysm.
- Prothrombin time (PT) or C-reactive protein (CRP): PT assesses coagulation, and CRP is a marker of general inflammation. Neither is specific for myocardial ischemia, so normal levels do not confirm or exclude angina. Troponin is the key biomarker for cardiac injury.
A 57-year-old male client is brought to the emergency department (ED) by emergency medical services (EMS) with reports of chest pain. Client was mowing his lawn and noticed chest pain presenting as tightness and pressure. The pain continued to increase over about 30 minutes when the client decided to rest. The client's wife called emergency medical services (EMS) when the pain was unrelieved after 20 minutes of rest. Client reports no other incidents of experiencing this pain. His medical history includes hypertension, obesity, and a 20 year history of smoking, having quit about 5 years ago. Takes metoprolol succinate ER 25 mg PO daily.
1230
The client presents to the emergency department (ED) after arrival via emergency medical services (EMS) with reports on increasing chest pain.
Assessment
Neurological: Alert and oriented to person, place, time, and situation. Agitated. Denies headaches.
Cardiovascular: Reported chest pain described as pressure and tightness that is unrelieved with rest. Rapid regular rhythm. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.
Respiratory: Rapid and shallow breaths. Clear breath sounds throughout bilateral lungs.
Gastrointestinal: Within normal limits (WNL).
Genitourinary: WNL
Musculoskeletal: WNL
Pain: Reported 7 on a 0 to 10 scale, tightness and pressure in chest. Started approximately 2 hours ago and got progressively worse, unrelieved by rest.
|
Laboratory Test |
Result |
Range |
|
Cholesterol |
240 mg/dL (6.2 mmol/L) |
Less than 200 mg/dL (Less than 5.2 mmol/L) |
|
Triglycerides |
186 mg/dL (2.1 mmol/L) |
40 to 160 mg/dL (0.45 to 1.81 mmol/L) |
|
High-density lipoproteins (HDLs) |
27 mg/dL (0.62 mmol/L) |
Greater than 45 mg/dL (Greater than 1.16 mmol/L) |
|
Low-density lipoproteins (LDLs) |
150.8 mg/dL (3.9 mmol/L) |
Less than 130 mg/dL (Less than 3.4 mmol/L) |
|
Laboratory Test |
Result |
Range |
|
Prothrombin time |
12 seconds |
11 to 12.5 seconds |
|
International normalized ratio |
1.0 |
0.8 to 1.1 |
|
Troponin T |
0.01 ng/mL (0.01 μg/L) |
Less than 0.1 ng/mL (Less than 0.1 μg/L) |
|
Troponin I |
0.02 ng/mL (0.02 μg/L) |
Less than 0.03 ng/mL (Less than 0.03 μg/L) |
|
C-reactive protein |
2.2 mg/dL (22 mg/L) |
Less than 1.0 mg/dL (Less than 10 mg/L) |
1230
Vital signs
- Temperature: 98.1° F (36.7° C) orally
- Heart rate: 121 beats/minute
- Respirations: 21 breaths/minute
- Blood pressure: 162/98 mm Hg
- Oxygen saturation: 92% on room air
- Body mass index (BMI): 32 kg/m2 (normal 18 to 24.9 kg/m2)
- Pain: 7 on a 0 to 10 scale, tightness and pressure in chest
1245
12-lead electrocardiogram (ECG)
Prothrombin time (PT), International normalized ratio (INR), troponin T, troponin I, C-reactive protein, cholesterol, triglycerides, high-density lipoproteins (HDL), low-density lipoproteins (LDL)
Titrate oxygen via nasal cannula to maintain oxygen saturation greater than 94%
Insert peripheral IV (PIV) access device and maintain per unit protocol
Imaging Studies
1300
12-lead electrocardiogram (ECG): Sinus tachycardia (ST) with a 1st degree heart block PR interval (PRI) 0.22 seconds, ST depression.
The client was given oxygen, sublingual nitroglycerin, and aspirin. After one dose of nitroglycerin, the client's pain decreased to a reported 2 on a 0 to 10 scale with squeezing pain. The client was admitted for observation and percutaneous coronary intervention (PCI) to be completed later within the evening. The client asks the nurse to explain why a PCI is being completed.
Drag and drop word choices to complete the sentence.
If healthcare providers (HCPs) see a narrowed heart vessel while performing a percutaneous coronary intervention (PCI), they may perform a balloon angioplasty to compress the plaque against the vessel wall and hold it there with a stent, which will lessen
Explanation
Rationale for correct answers:
- Pain: Chest pain (angina) is the heart’s way of signaling "ischemia" (lack of oxygen). By opening the vessel and compressing the plaque, the oxygen supply-demand balance is restored, which directly reduces or eliminates the ischemic pain.
- Dysrhythmias: Heart muscle that is deprived of oxygen becomes "irritable." This electrical instability in the ischemic tissue often leads to dangerous dysrhythmias (abnormal heart rhythms). Restoring blood flow stabilizes the electrical conduction system of the heart.
Rationale for incorrect choices:
- Vasospasms: These are sudden constrictions of the muscular walls of the artery. While medications (like nitroglycerin) treat vasospasms, a mechanical stent is primarily designed to address physical obstructions (plaque) rather than the physiological spasm of the vessel wall.
- Heart Blocks: These are specific delays or interruptions in the electrical signals between the heart's atria and ventricles. While ischemia can cause heart blocks, they are usually managed with pacemakers or by treating the underlying cause, rather than being the primary focus of a standard PCI for plaque compression.
A 57-year-old male client is brought to the emergency department (ED) by emergency medical services (EMS) with reports of chest pain. Client was mowing his lawn and noticed chest pain presenting as tightness and pressure. The pain continued to increase over about 30 minutes when the client decided to rest. The client's wife called emergency medical services (EMS) when the pain was unrelieved after 20 minutes of rest. Client reports no other incidents of experiencing this pain. His medical history includes hypertension, obesity, and a 20 year history of smoking, having quit about 5 years ago. Takes metoprolol succinate ER 25 mg PO daily.
1230
The client presents to the emergency department (ED) after arrival via emergency medical services (EMS) with reports on increasing chest pain.
Assessment
Neurological: Alert and oriented to person, place, time, and situation. Agitated. Denies headaches.
Cardiovascular: Reported chest pain described as pressure and tightness that is unrelieved with rest. Rapid regular rhythm. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.
Respiratory: Rapid and shallow breaths. Clear breath sounds throughout bilateral lungs.
Gastrointestinal: Within normal limits (WNL).
Genitourinary: WNL
Musculoskeletal: WNL
Pain: Reported 7 on a 0 to 10 scale, tightness and pressure in chest. Started approximately 2 hours ago and got progressively worse, unrelieved by rest.
|
Laboratory Test |
Result |
Range |
|
Cholesterol |
240 mg/dL (6.2 mmol/L) |
Less than 200 mg/dL (Less than 5.2 mmol/L) |
|
Triglycerides |
186 mg/dL (2.1 mmol/L) |
40 to 160 mg/dL (0.45 to 1.81 mmol/L) |
|
High-density lipoproteins (HDLs) |
27 mg/dL (0.62 mmol/L) |
Greater than 45 mg/dL (Greater than 1.16 mmol/L) |
|
Low-density lipoproteins (LDLs) |
150.8 mg/dL (3.9 mmol/L) |
Less than 130 mg/dL (Less than 3.4 mmol/L) |
|
Laboratory Test |
Result |
Range |
|
Prothrombin time |
12 seconds |
11 to 12.5 seconds |
|
International normalized ratio |
1.0 |
0.8 to 1.1 |
|
Troponin T |
0.01 ng/mL (0.01 μg/L) |
Less than 0.1 ng/mL (Less than 0.1 μg/L) |
|
Troponin I |
0.02 ng/mL (0.02 μg/L) |
Less than 0.03 ng/mL (Less than 0.03 μg/L) |
|
C-reactive protein |
2.2 mg/dL (22 mg/L) |
Less than 1.0 mg/dL (Less than 10 mg/L) |
1230
Vital signs
- Temperature: 98.1° F (36.7° C) orally
- Heart rate: 121 beats/minute
- Respirations: 21 breaths/minute
- Blood pressure: 162/98 mm Hg
- Oxygen saturation: 92% on room air
- Body mass index (BMI): 32 kg/m2 (normal 18 to 24.9 kg/m2)
- Pain: 7 on a 0 to 10 scale, tightness and pressure in chest
1245
12-lead electrocardiogram (ECG)
Prothrombin time (PT), International normalized ratio (INR), troponin T, troponin I, C-reactive protein, cholesterol, triglycerides, high-density lipoproteins (HDL), low-density lipoproteins (LDL)
Titrate oxygen via nasal cannula to maintain oxygen saturation greater than 94%
Insert peripheral IV (PIV) access device and maintain per unit protocol
1300
12-lead electrocardiogram (ECG): Sinus tachycardia (ST) with a 1st degree heart block PR interval (PRI) 0.22 seconds, ST depression.
The nurse has provided discharge teaching to the client to manage his chest pain at home. Which 2 statements from the client should the nurse recognize as a need for further education?
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