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Hesi RN exit exam
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Showing 10 questions, Sign in for moreA 24-year-old female client presents to emergency department with reports of abdominal pain. The client reports that she was vacuuming her home approximately 1 hour prior to arrival when she had a sudden onset of abdominal pain. She also reports nausea and vomiting. The client has a prior medical history of anxiety and constipation. The client has regular bowel movements every day. Her last bowel movement was this morning.
The stool was soft and formed. There are no known diagnosed allergies. Her last menstrual period was reported to be 1 week ago. She is not currently sexually active. Her last partner was 2 years ago.
Day 1, 0930
The client arrives to the emergency department with reports of abdominal pain, nausea, and vomiting.
Neurological Alert and oriented. Reports she feels anxious.
Cardiovascular Tachycardic. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.
Respiratory Tachypneic and shallow breathing. Clear breath sounds bilaterally.
Gastrointestinal Severe abdominal pain in right lower quadrant. Reports nausea, vomiting small amounts of green bile
Day 1, 0930
Temperature: 100.8° F (38.2° C) Heart rate 121 beats/minute Respirations 28 breaths/minute Blood pressure 115/76 mm Hg Oxygen saturation 95% on room air. Pain rating of 9 on 0 to 10 scale
Day 1. 1100
Day 1, 1000
Complete blood count (CBC), comprehensive metabolic panel (CMP), urine pregnancy test
Place peripheral IV catheter Lactated Ringer's 1 liter bolus Ondansetron 4 mg IV STAT Morphine 4 mg IV STAT.
Computed tomography (CT) scan of abdomen Day 1, 1130
Admit client to hospital
Day 1, 1100
Computed tomography (CT) scan of abdomen dilated appendix 7 mm in diameter and fat stranding noted.
The nurse is stabilizing the client and preparing her for surgery.
What goal(s) should the nurse prioritize in the care plan for the client while in the emergency department? Select all that apply.
A 24-year-old female client presents to emergency department with reports of abdominal pain. The client reports that she was vacuuming her home approximately 1 hour prior to arrival when she had a sudden onset of abdominal pain. She also reports nausea and vomiting. The client has a prior medical history of anxiety and constipation. The client has regular bowel movements every day. Her last bowel movement was this morning.
The stool was soft and formed. There are no known diagnosed allergies. Her last menstrual period was reported to be 1 week ago. She is not currently sexually active. Her last partner was 2 years ago.
Day 1, 0930
The client arrives to the emergency department with reports of abdominal pain, nausea, and vomiting.
Assessment
Neurological Alert and oriented. Reports she feels anxious. Cardiovascular Tachycardic. Normal heart
Laboratory Results Imaging Studies
Day 1, 0930
Temperature: 100.8° F (38.2° C) Heart rate 121 beats/minute Respirations 28 breaths/minute Blood pressure 115/76 mm Hg Oxygen saturation 95% on room air. Pain rating of 9 on 0 to 10 scale
Day 1. 1100
Day 1, 1000
Complete blood count (CBC), comprehensive metabolic panel (CMP), urine pregnancy test
Place peripheral IV catheter Lactated Ringer's 1 liter bolus Ondansetron 4 mg IV STAT Morphine 4 mg IV STAT
Computed tomography (CT) scan of abdomen dilated appendix 7 mm in diameter and fat stranding noted
The nurse is caring for the client the morning after her surgery.
Patient Data
Click to select the 5 most important nursing interventions for postoperative client care.
A 24-year-old female client presents to emergency department with reports of abdominal pain. The client reports that she was vacuuming her home approximately 1 hour prior to arrival when she had a sudden onset of abdominal pain. She also reports nausea and vomiting. The client has a prior medical history of anxiety and constipation. The client has regular bowel movements every day. Her last bowel movement was this morning.
The stool was soft and formed. There are no known diagnosed allergies. Her last menstrual period was reported to be 1 week ago. She is not currently sexually active. Her last partner was 2 years ago.
Day 1, 0930
The client arrives to the emergency department with reports of abdominal pain, nausea, and vomiting.
Assessment
Neurological Alert and oriented. Reports she feels anxious.
Cardiovascular Tachycardic. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.
Respiratory Tachypneic and shallow breathing. Clear breath sounds bilaterally.
Gastrointestinal Severe abdominal pain in right lower quadrant. Reports nausea, vomiting small amounts of green bile
Day 1, 0930
Temperature: 100.8° F (38.2° C) Heart rate 121 beats/minute Respirations 28 breaths/minute Blood pressure 115/76 mm Hg Oxygen saturation 95% on room air. Pain rating of 9 on 0 to 10 scale
Day 1. 1100
Day 1, 1000
Complete blood count (CBC), comprehensive metabolic panel (CMP), urine pregnancy test
Place peripheral IV catheter Lactated Ringer's 1 liter bolus Ondansetron 4 mg IV STAT Morphine 4 mg IV STAT.
Computed tomography (CT) scan of abdomen Day 1, 1130
Admit client to hospital
Day 1, 1100
Computed tomography (CT) scan of abdomen dilated appendix 7 mm in diameter and fat stranding noted.
The healthcare provider places orders to determine the cause of client symptoms.
Use the chart to indicate if the listed symptom or finding is consistent with gastroenteritis, appendicitis, or ectopic pregnancy.
Each row must have at least one, but may have more than one, response option selected.
Symptom: Appendicitis/ Ectopic Pregnancy/ Gastroenteritis
Explanation
Fever is a common symptom that can be present in gastroenteritis, appendicitis, and, less commonly, ectopic pregnancy. Tachycardia may occur in all three conditions but is more commonly associated with ectopic pregnancy, especially if there is internal bleeding.
Nausea and vomiting are symptoms that can be seen in gastroenteritis and appendicitis, and occasionally in ectopic pregnancy. Diarrhea is most commonly associated with gastroenteritis.
A 24-year-old female client presents to emergency department with reports of abdominal pain. The client reports that she was vacuuming her home approximately 1 hour prior to arrival when she had a sudden onset of abdominal pain. She also reports nausea and vomiting. The client has a prior medical history of anxiety and constipation. The client has regular bowel movements every day. Her last bowel movement was this morning.
The stool was soft and formed. There are no known diagnosed allergies. Her last menstrual period was reported to be 1 week ago. She is not currently sexually active. Her last partner was 2 years ago.
Day 1, 0930
The client arrives to the emergency department with reports of abdominal pain, nausea, and vomiting.
Assessment
Neurological Alert and oriented. Reports she feels anxious.
Cardiovascular Tachycardic. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.
Respiratory Tachypneic and shallow breathing. Clear breath sounds bilaterally.
Gastrointestinal Severe abdominal pain in right lower quadrant. Reports nausea, vomiting small amounts of green bile
Day 1, 0930
Temperature: 100.8° F (38.2° C) Heart rate 121 beats/minute Respirations 28 breaths/minute Blood pressure 115/76 mm Hg Oxygen saturation 95% on room air. Pain rating of 9 on 0 to 10 scale
Day 1. 1100
Day 1, 1000
Complete blood count (CBC), comprehensive metabolic panel (CMP), urine pregnancy test
Place peripheral IV catheter Lactated Ringer's 1 liter bolus Ondansetron 4 mg IV STAT Morphine 4 mg IV STAT.
Computed tomography (CT) scan of abdomen
Day 1, 1130
Admit client to hospital
Day 1, 1100
Computed tomography (CT) scan of abdomen dilated appendix 7 mm in diameter and fat stranding noted.
The nurse is caring for the client.
Which of the following assessment findings should the nurse prioritize?
Which is the best approach for the nurse to use when interviewing a client about sexual abuse?
The healthcare provider prescribes 1 unit (350 mL) of packed red blood cells (PRBC) to infuse over 4 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter the numeric value only. Round to the nearest whole number.)
Explanation
To calculate the drip rate for an IV, you can use the formula: (Volume to be infused (mL) x Drop factor (gtt/mL)) / Time (min). For the prescribed 1 unit of PRBC at 350 mL to be infused over 4 hours with a drop factor of 15 gtt/mL, the calculation would be: (350 mL x 15 gtt/mL) / (4 hours x 60 minutes/hour). This simplifies to (5250 gtt) / (240 min), which equals 21.875 gtt/min. When rounded to the nearest whole number, the nurse should regulate the infusion to 22 gtt/min.
A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare?
The adult child of an older adult client who has Parkinson's disease, calls the clinic and reports that the client has been confused for the past week. What action(s) should the nurse take? Select all that apply.
A 2-year-old is brought to the emergency department (ED) with a history of several days of rhinitis and now exhibits a productive barking cough and difficulty breathing. Which additional finding should alert the nurse that the child is experiencing respiratory distress?
The nurse is preparing a client for discharge who underwent a percutaneous nephrolithotomy with nephrostomy tube placement. Which instruction should the nurse include in the client's postoperative discharge teaching?
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Ana: Appendicitis, preventing infection is crucial. High risk for developing an infection for sepsis if the appendix perforates, which could result in peritonitis. ~ 7mos ago