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HESI RN Health Assessment
Total Questions : 59
Showing 10 questions, Sign in for more(0700hrs):
The client reports feeling increasingly short of breath over the past two days. He has a productive cough with greenish sputum. He denies chest pain but mentions feeling very fatigued. The client appears anxious and is using accessory muscles to breathe. He is sitting upright in bed and leaning forward slightly. The client states he has not been able to sleep well due to the cough. He also reports a decreased appetite over the past few days.
(0700hrs):
The client is alert and oriented to person, place, and time. He has a productive cough with greenish sputum. His skin is warm and dry to the touch. Breath sounds are diminished in the lower lobes with crackles heard bilaterally. The client is using accessory muscles to breathe and has a prolonged expiratory phase. His nail beds are slightly cyanotic. The client is diaphoretic and appears fatigued.
(0700hrs):
- Temperature: 38.3°C (100.9°F)
- Heart Rate: 110 bpm
- Respiratory Rate: 28 breaths per minute
- Blood Pressure: 140/90 mmHg
- Oxygen Saturation: 88% on room air
A nurse is caring for a 65-year-old male client in the clinic who presents with shortness of breath and a productive cough. The client has a history of smoking and was recently treated with antibiotics for pneumonia.
Which of the following actions should the nurse take first?
The client reports a nonproductive cough for the past two days. Upon assessment, decreased lung sounds are noted in the right lower base. Percussion reveals dullness over the same area. The client is using accessory muscles to breathe, and chest expansion is decreased on the right side. The skin is warm to touch but pale in color. The client denies any recent travel or exposure to sick individuals. He has a history of smoking one pack per day for 20 years but quit five years ago. No known allergies.
- History of chronic obstructive pulmonary disease (COPD)
- Hypertension, managed with medication
- Previous episodes of bronchitis
- No recent hospitalizations or surgeries
- Chest X-ray: Consolidation in the right lower lobe
- White Blood Cell (WBC) count: 14,000/mm³ (4,500-11,000/mm³)
- Hemoglobin: 13.5 g/dL (13.8-17.2 g/dL)
- Platelet count: 250,000/mm³ (150,000-450,000/mm³)
- C-reactive protein (CRP): 12 mg/L (<10 mg/L)
- Arterial Blood Gas (ABG): pH 7.35 (7.35-7.45), PaCO₂ 45 mm Hg (35-45 mm Hg), PaO₂ 60 mm Hg (75-100 mm Hg), HCO₃
24 mEq/L (22-26 mEq/L)
- Temperature: 99.0°F (37.2°C) orally
- Heart rate: 86 beats/minute
- Respiratory rate: 24 breaths/minute
- Blood pressure: 142/86 mm Hg
- Oxygen saturation: 94% on room air
- Oxygen 2 L/minute via nasal cannula and titrate to keep saturation above 94%
- Insert peripheral IV
- Begin lactated Ringer’s IV infusion at 125 mL/hour
- Administer broad-spectrum antibiotics IV
- Obtain sputum culture and sensitivity
The client appears in mild respiratory distress. There is decreased lung expansion on the right side with dullness to percussion and decreased breath sounds in the right lower lobe. No cyanosis is observed, but the client is using accessory muscles for breathing. The skin is warm and pale. No jugular venous distention is noted. The abdomen is soft and non-tender, and bowel sounds are present.
A nurse is caring for a 46-year-old male client in the emergency department who is experiencing difficulty breathing that has worsened over the last 24 hours.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.
No explanation
(0700hrs):
- The client reports experiencing joint pain and stiffness in her hands for the past few months.
- The pain is described as aching and is worse in the morning, lasting for about an hour before improving.
- The client mentions difficulty in performing daily tasks such as buttoning clothes and opening jars.
- There is visible swelling in the small joints of both hands.
- The client denies any recent trauma or injury to the hands.
- The client reports feeling fatigued and has had occasional low-grade fevers.
- The client is currently taking medication for hypertension and diabetes.
- Hypertension for 10 years, managed with medication.
- Type 2 diabetes for 5 years, managed with oral hypoglycemic agents.
- No known allergies.
- Family history of autoimmune diseases.
(0700hrs):
- Temperature: 37.8°C (100°F)
- Blood Pressure: 140/90 mmHg
- Heart Rate: 82 bpm
- Respiratory Rate: 18 breaths per minute
- Oxygen Saturation: 98% on room air
(0700hrs):
- Swelling and tenderness in the metacarpophalangeal and proximal interphalangeal joints of both hands.
- Limited range of motion in the affected joints.
- No deformities observed.
- Skin over the joints appears slightly erythematous.
- No signs of infection or injury.
(0700hrs):
- Complete Blood Count (CBC): WBC 8,000/mm³ (4,000-11,000/mm³), Hemoglobin 13.5 g/dL (12-16 g/dL), Platelets 250,000/mm³ (150,000-450,000/mm³)
- Erythrocyte Sedimentation Rate (ESR): 40 mm/hr (0-20 mm/hr)
- C-Reactive Protein (CRP): 15 mg/L (0-10 mg/L)
- Rheumatoid Factor (RF): Positive
A nurse is caring for a 57-year-old female client in the emergency department who presents with joint pain and stiffness in her hands. The client has a history of hypertension and type 2 diabetes.
A nurse is analyzing the assessment findings. Which findings are indicative of rheumatoid arthritis? Select all that apply.
(0700hrs)
- The client is alert but has minimal confusion and can answer simple questions.
- The client reports difficulty in performing self-care activities such as dressing and feeding.
- The client is observed to have a noticeable decline in the ability to move the right arm.
- The client expresses frustration and sadness about the loss of independence.
- The client has a supportive family who visits regularly.
- The client is on a regular diet but needs assistance with feeding.
- The client is cooperative during the assessment but shows signs of fatigue.
(0700hrs)
- Right elbow: only able to straighten joint 20 degrees.
- Right wrist: able to bend wrist back toward forearm.
- Right shoulder: unable to move the arm away from the body.
(0700hrs)
- Temperature: 37.2°C (99°F)
- Heart rate: 82 bpm
- Blood pressure: 138/82 mmHg
- Respiratory rate: 18 breaths per minute
- Oxygen saturation: 96% on room air
(0700hrs)
- Complete Blood Count (CBC):
o WBC: 6.5 x 10^9/L (4.0-11.0 x 10^9/L)
-
- Hemoglobin: 13.5 g/dL (13.0-17.0 g/dL)
o Platelets: 250 x 10^9/L (150-400 x 10^9/L)
- Electrolytes:
- Sodium: 140 mmol/L (135-145 mmol/L)
- Potassium: 4.2 mmol/L (3.5-5.0 mmol/L)
- Chloride: 102 mmol/L (98-106 mmol/L)
A nurse is caring for a 73-year-old male client in an assisted living facility. The client has a history of a left-sided stroke and is experiencing increasing weakness and a decrease in range of motion (ROM) on the right side. The nurse begins the assessment at 0700hrs.
Based on the exhibits provided, what type of range of motion was being assessed for each joint? Select one response per row.
No explanation
(0800 hrs)
- The client is alert and oriented to person, place, time, and situation.
- The right forearm is visibly deformed with significant swelling and bruising.
- The client reports severe pain rated 10/10, described as sharp and throbbing.
- Capillary refill in the right hand is 4 seconds.
- The skin on the right forearm is warm to the touch.
- Radial pulse is 2+ and palpable.
- The client denies any numbness or tingling in the right hand.
(0800 hrs)
- Temperature: 37.2°C (99°F)
- Heart Rate: 88 bpm
- Blood Pressure: 138/82 mmHg
- Respiratory Rate: 18 breaths/min
- Oxygen Saturation: 98% on room air
(0800 hrs)
- X-ray results: Closed and displaced fracture of the right ulna and radius.
- Hemoglobin: 13.5 g/dL (Reference range: 13.8-17.2 g/dL)
- White Blood Cell Count: 8,000/mm³ (Reference range: 4,500-11,000/mm³)
(0800 hrs)
- 0.9% sodium chloride IV infusion at 75 mL/hr
- Morphine sulfate 2 mg IV push STAT once
- Obtain cast cart
- Neurovascular assessment every hour for the first 24 hours
A nurse is caring for a 45-year-old male client in the emergency department who sustained a fall from a ladder. The client has a closed and displaced fracture of the right ulna and radius. The nurse is monitoring the client closely for any changes in condition.
A nurse is caring for a 45-year-old male client in the emergency department with a closed and displaced fracture of the right ulna and radius. Based on the exhibits provided, what is the priority nursing action at this time?
When inspecting the client’s skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client’s history requires additional follow-up by the nurse?
When evaluating a client’s rectal bleeding, which findings should the nurse document?
Which skill should the nurse have an older client demonstrate to evaluate the ability to perform activities of daily living (ADL)?
To objectively confirm the presence of fever, before taking the client’s temperature, which action should the nurse take?
While assessing the legs of an adult client, the nurse observes leathery-looking skin. The client reports aching, tired legs that swell if standing for long periods of time.
To screen for venous insufficiency, the nurse should ask the client if they have experienced which subjective finding?
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