Video Library
HESI RN Capstone Exam
Total Questions : 124
Showing 10 questions, Sign in for more- The client is a 77-year-old male with mitral valve stenosis and heart failure (HF).
- Initial Assessment:
- Heart rate: 63 beats/minute
- Respiratory rate: 22 breaths/minute
- Blood pressure: 142/99 mm Hg
- Oxygen saturation: 94% on 2 L/minute oxygen via nasal cannula
- Follow-up Assessment:
- Heart rate: 72 beats/minute
- Respiratory rate: 21 breaths/minute
- Blood pressure: 122/85 mm Hg
- Oxygen saturation: 95% on 2 L/minute oxygen via nasal cannula
- Initial Findings:
- Heart monitor shows atrial fibrillation
- Client is sleepy but awakes easily and follows commands
- Pulses 1+ in all extremities
- Mild edema noted to both legs
- Wheezes heard in all lung fields upon auscultation
- Productive cough with pink-tinged mucus
- Follow-up Findings:
- Heart monitor shows normal sinus rhythm
- Client is awake and following commands
- Ate 50% of lunch tray
- Pulses 1+ in all extremities
- Breath sounds clear and equal
- Potassium: 3.1 mEq/L
- Prothrombin time/International normalized ratio (INR): 2.2
- Urine output: 600 mL since 0800
- Admit to the cardiac floor
- Heart healthy diet with protein supplement shakes
- Out of bed with assistance
- Place on a cardiorespiratory monitor
- Vital signs every 4 hours
- Apply oxygen 2 L/minute via nasal cannula to keep oxygen saturation greater than 93%
- Monitor potassium level, prothrombin time/INR every 6 hours
- Furosemide 30 mg IV push (IVP) every 12 hours
- Propranolol 10 mg PO every 8 hours
- Warfarin 10 mg PO every 12 hours
- Initial Notes:
- Heart monitor shows atrial fibrillation
- Client is sleepy but awakes easily and follows commands
- Pulses 1+ in all extremities
- Mild edema noted to both legs
- Wheezes heard in all lung fields upon auscultation
- Has a productive cough with pink-tinged mucus
- Follow-up Notes:
- Heart monitor shows normal sinus rhythm
- Client is awake and following commands
- Ate 50% of lunch tray
- Pulses 1+ in all extremities
- Breath sounds clear and equal
- Client has a total of 600 mL of urine output since 0800
Review the exhibits and click to mark whether each assessment finding represents a therapeutic result of the furosemide administered, a non-therapeutic side effect, or an unrelated finding. Each row must have one option selected.
- Potassium 3.1 mEq/L
- Prothrombin time/International normalized ratio (INR) 2.2
- Urine output: 600 mL
Explanation
Based on the questionand the known effects of furosemide, here’s how each assessment finding can be categorized:
- Potassium 3.1 mEq/L: This is anon-therapeutic side effect.Furosemide is a diuretic that increases the excretion of water, sodium, and potassium from the body.This can lead to hypokalemia, or low potassium levels.
- Prothrombin time/INR 2.2: This is likely anunrelated finding.Furosemide does not typically affect prothrombin time or INR.However, the patient is also taking warfarin, which is an anticoagulant known to increase INR.
- Urine output: 600 mL: This is atherapeutic result.Furosemide works by increasing the amount of urine the body makes, which helps reduce swelling and symptoms of fluid retention.
- 44-year-old male
- Anterior-posterior spinal fusion surgery 3 days ago
The client is a 44-year-old male who had an anterior-posterior spinal fusion 3 days ago. Today, upon assessment, the client was found awake and alert. Breath sounds were clear and equal, with a regular and rhythmic heart rate. Bowel sounds were noted to be hypoactive, and the client's abdomen was visibly distended. The client reported not having had a bowel movement since the surgery. Skin was observed to be pink and well-perfused, with capillary refill taking less than 3 seconds. The surgical dressing was found to be clean and intact. The client reported a pain level of 8 on a 0-10 numeric pain scale, for which morphine was administered as ordered. However, the client expressed dissatisfaction with the current dosage and requested a higher dose of morphine due to uncontrolled pain. In response to this, the healthcare provider was promptly notified.
- Out of bed 3 times per day with physical therapy
- Regular diet
- Ibuprofen 600 mg PO every 6 hours PRN for pain 4 or less on a 0 to 10 pain scale
- Morphine 1 mg IM every 4 hours PRN for pain greater than 4 on a 0 to 10 pain scale
- Temperature: 98.5° F (37° C) orally
- Heart rate: 83 beats/minute
- Respiratory rate: 19 breaths/minute
- Blood pressure: 122/77 mm Hg
- Oxygen saturation: 100% on room air
- Abdomen distended
- Bowel sounds hypoactive
- Skin pink and well-perfused
- Capillary refill less than 3 seconds
- Surgical dressing clean and intact
A nurse is caring for a 44-year-old male client who had an anterior-posterior spinal fusion 3 days ago. The client is experiencing uncontrolled pain and has not had a bowel movement since the surgery. Which actions should the nurse take to assess the client's progress?
Select all that apply.
- Neurological: Agitation. Oriented x4. Dizziness. Pupils equal and reactive to light.
- Cardiovascular: Bradycardia. Bilateral radial pulses weak. Capillary refill 2 seconds. No lower leg edema noted.
- Respiratory: Clear breath sounds.
- Gastrointestinal: Last reported bowel movement 4 days ago.
- Integumentary: Appears pale. Dry skin. Cool to touch. Lanugo-type hair present.
- Musculoskeletal: Poor muscle tone. Limited range of motion. Reports feeling cold.
- Genitourinary: Reports irregular cycles occurring every 30 to 45 days, very light, no cramps. Last menstrual period (LMP) 39 days ago.
- 22-year-old female
- History of irregular menstrual cycles
- History of thin build and athleticism
- Recent weight loss
- Recent dizziness and fall
- Temperature: 96.2°F (35.7°C)
- Heart rate: 48 beats/minute
- Respirations: 17 breaths/minute
- Blood pressure: 91/43 mm Hg
- Oxygen saturation: 95% on room air
- Height: 5 feet, 4 inches (162.56 cm)
- Weight: 98 pounds (44.5 kg)
- Pain rating: 0 on a 0 to 10 scale
- Temperature: 96.2°F (35.7°C)
- Heart rate: 48 beats/minute
- Respirations: 17 breaths/minute
- Blood pressure: 91/43 mm Hg
- Oxygen saturation: 95% on room air
A 22-year-old female client is brought to the emergency department by her mother after the client became dizzy and fell. The mother says that the client has been away at college and is home for winter break. The client's mother is greatly concerned because while her daughter has always been thin and athletic, she has never seen her so skinny and emaciated. The client responds by telling her mother, "That is not true. You keep trying to force food down my throat even though it is obvious that I have so much weight to lose!"
The client is resting in bed and cooperative with her mother at her bedside.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Explanation
Based on the information provided, the client is most likely experiencinganorexia nervosa.This is suggested by her significant weight loss, bradycardia, hypothermia, lanugo-type hair, and her expressed fear of gaining weight despite being underweight. However, this is a preliminary assessment and a definitive diagnosis should be made by a healthcare professional.
Actions the nurse should take to address this condition include:
- Acknowledge anxious feelings: It’s important to validate the client’s feelings and fears about food and weight gain.This can help build trust and facilitate further discussion about her health.
- Provide emotional support: Emotional support is crucial in managing eating disorders.The nurse can provide reassurance, listen empathetically, and encourage the client to express her feelings.
Parameters the nurse should monitor to assess the client’s progress include:
- Nutritional intake: Monitoring the client’s food and fluid intake can help assess her nutritional status and response to treatment.
- Weight and BMI: Regular monitoring of the client’s weight and BMI can provide objective measures of her nutritional status and response to treatment.
The client is resting in bed, grimacing. Swelling and bruising are present. The left arm is cool. The nurse reviews the orders and plans initial steps for caring for the client.
Day 1, 1930: Admit client to surgical unit.
Day 1, 2305: Prepare client for surgery.
- Initiate peripheral IV access.
- Morphine 2 mg IV, once, now.
- Oxycodone 7.5 mg PO every 4 hours, PRN for pain greater than 5 on 0 to 10 scale.
- Acetaminophen 500 mg PO every 4 hours, PRN for pain greater than 2 on 0 to 10 scale.
- 0.9% sodium chloride 100 mL/hr continuous IV infusion.
- Enoxaparin 30 mg SUBQ every 12 hours.
- X-ray of left shoulder and right knee, STAT.
- Computed tomography (CT) of brain, STAT.
- Complete blood count (CBC) and complete metabolic panel (CMP).
- Knee x-ray, 3 views: No osseous abnormality. Osteoarthropathy of the patellofemoral compartment.
- Computed tomography (CT) brain: No acute intracranial abnormality.
- Shoulder x-ray, 3 views: Fracture of left humeral head/neck junction. Bony impaction with comminution is noted. The fracture extends to the shoulder joint. Significant displacement of the fracture at the humeral head/neck junction is seen. There is a bony offset of the fracture fragment most pronounced in the neck region.
Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.
Explanation
Based on the provided information, here are the interventions the nurse should perform:
- Check capillary refill on bilateral upper extremities.- Indicated: This is important to assess the client’s circulation, especially given the coolness of the left arm and the fracture in the left shoulder.
- Administer ondansetron 4 mg IV.- Contraindicated: There is no prescription for ondansetron and no indication of nausea or vomiting from the client.
- Inspect the bandage for drainage.- Indicated: Given the client’s recent surgery and the presence of swelling and bruising, it’s important to monitor for any signs of infection or complications.
A 68-year-old male, with a history of bilateral total hip arthroplasty two years ago, presents to the emergency department (ED) by ambulance. The client reports he simply slipped today and did not feel lightheaded or dizzy before the fall. He returned home from the store and was putting his groceries away. He dropped a can and bent over to pick it up. He lost his balance and fell face-forward, hitting his head on the wall and his left shoulder on the floor. Reports pain mainly in his shoulder. However, he also notes pain in his right knee. Additionally, the client reports he feels nauseated and tired.
Day 1, 1820: Client is resting in bed, grimacing. Reports intense pain and the inability to move his left arm. He is guarded. Shoulder swelling and bruising are present. Left arm is cool to the touch. Collarbone appears out of alignment on the left side.
- Temperature: 98.1° F(36.7° C)
- Heart rate: 88 beats/minute
- Respiratory rate: 18 breaths/minute
- Blood pressure: 136/90 mm Hg
- Oxygen saturation: 95% on room air
- Weight: 344 lb (156.1 kg)
- Height: 6 ft 2 in (182.8 cm)
- Body mass index (BMI): 46.67 kg/m²
- Pain rating: 10 on a 0 to 10 scale, sharp, constant pain in the left arm; pain rating of 3 on a 0 to 10 pain scale, dull, achy pain in the right knee
The client is a 44-year-old female who was admitted for an abdominal abscess and sepsis. She has been intubated with mechanical ventilatory support for the last 2 weeks. The client will start ventilator weaning today. She is currently on pressure support of 25 cm water (H2O) with no mandatory breaths and a fraction of inspired oxygen (FiO2) of 35%.
The nurse has been decreasing the pressure support by 4 cm H2O every hour. The following changes were noted:
- At 0400, the pressure support was decreased to 21 cm H2O.
- At 0500, the pressure support was decreased to 17 cm H2O.
- At 0600, the pressure support was decreased to 13 cm H2O.
- At 0700, the pressure support was decreased to 9 cm H2O.
- At 0800, the pressure support was decreased to 5 cm H2O.
- At 0900, the pressure support was decreased to 1 cm H2O.
- At 1000, the pressure support was decreased to 0 cm H2O.
- At 1100 and 1200, the pressure support remained at 0 cm H2O.
The nurse notifies the healthcare provider of the client’s status. The healthcare provider comes to the bedside to evaluate the client. Which should the nurse do? Select all that apply.
Potential Actions
- Height: 5 ft 6 in (168 cm)
- Weight: 140 lb (63.5 kg)
- Oral intake: 100 mL
- IV intake: 32.5 mL
- Urine output: 150 mL
- Blood loss output: 1/2 saturated pad
The client has clear yellow urine. Lochia rubra is moderate with small clots, and no foul odor is noted. The fundus is firm at the umbilicus. The episiotomy edges are well approximated.
- Red blood cells (RBC): 3 million/mm (3 x 10^6)
- Hematocrit: 35%
- Hemoglobin: 1 g/dL (110 g/L)
Reference Range
- Red blood cells (RBC): 4.2 to 5.4 million/mm (4.2 to 5.4 x 10^6)
- Hematocrit: 27 to 47%
- Hemoglobin: 12.0 to 16.0 g/dL (120 to 160 g/L)
Please drag the condition from the choices above to fill in the blank in the sentence. Based on the client’s history and physical, the nurse notes that this postpartum client is most at risk for developing
Explanation
Based on the client’s history and physical, the nurse notes that this postpartum client is most at risk for developingC. Postpartum hemorrhage.
The client’s laboratory results show a decrease in red blood cells (RBC), hematocrit, and hemoglobin levels, which are all signs of blood loss. Additionally, the nurse’s notes mention moderate lochia rubra with small clots, which could be a sign of postpartum hemorrhage. The firm fundus at the umbilicus is a good sign, but the blood loss output and decreased blood values indicate that the client is at risk for postpartum hemorrhage.
The client is admitted to the medical floor. She has been diagnosed with asthma and has had related symptoms at ages 14 and 16. She denies any other medical history.
- Heart rate: 122 beats/minute
- Blood pressure: 134/85 mm Hg
- Oxygen saturation: 91% on room air
- The client has mild subcostal retractions and is sitting in an upright position.
- Wheezes are noted throughout the lung fields.
- The client is pale.
- She has strong peripheral pulses that are equal bilaterally.
- Regular diet
- Keep oxygen saturation greater than 94%
- Fluticasone/Salmeterol 250/50 mcg 1 inhalation
The nurse begins client education and asks the client what potential asthma triggers may have been involved in her recent exacerbation.
“I should have taken some allergy medications before going on the hike. I have been very stressed out lately and should work on stress management. I should have taken an extra dose of fluticasone-salmeterol. I should have eaten a snack halfway through the hike. My friend smoked cigarettes during the hike.”
For each statement, specify if the client has an understanding or no understanding of asthma triggers. Each row must have one option selected.
Explanation
- I should have taken some allergy medications before going on the hike.- Understanding: Allergens can trigger asthma symptoms, and taking allergy medication can help prevent an asthma attack.
- I have been very stressed out lately and should work on stress management.- Understanding: Stress can exacerbate asthma symptoms. Managing stress effectively can help control asthma.
- I should have taken an extra dose of fluticasone-salmeterol.- No Understanding: Medication dosage should be as prescribed by the healthcare provider. Taking an extra dose without medical advice can lead to side effects and is not necessarily effective in preventing an asthma attack.
- I should have eaten a snack halfway through the hike.- No Understanding: While maintaining good nutrition is important for overall health, eating a snack specifically during a hike is not directly related to preventing an asthma attack.
- My friend smoked cigarettes during the hike.- Understanding: Secondhand smoke is a common trigger for asthma. Avoiding exposure to cigarette smoke can help prevent asthma symptoms.
The client is a 22-year-old female with a history of asthma. She was diagnosed at the age of 4 years old and has 2 previous hospitalizations for asthma-related symptoms at ages 14 and 16. She denies smoking but drinks alcohol 1 to 2 times a week. She reports taking edible marijuana to relieve severe premenstrual symptoms.
The client came to the emergency department when she started having difficulty breathing on a hike. She took her usual dose of albuterol, but the symptoms did not resolve. The client’s friend called an ambulance when they got back to the car because the client was unable to speak well enough to tell the 911 operator the client’s location. The paramedics gave 2 more doses of albuterol en route. The client is pale, has subcostal retractions, and is sitting in an upright position. She has strong peripheral pulses that are equal bilaterally. Her heart rate is 122.
- Admit to the medical floor
- Vital signs every 4 hours
- Perform peak expiratory flow test every 2 hours
- Regular diet
- Chest x-ray
- Oxygen 1 L/minute nasal cannula, titrate to keep oxygen saturation greater than 94%
- Fluticasone/Salmeterol 250/50 mcg 1 inhalation every 12 hours
- Azithromycin 500 mg PO every day for 3 days
- Diphenhydramine 25 mg PO every 12 hours
- Albuterol 2.5 mg by nebulization now and every 4 hours PRN for wheezing
After the nurse assesses the client, the healthcare provider writes prescriptions. The nurse reviews the prescriptions. Which 2 prescriptions should the nurse complete first?
The client is a 22-year-old female with a history of asthma. She was diagnosed at the age of 4 years old and has had 2 previous hospitalizations for asthma-related symptoms at ages 14 and 16. She denies smoking but drinks alcohol 1 to 2 times a week. She reports taking edible marijuana to relieve severe premenstrual symptoms. She came to the emergency department when she started having difficulty breathing on a hike. She took her usual dose of albuterol, but the symptoms did not resolve. The client’s friend called an ambulance when they noticed her distress.
The client is admitted to the medical floor. She has mild subcostal retractions and is sitting in an upright position. Wheezes are noted throughout the lung fields. The client is pale. She has strong peripheral pulses that are equal bilaterally.
Her heart rate is 122 beats/minute, blood pressure 134/85 mm Hg, oxygen saturation 91% on room air.
Patient Data
History and Physical
The client is a 22-year-old female with a history of asthma. She was diagnosed at the age of 4 years old and has had 2 previous hospitalizations for asthma-related symptoms at ages 14 and 16. She denies smoking but drinks alcohol 1 to 2 times a week. She reports taking edible marijuana to relieve severe premenstrual symptoms. She came to the emergency department when she started having difficulty breathing on a hike. She took her usual dose of albuterol, but the symptoms did not resolve. The client’s friend called an ambulance when they noticed her distress.
Nurses’ Notes
The client is admitted to the medical floor. She has mild subcostal retractions and is sitting in an upright position. Wheezes are noted throughout the lung fields. The client is pale. She has strong peripheral pulses that are equal bilaterally.
Vital Signs
Her heart rate is 122 beats/minute, blood pressure 134/85 mm Hg, oxygen saturation 91% on room air.
Click to highlight the assessment findings that require immediate follow up by the nurse.
Explanation
Based on the provided information, the following assessment findings require immediate follow-up by the nurse:
- Difficulty breathing on a hike: This is a significant symptom of asthma exacerbation and needs immediate attention.
- Symptoms did not resolve after taking albuterol: Albuterol is a quick-relief medication for asthma symptoms. If symptoms do not improve after its use, it indicates that the asthma exacerbation is severe.
- Mild subcostal retractions: This is a sign of respiratory distress and indicates that the client is using accessory muscles to breathe.
- Wheezes noted throughout the lung fields: Wheezing is a common sign of asthma and indicates airway obstruction.
- The client is pale: Paleness can be a sign of decreased oxygenation.
- Heart rate of 122 beats/minute: A high heart rate can be a sign of distress or could be due to the body’s attempt to compensate for decreased oxygenation.
- Oxygen saturation of 91% on room air: Normal oxygen saturation is typically 95% or higher. A saturation of 91% indicates that the client is not getting enough oxygen.
Sign Up or Login to view all the 124 Questions on this Exam
Join over 100,000+ nursing students using Naxlex’s science-backend flashcards, practice tests and expert solutions to improve their grades and reach their goals.
Sign Up Now
