capstone hesi
the nurse is preparing a client for discharge to home who had a below-the-knee amputation. which
recommendations does the nurse provide the client? SATA
a) inspect skin for redness
b) use a residual limb shrinker
c) apply alcohol after bathing
d) wash with soap and water
e) avoid range of motion exercises ANS: a) inspect skin for redness
b) use a residual limb shrinker
d) wash with soap and water
when triaging emergency room clients, which client should the nurse assess first?
a) a male adolescent who has been vomiting for the past 12 hours and describes himself as very weak.
b) an elderly client with peripheral vascular disease who is complaining of severe leg pain when
ambulating
c) a female client with severe lower right abdominal pain who is febrile and vomiting
d) a child who has a cold for two days and now is coughing up green sputum ANS: c) a female client with
severe lower right abdominal pain who is febrile and vomiting
after assessing a client, the nurse identifies three nursing problems. When developing the client's plan of
care, which action should the nurse take?
a) collaborate with client to establish goals
b) cluster supportive client data
,c) identify client care interventions
d) prioritize the identified nursing diagnoses ANS: d) prioritize the identified nursing diagnoses
the nursing problems must be identified, then prioritized (D) before (A and C) can be implemented. (b)
should be completed before identifying the nursing problem
A 55-year-old female client with symptoms of osteoarthritis asks what form of exercise would be most
beneficial for her. What is the best response by the nurse?
a) "limit your exercise to just your daily activities"
b) "Jogging or running are excellent aerobic exercises"
c) "swimming is an excellent exercise for you"
d) "Tennis or racquetball will increase your muscle strength" ANS: c) "swimming is an excellent exercise
for you"
a client receives a new prescription for guaifensesin (Robutissin) 2 tablespoons PO every 6 hours. The
client takes the perscribed dose for 3 days every 6 hours. What is the total number of ounces of
Robitussin the client has taken? ANS: 12
At 20-weeks gestation, a client who has gained 20 pounds during this pregnancy tells the nurse that she
is feeling fetal movement. Fundal height measurement is 20 cm, and the client's only complaint is that
her breath sounds are leaking clear fluid. Which assessment finding warrants further evaluation?
a) Presence of fetal movement
b) leakage from breasts
c) gestational weight gain
d) fundal height measurement ANS: c) gestational weight gain
,At this point in the pregnancy, the client should have gained 10.3 lbs and a weight gain of 20 should be
investigated further.
A client who is admitted to the emergency room following a motorcycle accident is having difficulty
breathing. While assessing the client's chest and lungs, the nurse notes there are no breath sounds over
the left fields. Which actions should the nurse implement? (SATA)
a) place client in Trendelenburg position
b) apply a high-flow oxygen by face mask
c) elevate the head of the bed 45 degrees
d) withhold narcotic pain medication
e) obtain a chest tube insertion kit. ANS: b) apply a high-flow oxygen by face mask
c) elevate the head of the bed 45 degrees
e) obtain a chest tube insertion kit.
What equipment should the nurse use to most accurately measure a 2 ml dose of a viscous liquid
solution to be administered orally?
a) 3 ml syringe and a sterile needle
b) 3 ml syringe
c) Tuberculin syringe
d) One ounce medicine cup ANS: b) 3 ml syringe
An older man with a history of multiple falls at home tells the clinic nurse that his son, who has
incarcerated last year for battery, has become increasingly abusive since his release from prison six
weeks ago. Which intervention is most important for the nurse to implement?
a) Tell the client to call Adult Protective Services if son's abuse continues
, b) Refer the client to a program for victims of domestic violence
c) verify the clients report by determining if there is physical evidence of abuse
d) assist the client in developing an emergency safety pain ANS: d) assist the client in developing an
emergency safety pain
think SAFETY first
While auscultating a client's abdomen, the nurse her a low pitched blowing sound in the upper midline
area. What is the likely indication of this finding?
a) normal borborygmus sounds
b) a minor variation
c) hyperactive bowel sounds
d) possible renal artery stenosis ANS: d) possible renal artery stenosis
This sound is a vascular bruit, which is a blowing sound that is auscultated over a stenosed artery. The
location of the sound at the upper midline area is suggestive of a renal artery stenosis.
A post-menopausal female client with osteoporosis tells the nurse that she has increased her physical
activity and hopes to participate in a charity walk-a-thon. How should the nurse respond?
a) Affirm the benefits of increasing her weight-bearing activity
b) Review the need for her to avoid large crowds of people
c) Teach her how to take her pulse during prolonged activity
d) Explain the need to limit phyiscal activity to reduce fracture risk ANS: a) Affirm the benefits of
increasing her weight-bearing activity
the nurse is preparing a client for discharge to home who had a below-the-knee amputation. which
recommendations does the nurse provide the client? SATA
a) inspect skin for redness
b) use a residual limb shrinker
c) apply alcohol after bathing
d) wash with soap and water
e) avoid range of motion exercises ANS: a) inspect skin for redness
b) use a residual limb shrinker
d) wash with soap and water
when triaging emergency room clients, which client should the nurse assess first?
a) a male adolescent who has been vomiting for the past 12 hours and describes himself as very weak.
b) an elderly client with peripheral vascular disease who is complaining of severe leg pain when
ambulating
c) a female client with severe lower right abdominal pain who is febrile and vomiting
d) a child who has a cold for two days and now is coughing up green sputum ANS: c) a female client with
severe lower right abdominal pain who is febrile and vomiting
after assessing a client, the nurse identifies three nursing problems. When developing the client's plan of
care, which action should the nurse take?
a) collaborate with client to establish goals
b) cluster supportive client data
,c) identify client care interventions
d) prioritize the identified nursing diagnoses ANS: d) prioritize the identified nursing diagnoses
the nursing problems must be identified, then prioritized (D) before (A and C) can be implemented. (b)
should be completed before identifying the nursing problem
A 55-year-old female client with symptoms of osteoarthritis asks what form of exercise would be most
beneficial for her. What is the best response by the nurse?
a) "limit your exercise to just your daily activities"
b) "Jogging or running are excellent aerobic exercises"
c) "swimming is an excellent exercise for you"
d) "Tennis or racquetball will increase your muscle strength" ANS: c) "swimming is an excellent exercise
for you"
a client receives a new prescription for guaifensesin (Robutissin) 2 tablespoons PO every 6 hours. The
client takes the perscribed dose for 3 days every 6 hours. What is the total number of ounces of
Robitussin the client has taken? ANS: 12
At 20-weeks gestation, a client who has gained 20 pounds during this pregnancy tells the nurse that she
is feeling fetal movement. Fundal height measurement is 20 cm, and the client's only complaint is that
her breath sounds are leaking clear fluid. Which assessment finding warrants further evaluation?
a) Presence of fetal movement
b) leakage from breasts
c) gestational weight gain
d) fundal height measurement ANS: c) gestational weight gain
,At this point in the pregnancy, the client should have gained 10.3 lbs and a weight gain of 20 should be
investigated further.
A client who is admitted to the emergency room following a motorcycle accident is having difficulty
breathing. While assessing the client's chest and lungs, the nurse notes there are no breath sounds over
the left fields. Which actions should the nurse implement? (SATA)
a) place client in Trendelenburg position
b) apply a high-flow oxygen by face mask
c) elevate the head of the bed 45 degrees
d) withhold narcotic pain medication
e) obtain a chest tube insertion kit. ANS: b) apply a high-flow oxygen by face mask
c) elevate the head of the bed 45 degrees
e) obtain a chest tube insertion kit.
What equipment should the nurse use to most accurately measure a 2 ml dose of a viscous liquid
solution to be administered orally?
a) 3 ml syringe and a sterile needle
b) 3 ml syringe
c) Tuberculin syringe
d) One ounce medicine cup ANS: b) 3 ml syringe
An older man with a history of multiple falls at home tells the clinic nurse that his son, who has
incarcerated last year for battery, has become increasingly abusive since his release from prison six
weeks ago. Which intervention is most important for the nurse to implement?
a) Tell the client to call Adult Protective Services if son's abuse continues
, b) Refer the client to a program for victims of domestic violence
c) verify the clients report by determining if there is physical evidence of abuse
d) assist the client in developing an emergency safety pain ANS: d) assist the client in developing an
emergency safety pain
think SAFETY first
While auscultating a client's abdomen, the nurse her a low pitched blowing sound in the upper midline
area. What is the likely indication of this finding?
a) normal borborygmus sounds
b) a minor variation
c) hyperactive bowel sounds
d) possible renal artery stenosis ANS: d) possible renal artery stenosis
This sound is a vascular bruit, which is a blowing sound that is auscultated over a stenosed artery. The
location of the sound at the upper midline area is suggestive of a renal artery stenosis.
A post-menopausal female client with osteoporosis tells the nurse that she has increased her physical
activity and hopes to participate in a charity walk-a-thon. How should the nurse respond?
a) Affirm the benefits of increasing her weight-bearing activity
b) Review the need for her to avoid large crowds of people
c) Teach her how to take her pulse during prolonged activity
d) Explain the need to limit phyiscal activity to reduce fracture risk ANS: a) Affirm the benefits of
increasing her weight-bearing activity
