Study for Exit HESI

The nurse is performing an assessment on a 64-year old client admitted with chest pain who has a history of coronary artery disease, type 2 diabetes mellitus, hypertension, and smoking 1 pack per day for 40 years. The nurse notes the following clinical findings on assessment. Vital signs: Blood pressure = 134/72mmHg Heart rate = 96 beats per minute (bpm) Respirations = 18 breaths per minute (bp) Oxygen saturation = 97% on room air Temperature = 98.9 degrees F (37.2 degrees C) Laboratory test results: Serum glucose = 389mg/dL (22.2 mmol/L) Serum potassium = 3.8mEq/L (3.8mmol/L) Serum creatinine = 0.8mg/dL (70.6 mcmol/L) HbA1C = 10.2% Serum troponin = I0.8 ng/mL Physical assessment findings: Neurological = PERRLA Respiratory = Clear to auscultation bilaterally Cardiovascular = S1, S2, no S3, S4, no murmurs, rubs, gallops; whooshing noted over the right carotid artery Gastrointestinal = BS normoactive in all 4 quadrants, soft, non-tender, non-distended to palpation Genitourinary = No suprapubic tenderness, no bladder distention Which actions should the nurse take? Select all that apply. 1. Assess for focal neurological deficits 2. Administer an as needed antihypertensive medication 3. Assess for a history of light-headedness, dizziness, and syncope 4. Discuss with the primary health care provider performing serial troponin levels 5. Initiate a referral for the diabetes nurse educator and outpatient endocrinology follow-up 6. Collaborate with the primary health care provider on prescribing a bilateral carotid ultrasound

1. Assess for focal neurological deficits 3. Assess for a history of light-headedness, dizziness, and syncope 4. Discuss with the primary health care provider performing serial troponin levels 5. Initiate a referral for the diabetes nurse educator and outpatient endocrinology follow-up 6. Collaborate with the primary health care provider on prescribing a bilateral carotid ultrasound RATIONALE: The carotid arteries are located in the groove between the trachea and sternocleidomastoid muscle, medial to and alongside the muscle. On auscultation, the nurse listens for the presence of a bruit (a blowing, swishing sound), which indicates blood flow turbulence. Normally a bruit is not present, so this finding, whooshing noted over the right carotid artery, necessitates the need for follow-up. Assessing for focal neurological deficits and a history of light-headedness, dizziness, and syncope are important to determine if blood flow to the brain has been compromised as a result of carotid stenosis. A carotid ultrasound should be done due to the detection of a bruit on physical assessment, as well as the risk factors of hypertension, type 2 diabetes mellitus, coronary artery disease, and smoking. Serial troponin levels should be prescribed because of the elevation noted with the first level, as well as consultation with cardiology for further testing to determine if the client experienced a myocardial infarction. The client's serum glucose level and HbA1C indicate poor diabetes control; therefore, the nurse should initiate a referral to the diabetes nurse educator and outpatient endocrinology follow-up. An as needed antihypertensive should not be administered at this time because the blood pressure, although elevated beyond normal levels, is not elevated to the point of requiring additional blood pressure management.

The nurse is preparing to administer 30 milliliters (mL) of a liquid medication to an assigned client. What should the nurse do when preparing this medication? Choose the most likely option for the missing information in the statements below by choosing from the lists of options. Question 1: The nurse should use a _________, pouring liquid into it after placing it on a flat surface. Select answer... syringe medicine cup graduated cylinder Question 2: If too much is poured, the nurse should..... Select answer... discard the medicine per policy return the medication to its container pour the unused medication into the sink

Answer 1: Medicine cup Answer 2: discard the medicine per policy RATIONALE: When preparing to administer a liquid medication, the nurse should use a medicine cup, pouring the liquid into it after placing it on a flat surface at eye level with the thumbnail at the medicine cup line indicating the desired amount. Liquids should not be mixed with tablets or with other liquids in the same container. The nurse should be sure not to return poured medication to its container and should properly discard poured medication if not used. The nurse should pour liquids from the side opposite the bottle's label to avoid spilling medicine on the label. Medications that irritate the gastric mucosa, such as liquid potassium products, should be diluted or taken with meals. Ice chips should be offered before administering unpleasant-tasting medications in order to numb the client's taste buds.

A pregnant client with diabetes mellitus asks the nurse about insulin needs during pregnancy. What information should the nurse provide to the client? Choose the most likely option for the missing information in each statement below by choosing from the lists of options. Question 1: Pregnancy places demands on ____________________ metabolism and causes insulin requirements to change. Select Answer: fat lipid glucose carbohydrate Question 2: Maternal ____________ crosses the placenta, but _________________ does not. Select 2 answers to fill in both blanks: glucose insulin lipid protein Question 3: During the ________________ trimester, maternal insulin needs decrease. Select answer: first second third Question 4: During the (4A) ________________ and (4B) ______________ trimesters, increases in placental hormones cause an insulin-(4C)_________________ state, requiring a(n) (4D)________________ in the client's insulin dose. Select answer (4A): first second dependent modeling Select answer (4B): second third increase resistant Select answer (4C): first third resistant decrease Select answer (4D): second third modeling decrease Question 5: Due to the fact that the fetus produces its own (5A) _____________________ and pulls (5B) _____________________ from the mother, the mother is predisposed to (5C) _______________ reactions. Select answer (5A): insulin glucose hypoglycemic Select answer (5B): glucose insulin hyperglycemic Select answer (5C): protein albumin hypoglycemic reactions.

Answer 1: carbohydrate Answer 2: glucose/insulin Answer 3: first Answer 4: (A) second (B) third (C) resistant (D) increase Answer 5: (A) insulin (B) glucose (C) hypoglycemic reactions RATIONALE: The nurse should begin by explaining to the client that pregnancy places demands on carbohydrate metabolism and causes insulin requirements to change. The nurse should inform the client that maternal glucose crosses the placenta, but insulin does not. During the first trimester, maternal insulin needs decrease. During the second and third trimesters, increases in placental hormones cause an insulin-resistant state, requiring an increase in the client's insulin dose. After placental delivery, placental hormone levels abruptly decrease and insulin requirements decrease. In addition, the fetus produces its own insulin and pulls glucose from the mother, which predisposes the mother to hypoglycemic reactions.

The mother of a 4-year-old child calls the clinic nurse and expresses concern because the child has been masturbating. In considering the child's developmental stage, the nurse should determine that this is an expected finding. Using Freud's psychosexual stages of development, use the list of options to choose the behaviors to the associated stage that can be taught to the mother to alleviate her concerns.

Oral = Focus is on oral gratification and mouth-sucking and swallowing Anal = Gains a sense of control over instinctive drives and withholding or expelling feces Phallic = Becomes aware of self as a sexual being and masturbation is common Latent = Developing peer relationships with little to no sexual motivation present Genital = Develops relationships with people of the opposite sex RATIONALE: According to Freud's psychosexual stages of development, the oral phase is associated with oral gratification and mouth-sucking and swallowing. In the anal stage, the child gains a sense of control over instinctive drives characterized by withholding or expelling feces. In the phallic stage, the child becomes aware of self as a sexual being and devotes much energy to examining genitalia, masturbating, and expressing interest in sexual concerns. The latent focuses on developing peer relationships with little to no sexual motivation, and in the genital stage the individual focuses with developing relationships with people of the opposite sex. The nurse should alleviate the mother's concern by telling the mother that this behavior, masturbation, is normal.

The nurse is preparing assignments for the day for the eight clients below and needs to assign clients to a registered nurse (RN), a licensed practical nurse (LPN), and an assistive personnel (AP). Choose the most appropriate health care provider for each client. A client who requires hourly pulse and blood pressure measurements. A bed-bound client who needs range of motion exercises. A client requiring abdominal wound irrigations and dressing changes. A client requiring post-operative ambulation who has a steady gait. A client on intravenous fluids for hypovolemic shock. A client requiring a transfusion of fresh frozen plasma. A client receiving intermittent tube feedings. A client requiring a colostomy appliance change.

RN Assignment: A client on intravenous fluids for hypovolemic shock. A client requiring a transfusion of fresh frozen plasma. LPN Assignment: A client receiving intermittent tube feedings. A client requiring abdominal wound irrigations and dressing changes. A client requiring a colostomy appliance change. AP Assignment: A bed-bound client who needs range of motion exercises. A client who requires hourly pulse and blood pressure measurements. A client requiring post-operative ambulation who has a steady gait. RATIONALE: A client in hypovolemic shock requires the skills set of an RN; close assessment is required because shock can be life-threatening. A client requiring a transfusion of fresh frozen plasma also requires management by an RN because of the risks associated with a transfusion. A client requiring intermittent tube feedings, a colostomy appliance change, and abdominal wound irrigations and dressing changes can be safely managed by the LPN because the LPN is trained to perform these procedures. A bed-bound client needing range of motion exercises, a post-operative client who has a steady gait requiring ambulation, and a client requiring hourly blood pressure and pulse measurements can be managed by the AP because the AP is trained to perform these activities. Care to all clients is ultimately overseen by the RN.