NURSING 3345 HESI CAPSTONE EXAM

NURSING 3345 HESI CAPSTONE EXAM

REVIEW

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

• inspect skin for redness
• use a residual limb shrinker
• apply alcohol after bathing
• wash with soap and water
• avoid range of motion exercises

(ANS-

• inspect skin for redness
• use a residual limb shrinker
• wash with soap and water

when triaging emergency room clients, which client should the nurse assess first?

• a male adolescent who has been vomiting for the past 12 hours and describes

himself as very weak.

• an elderly client with peripheral vascular disease who is complaining of severe

leg pain when ambulating

• a female client with severe lower right abdominal pain who is febrile and

vomiting

• a child who has a cold for two days and now is coughing up green sputum

(ANS- 1 / 4

• 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?

• collaborate with client to establish goals
• cluster supportive client data
• identify client care interventions
• prioritize the identified nursing diagnoses

(ANS-

• 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?

• "limit your exercise to just your daily activities"
• "Jogging or running are excellent aerobic exercises"
• "swimming is an excellent exercise for you"
• "Tennis or racquetball will increase your muscle strength"

(ANS-

• "swimming is an excellent exercise for you" 2 / 4

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

• leakage from breasts
• gestational weight gain
• fundal height measurement

(ANS-

• 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)

• place client in Trendelenburg position
• apply a high-flow oxygen by face mask 3 / 4

• elevate the head of the bed 45 degrees
• withhold narcotic pain medication
• obtain a chest tube insertion kit.

(ANS-

• apply a high-flow oxygen by face mask
• elevate the head of the bed 45 degrees
• 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?

• 3 ml syringe and a sterile needle
• 3 ml syringe

c) Tuberculin syringe

d) One ounce medicine cup

(ANS-

• 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

• verify the clients report by determining if there is physical evidence of abuse
• assist the client in developing an emergency safety pain
• / 4