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Wgu Hesi Professional Nursing Role Proctored Exam
Total Questions : 129
Showing 10 questions, Sign in for moreThe nurse identifies an electrolyte imbalance, elevated blood pressure, and exhibited changes in mental status for a client with chronic kidney disease. Which is the most important action for the nurse to take?
While assessing a client's health history, the nurse notes that the client has been receiving enoxaparin. Which health outcome would indicate this medication is effective?
Reference Range:
- Glycosylated hemoglobin (A1C) [4% to 5.9% ]
- Hemoglobin (Hgb) [12 to 16 g/dL (120 to 160 g/L)]
The nurse working on a mental health unit is prioritizing nursing care activities because of a staffing shortage. One practical nurse (PN) is on the unit with the nurse, and another RN is expected to arrive within two hours. Clients need to be awakened and morning medications need to be prepared. Which plan is best for the nurse to implement?
An older adult female asks the clinic nurse about getting a herpes vaccination because she gets cold sores on her mouth when she is sick or stressed. How should the nurse respond?
When the parents of a 6-year-old boy with a brain tumor are told that his condition is terminal, the mother shouts at the father, "This is your fault! It never would have happened if we had sought treatment sooner!" Which intervention is best for the nurse to implement?
An 81-year-old, male presents to the emergency department via emergency medical services (EMS). He presents with aphasia, right-sided weakness, and right-sided sensory loss. The client's spouse reported that they were sitting at the table eating breakfast when suddenly the client dropped his coffee mug and was unable to speak. Per the spouse, client is normally alert, oriented, and independent with activities of daily living (ADL). His medical history includes hypertension, type 2 diabetes mellitus, benign prostatic hyperplasia (BPH), gout, and hypercholesterolemia. Is a nonsmoker. Spouse informs the client drinks 2 to 3 beers per day.
Current medications
- Lisinopril 10 mg by mouth (PO) daily
- Metformin 500 mg by mouth (PO) twice daily (BID)
- Tamsulosin 0.4 mg by mouth (PO) daily
- Allopurinol 300 mg by mouth (PO) daily
- Atorvastatin 10 mg by mouth (PO) daily at bedtime
0900
- Client laying on stretcher. Assessment completed. Healthcare provider (HCP) arrives to do their evaluation. Stroke protocol activated.
Assessment
- Neurological: Alert and keenly attentive, able to follow commands, right facial paresis, speech unintelligible. Decreased sensation to right face, arm, and leg. Normal sensation in the left face, arm, and leg.
- Cardiovascular: Irregular rhythm with 3+ bounding radial pulses.
- Respiratory: Lungs clear, diminished at bases.
- Musculoskeletal: Right arm flaccid, right leg with motor drift. Left upper and lower extremity with normal strength and movement.
- Gastrointestinal: Bowel sounds present in all 4 quadrants. Abdomen soft, nondistended.
- Integumentary: Skin dry and intact.
- National Institutes of Health Stroke Scale (NIHSS): 14 out of 42.
0900
Vital signs
- Temperature: 97.9° F (36.6° C)
- Heart rate: 88 beats/minute, irregular
- Respirations: 18 breaths/minute
- Blood pressure: 205/98 mm Hg
- Oxygen saturation: 97% on room air
- Height: 5 feet, 10 inches (177.8 cm)
- Weight: 165 pounds (74.8 kg)
- Pain: no pain per FACES pain scale
The nurse reviews the information from the initial assessment and history and physical.
Which 6 findings in the client's history should the nurse recognize as risk factors for a cerebrovascular event?
An 81-year-old, male presents to the emergency department via emergency medical services (EMS). He presents with aphasia, right-sided weakness, and right-sided sensory loss. The client's spouse reported that they were sitting at the table eating breakfast when suddenly the client dropped his coffee mug and was unable to speak. Per the spouse, client is normally alert, oriented, and independent with activities of daily living (ADL). His medical history includes hypertension, type 2 diabetes mellitus, benign prostatic hyperplasia (BPH), gout, and hypercholesterolemia. Is a nonsmoker. Spouse informs the client drinks 2 to 3 beers per day.
Current medications
- Lisinopril 10 mg by mouth (PO) daily
- Metformin 500 mg by mouth (PO) twice daily (BID)
- Tamsulosin 0.4 mg by mouth (PO) daily
- Allopurinol 300 mg by mouth (PO) daily
- Atorvastatin 10 mg by mouth (PO) daily at bedtime
0900
Client laying on stretcher. Assessment completed. Healthcare provider (HCP) arrives to do their evaluation. Stroke protocol activated.
Assessment
Neurological: Alert and keenly attentive, able to follow commands, right facial paresis, speech unintelligible. Decreased sensation to right face, arm, and leg. Normal sensation in the left face, arm, and leg.
Cardiovascular: Irregular rhythm with 3+ bounding radial pulses.
Respiratory: Lungs clear, diminished at bases.
Musculoskeletal: Right arm flaccid, right leg with motor drift. Left upper and lower extremity with normal strength and
movement.
Gastrointestinal: Bowel sounds present in all 4 quadrants. Abdomen soft, nondistended.
Integumentary: Skin dry and intact.
National Institutes of Health Stroke Scale (NIHSS): 14 out of 42.
0900
Vital signs
- Temperature: 97.9° F (36.6° C)
- Heart rate: 88 beats/minute, irregular
- Respirations: 18 breaths/minute
- Blood pressure: 205/98 mm Hg
- Oxygen saturation: 97% on room air
- Height: 5 feet, 10 inches (177.8 cm)
- Weight: 165 pounds (74.8 kg)
- Pain: no pain per FACES pain scale
0910
- Head computed tomography (CT) without contrast STAT
- Point of care (POC) blood glucose level STAT
- Prothrombin time (PT) STAT
- International normalized ratio (INR) STAT
- Insert two (2) peripheral intravenous (IV) sodium chloride locks
- 12-lead electrocardiogram (ECG) STAT
Patient Data
The nurse considers the client's symptoms.
Which assessment finding(s) support the suspected diagnosis of acute stroke? Select all that apply.
An 81-year-old, male presents to the emergency department via emergency medical services (EMS). He presents with aphasia, right-sided weakness, and right-sided sensory loss. The client's spouse reported that they were sitting at the table eating breakfast when suddenly the client dropped his coffee mug and was unable to speak. Per the spouse, client is normally alert, oriented, and independent with activities of daily living (ADL). His medical history includes hypertension, type 2 diabetes mellitus, benign prostatic hyperplasia (BPH), gout, and hypercholesterolemia. Is a nonsmoker. Spouse informs the client drinks 2 to 3 beers per day.
Current medications
- Lisinopril 10 mg by mouth (PO) daily
- Metformin 500 mg by mouth (PO) twice daily (BID)
- Tamsulosin 0.4 mg by mouth (PO) daily
- Allopurinol 300 mg by mouth (PO) daily
- Atorvastatin 10 mg by mouth (PO) daily at bedtime
0900
- Client laying on stretcher. Assessment completed. Healthcare provider (HCP) arrives to do their evaluation. Stroke protocol activated.
Assessment
- Neurological: Alert and keenly attentive, able to follow commands, right facial paresis, speech unintelligible. Decreased sensation to right face, arm, and leg. Normal sensation in the left face, arm, and leg.
- Cardiovascular: Irregular rhythm with 3+ bounding radial pulses.
- Respiratory: Lungs clear, diminished at bases.
- Musculoskeletal: Right arm flaccid, right leg with motor drift. Left upper and lower extremity with normal strength and movement.
- Gastrointestinal: Bowel sounds present in all 4 quadrants. Abdomen soft, nondistended.
- Integumentary: Skin dry and intact.
- National Institutes of Health Stroke Scale (NIHSS): 14 out of 42.
0900
Vital signs
- Temperature: 97.9° F (36.6° C)
- Heart rate: 88 beats/minute, irregular
- Respirations: 18 breaths/minute
- Blood pressure: 205/98 mm Hg
- Oxygen saturation: 97% on room air
- Height: 5 feet, 10 inches (177.8 cm)
- Weight: 165 pounds (74.8 kg)
- Pain: no pain per FACES pain scale
0910
- Head computed tomography (CT) without contrast STAT
- Point of care (POC) blood glucose level STAT
- Prothrombin time (PT) STAT
- International normalized ratio (INR) STAT
- Insert two (2) peripheral intravenous (IV) sodium chloride locks
- 12-lead electrocardiogram (ECG) STAT
Patient Data
The nurse considers the pathophysiological similarities and differences between hemorrhagic and ischemic stroke. Click to indicate which manifestation is typically indicative of hemorrhagic, ischemic, or both types of strokes. Each column must have at least one response option selected.
Explanation
Rationale for correct choices
• Decreased level of consciousness (LOC): Hemorrhagic strokes involve bleeding into the brain tissue or subarachnoid space, which increases intracranial pressure and can rapidly impair cerebral perfusion. This often results in decreased LOC or sudden deterioration in alertness. Ischemic strokes may present with normal LOC, particularly in smaller or non-dominant hemisphere infarcts.
• Unilateral symptoms: Both stroke types typically cause deficits on one side of the body corresponding to the affected cerebral hemisphere. Manifestations may include hemiparesis, facial droop, and unilateral sensory loss. The laterality of symptoms is a hallmark in both ischemic and hemorrhagic strokes.
• Sudden symptom onset: Hemorrhagic strokes usually present with abrupt, severe onset, often described as “worst headache of my life” or sudden neurological deficits. While ischemic strokes can also develop suddenly, hemorrhagic strokes generally have a more dramatic and immediate presentation.
• Alert at cognitive baseline: Many ischemic strokes, especially small-vessel infarcts, may occur without immediately affecting consciousness. Patients often remain alert and oriented at baseline, although unilateral neurological deficits are present. This contrasts with hemorrhagic strokes, where LOC is frequently compromised.
An 81-year-old, male presents to the emergency department via emergency medical services (EMS). He presents with aphasia, right-sided weakness, and right-sided sensory loss. The client's spouse reported that they were sitting at the table eating breakfast when suddenly the client dropped his coffee mug and was unable to speak. Per the spouse, client is normally alert, oriented, and independent with activities of daily living (ADL). His medical history includes hypertension, type 2 diabetes mellitus, benign prostatic hyperplasia (BPH), gout, and hypercholesterolemia. Is a nonsmoker. Spouse informs the client drinks 2 to 3 beers per day.
Current medications
- Lisinopril 10 mg by mouth (PO) daily
- Metformin 500 mg by mouth (PO) twice daily (BID)
- Tamsulosin 0.4 mg by mouth (PO) daily
- Allopurinol 300 mg by mouth (PO) daily
- Atorvastatin 10 mg by mouth (PO) daily at bedtime
0900
Show calculator
Client laying on stretcher. Assessment completed. Healthcare provider (HCP) arrives to do their evaluation. Stroke protocol activated.
Assessment
Neurological: Alert and keenly attentive, able to follow commands, right facial paresis, speech unintelligible. Decreased sensation to right face, arm, and leg. Normal sensation in the left face, arm, and leg.
Cardiovascular: Irregular rhythm with 3+ bounding radial pulses.
Respiratory: Lungs clear, diminished at bases.
Musculoskeletal: Right arm flaccid, right leg with motor drift. Left upper and lower extremity with normal strength and movement.
Gastrointestinal: Bowel sounds present in all 4 quadrants. Abdomen soft, nondistended.
Integumentary: Skin dry and intact.
National Institutes of Health Stroke Scale (NIHSS): 14 out of 42.
0910
Acute stroke is suspected. Prescriptions received.
0915
Point of care blood glucose, prothrombin time (PT), and international normalized ratio (INR) obtained at bedside. 20 gauge peripheral intravenous (IV) sodium chloride locks are inserted into the right and left antecubital space. Client transported to radiology for computed tomography (CT) accompanied by transporter and nurse.
0935
The healthcare provider is at bedside discussing diagnosis of acute ischemic stroke and the plan of care with client and spouse. Decision made to administer intravenous (IV) recombinant tissue plasminogen activator (tPA).
0900
Vital signs
- Temperature: 97.9° F (36.6° C)
- Heart rate: 88 beats/minute, irregular
- Respirations: 18 breaths/minute
- Blood pressure: 205/98 mm Hg
- Oxygen saturation: 97% on room air
- Height: 5 feet, 10 inches (177.8 cm)
- Weight: 165 pounds (74.8 kg)
- Pain: no pain per FACES pain scale
0930
Vital signs
- Temperature: 97.9° F (36.6° C)
- Heart rate: 92 beats/minute, irregular
- Respirations: 17 breaths/minute
- Blood pressure: 180/90 mm Hg
- Oxygen saturation: 96% on room air
- Pain: no pain per FACES pain scale
0915
|
Point of Care Test |
Result |
Reference Range |
|
Blood glucose |
188 mg/dL (10.43 mmol/L) |
74 to 106 mg/dL (4.1 to 5.9 mmol/L) |
|
Prothrombin time |
12 seconds |
10 to 13 seconds |
|
International normalized ratio |
1.1 |
0.8 to 1.1 |
0910
- Head computed tomography (CT) without contrast STAT
- Point of care (POC) blood glucose level STAT
- Prothrombin time (PT) STAT
- International normalized ratio (INR) STAT
- Insert two (2) peripheral intravenous (IV) sodium chloride locks
- 12-lead electrocardiogram (ECG) STAT
0940
- Tenecteplase 0.4 mg/kg intravenous push (IVP) over 5 seconds STAT
- Admit to intensive care unit (ICU)
0915
- 12-lead electrocardiogram (ECG) results: Atrial fibrillation with normal ventricular response
0930
- Noncontrast head computed tomography (CT) results: No evidence of mass, hemorrhage, or hydrocephalus
The nurse prepares to educate the client and spouse.
Click to select the 3 items that the nurse should include in the plan of care after administration of tissue plasminogen activator (tPA).
An 81-year-old, male presents to the emergency department via emergency medical services (EMS). He presents with aphasia, right-sided weakness, and right-sided sensory loss. The client's spouse reported that they were sitting at the table eating breakfast when suddenly the client dropped his coffee mug and was unable to speak. Per the spouse, client is normally alert, oriented, and independent with activities of daily living (ADL). His medical history includes hypertension, type 2 diabetes mellitus, benign prostatic hyperplasia (BPH), gout, and hypercholesterolemia. Is a nonsmoker. Spouse informs the client drinks 2 to 3 beers per day.
Current medications
- Lisinopril 10 mg by mouth (PO) daily
- Metformin 500 mg by mouth (PO) twice daily (BID)
- Tamsulosin 0.4 mg by mouth (PO) daily
- Allopurinol 300 mg by mouth (PO) daily
- Atorvastatin 10 mg by mouth (PO) daily at bedtime
0900
Show calculator
Client laying on stretcher. Assessment completed. Healthcare provider (HCP) arrives to do their evaluation. Stroke protocol activated.
Assessment
Neurological: Alert and keenly attentive, able to follow commands, right facial paresis, speech unintelligible. Decreased sensation to right face, arm, and leg. Normal sensation in the left face, arm, and leg.
Cardiovascular: Irregular rhythm with 3+ bounding radial pulses.
Respiratory: Lungs clear, diminished at bases.
Musculoskeletal: Right arm flaccid, right leg with motor drift. Left upper and lower extremity with normal strength and movement.
Gastrointestinal: Bowel sounds present in all 4 quadrants. Abdomen soft, nondistended.
Integumentary: Skin dry and intact.
National Institutes of Health Stroke Scale (NIHSS): 14 out of 42.
0910
Acute stroke is suspected. Prescriptions received.
0915
Point of care blood glucose, prothrombin time (PT), and international normalized ratio (INR) obtained at bedside. 20 gauge peripheral intravenous (IV) sodium chloride locks are inserted into the right and left antecubital space. Client transported to radiology for computed tomography (CT) accompanied by transporter and nurse.
0935
The healthcare provider is at bedside discussing diagnosis of acute ischemic stroke and the plan of care with client and spouse. Decision made to administer intravenous (IV) recombinant tissue plasminogen activator (tPA).
0900
Vital signs
- Temperature: 97.9° F (36.6° C)
- Heart rate: 88 beats/minute, irregular
- Respirations: 18 breaths/minute
- Blood pressure: 205/98 mm Hg
- Oxygen saturation: 97% on room air
- Height: 5 feet, 10 inches (177.8 cm)
- Weight: 165 pounds (74.8 kg)
- Pain: no pain per FACES pain scale
0930
Vital signs
- Temperature: 97.9° F (36.6° C)
- Heart rate: 92 beats/minute, irregular
- Respirations: 17 breaths/minute
- Blood pressure: 180/90 mm Hg
- Oxygen saturation: 96% on room air
- Pain: no pain per FACES pain scale
0915
|
Point of Care Test |
Result |
Reference Range |
|
Blood glucose |
188 mg/dL (10.43 mmol/L) |
74 to 106 mg/dL (4.1 to 5.9 mmol/L) |
|
Prothrombin time |
12 seconds |
10 to 13 seconds |
|
International normalized ratio |
1.1 |
0.8 to 1.1 |
0910
- Head computed tomography (CT) without contrast STAT
- Point of care (POC) blood glucose level STAT
- Prothrombin time (PT) STAT
- International normalized ratio (INR) STAT
- Insert two (2) peripheral intravenous (IV) sodium chloride locks
- 12-lead electrocardiogram (ECG) STAT
0940
- Tenecteplase 0.4 mg/kg intravenous push (IVP) over 5 seconds STAT
- Admit to intensive care unit (ICU)
0915
- 12-lead electrocardiogram (ECG) results: Atrial fibrillation with normal ventricular response
0930
- Noncontrast head computed tomography (CT) results: No evidence of mass, hemorrhage, or hydrocephalus
For each assessment finding click to indicate whether these nursing interventions are appropriate or not appropriate. Each column must have at least one response option selected.
Explanation
Rationale:
• Insert indwelling urinary catheter: Invasive procedures, including catheterization, should be avoided for at least 24 hours after fibrinolytic (Tenecteplase/tPA) administration due to the high risk of internal bleeding. If absolutely necessary, they should have been inserted before the medication was given.
• Assess family strengths and resources: Evaluating the family’s ability to assist with care is critical for discharge planning. Stroke patients often require support with ADLs and mobility, and early assessment promotes safer transitions and continuity of care.
• Perform range-of-motion exercises twice per day: To prevent contractures, joint stiffness, and muscle atrophy, passive and active range-of-motion exercises should be performed on affected limbs. Early mobility interventions reduce complications of immobility.
• Apply graduated compression stockings or SCDs: Stroke patients are at increased risk for deep vein thrombosis due to immobility. Compression devices or stockings facilitate venous return and help prevent thromboembolic events.
• Have an oral suction device available: Clients with dysphagia, decreased gag reflex, or impaired consciousness are at risk for aspiration. Having suction available ensures airway protection and prevents respiratory complications.
• Establish a nonverbal communication code system: Clients with aphasia or expressive communication deficits benefit from a nonverbal code system to express needs, which supports patient safety, reduces frustration, and facilitates care delivery.
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