HESI Exit Exam Final Capstone 160 Questions 2023
Exit HESI 3 (160 Questions)
1. pt is experiencing hyperkalemia - in absence of
symptoms and EKG changes it is sufficiency to: switch
captopril (an ACE inhibitor that promote K retention) to another
(non-K sparing) htn drug such as amlodipine
2. pt is experiencing diplopia, dysphagia, descending
muscle weakness and diarrhea and is dianosed w botulism
what should nurse tell pts spouse?: throw out all of your home
canned foods. neurotoxin are typically found in home canned
foods.
3. premature atrial contractions: momentary interruption of
atrial rhythm (can be caused by stress, caffeine, drugs)
-tx if beta-blocker!!! not life-threatening, cannot change dose of
prescribed med, 4. fluxetine (prozax): antidepressant SSRI's ->
first few weeks of SSRI tx the risk of self-harm and suicide is
increased. 5. normal PR interval: 0.12-0.20 seconds
6. a thrombocyte count of 60,000 is: severely decreased (norm
150k-400k) and could mean that the pt is developing probs w
coagulation in addition to the existing pancreatitis and ARDS,
MODS is the most severe manifestation of sepsis and occurs
when 2 organ systems become dysfunctional and require
intervention to maintain homeostasis.
-elevated WBC and crackles over both lungs is expected with
ARDS
7. LaVeen Shunt: plastic tube that passes from the jugular vein to
the peritoneal cavity where a valve permits absorption of ascitic
fluid to be carried back to venous circulation by the way of the
superior vena cava.
8. irregular heartbeat in newborns?: common, normal finding.
9. Frontal Lobe (glioma): frontal lobe controls personality and
speech, personality changes and expressive aphasia are
expected manifestations from tumor
10. Parkland Burn Formula: 4mL x body weight (kg) x
percentage of body surface= total fluid requirement in mL for 24
hours
half to be given in 1st 8 hours, 1/4 in second 8 hours and 1/4
in last 8 hours... 11. patient's bill of rights include: - Right to
the least restrictive environment - Right to treatment
- Right to refuse treatment
- Right to have access to medical records
- Access to telephone, mail, visitors, privacy, TV
12. type 2 DM is prescribed daily insulin injections however
has limited manual dexterity: for a reduction in manual
dexterity, an insulin pen would ensure that the pt is compliant
w daily insulin injections bc insulin pens are easier to handle
than syringes.
13. inhaled corticosteroids are often prescribed for asthma
tx. steroids reduce: inflammaton and swelling in airways,
thereby improving air movement in lungs. an indication of
effectiveness is an improvement in peak flow meter rates on
pulmonary function testing. if the pts peak flow meter rates
have remained unchanged after 3 months of steroid use, the
current medication does is ineffective and needs to be
adjusted.
14. WIC program: a special supplemental food program for
women, infants, and children, sponsored by the USDA;
directed at low income pregnant and/or breastfeeding women,
infants, and children under age 5.
-include supplementation of nutritious foods and education. (dental
caries in children)
-also screens for immunization status of the participating students
15. PD pts are at risk for excessive: protein loss, which
manifests as weight loss, decreasing muscle mass, and
peripheral edema.
-albumin levels should be monitored regularly to ensure that pt's
protein levels remain within normal range.
-PD - RISK FOR HYPERGLYCEMIA due to the dialysate contains
dextrose.
16. Enalapril Maleate (Vasotec): has a common side effect of
male impotence
17. Enalapril MALEate (Vasotec): has a common side effect of
male impotence 18. paint thinner (Toluene): can cause
hearing loss!!! testing done to detect any changes in hearing
19. pt receiving tx in a mental health facility becomes
agitated and begins to act inappropriately in the pt lounge.
which action should nurse take?: excessive noise or sound can
be viewed as a threat by pts with psychiatric conditions. when the
nurse observes that one of the pt's is becoming agitated, the best
first action is to turn off the stereo to reduce environmental stimuli.
if the pt's agitation does not recede, the nurse should then escort
the pt to a quiet room to de-escalate behavior
20. Dawn phenomenon: is the end result of a combination of
natural body changes that occur during the sleep cycle. between
hours 3a-8a, the body increases the amounts of counter-regulatory
hormones that stop the action of insulin to lower blood glucose
levels. the increased release of these hormones, at a time when
bedtime insulin is wearing out, results in increase in blood sugars.
this causes blood glucose to rise in the morning. the bedtime dose
of insulin is prescribed to counter the effects of dawn phenomenon
21. activity intolerance: pt's hr has remained elevated 15 min
after physical activity is stopped. s/s: increase HR > 20 bpm from
resting hr in response to activity, continued elevation of HR >5 min
after stopping, cardiac rhythm changes, blood pressure changes >
15 mmHg during activity.
22. a pt w advanced dementia becomes agitated and verbally
aggressive while nurse is providing morning care: when a pt
refuses morning care and becomes agitated and verbally
aggressive, the best action for the nurse would be to avoid
confrontation, leave the room to let the pt calm down and retry at
another time.
23. ankylosing spondylitis (AS): the inflammatory response
that causes degenerative changes in the spinal vertebrae;
sacroiliac joints; connective tissues such as tendons and ligaments
in the hips, shoulders, knees, feet, and ribs; and tissues of the
lungs, eyes, and heart valves -see extensive kyphosis, not lordosis
-pain in AS is worse at night or with inactivity and is relieved by
exercise. pain that becomes worse when the day progresses is
seen in pts with osteoarthritis
24. 6 month old pt is diagnosed w intussusception. which
medical intervention would nurse prep for?: first intervention
would be enema or hydrostatic reduction -emergency bowel
resection surgery is only if pt is experiencing manifestations of
bowel perforation or peritonitis
25. nasal packing is used: after a submucosal resection for a
deviated nasal septum and is used to prevent postoperative
bleeding.
26. INITIAL SORTING FOR START TRIAGE: 1)walking
wounded (green) get them off site
2)immediate (red)
3)delayed (yellow)
4)unsalvageable (black)
27. check ABG for pt w pnuemonia: demonstrating change in
level of consciousness and responsiveness which could indicate
detrioration in oxygen. 28. lacto-vegetarian diet: no eggs!! no
meat, chicken, fish, eggs, adding brown rice with legumes together
create a complete protein!!!
can drink milk
29. pts in renal failure can continue to have an adequate
urine output but bc of damage, the kidney's may not be able
to eliminate metabolic wastes and electrolytes from the
body!!! (n/v/d weakness): pt is experiencing manifestations of
hyperkalemia. best action would be to remove K from IV fluids
30. contracture formation is a common complication of burn
injuries and can be prevented by proper positioning of the
affected limb, range of motion exercises and physical
therapy. to prevent flexion contractures of the hip and knee: ,
the nurse should instruct the pt to keep the hip and knee
extended. as a rule of tub, joints should be placed in their position
of function
31. abruptio placentae: abdominal pain and vaginal bleeding
30 weeks pregnant. 32. allergies and diazepam (Valium) for
generalized anxiety disorder: benzos such as diazepam are a
class of drugs that work on GABA receptors in the CNS.
stimulation of these receptors results in anxiolysis (reduced
anxiety) hyponosis (sleep induction), sedation, and muscle
relaxation. because overstimulation of the GABA reeptors can
cause severe CNS depression (decreased resp drive,
unconsciousness, coma, death), the pt should be instructed to
void concomitant use w other CNS depressants such as alc,
opioids, antihistamines. anti-allergy meds contain antihistamines
33. the nurse is preparing to admin med to a pt through a NG
tube connected to suction, what should nurse do first
when administering this med?: first disconnect the suction
from the NG tube.
34. measure what vitals when seeing elevated pain?: elevated
HR and BP -
35. akathisia: feeling of inner restlessness and or inability to sit
still. this condition is a common side effect of antipsychotic
drugs that occur within days of starting the med.
-breathing and relaxation techniques should be implemented for
symptomatic relief. 36. extravasation of dopamine can cause:
tissue sloughing and gangrene. the nurse would stop the infusion
and begin extravasation treatment.
37. pt just received an orthopedic surgical procedure and the
surgeon has prescribed traction to be applied in the postanesthesia
care
unit.
what
will
nurse
do
when
applying
the
traction?:
the
nurse
would
contact
the area where
the pt
will
be transferred
after stabilization
to have
the bed
sent
down
to the post
anesthesia
care
area so that
traction
can
be
applied.
38. normal respiratory rate for 2 year old toddler: 24-40
breaths per min.
39. pt unable to drive home due to general anesthetic uses
instead of local: ask the pt for the name of someone to
contact to drive the pt home. do not delay discharge as this
can last several hours and we will not know pre-determined
time 40. bulge in the inguinal area of an infant could
indicate: cryptorchidism or undescended testes. Notify HCP
of finding
41. 5 year old erikson's stage of development: initiative vs guilt
42. vaginal wall laceration expected assessment: bleeding that
spurts from the vagina
43. CAGE questionnaire: Have you ever felt you should Cut down
on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt bad or Guilty about your drinking?
Have you ever had a drink first thing in the morning to steady your
nerves (Eye-opener)? a score of 2 or more is considered clinically
significant and requires further investigation for alcoholism.
44. hemoglobin A1c blood test measures: the average blood
glucose level over the last 3-4 months.
45. Amiodarone (Cordarone): prescribed for the conversion of a-
fib to a normal sinus rhythm. this medication should be withheld
for a pulse less than 60 bpm.
46. cluster headache: excruciating stabbing or burning sensations
located in the eye or cheek
47. migraine headache: paroxysmal (sudden, periodic) attacks of
mostly unilateral headache, often accompanied by disordered
vision, nausea, or vomiting, lasting hours or days and caused
by dilation of arteries
48. extensive burn injury to both legs: intra-compartmental
pressure of 35mmHg indicates that the pt is developing
compartment syndrome in the affected limbs. compartment
syndrome can occur immediately after extensive burn injury
and the subsequent development of tissue edema, or later
when circumferential burns heal too tightly around a limb.
MEDICAL EMERGENCY
49. high-pitched bowel sounds over the right upper abdominal
quad: obstruction of the ascending colon
small bowel obstruction- heard lower in abdomen
descending/sigmoid colon obstruction- heard left upper or lower
abdominal quadrants
50. in acute pancreatitis - lipase and amylase: serum lipase
level will increase to over 280 U/L and remain elevated for 7-14
days. the level of 100U/L indicates pts health is improving.
amylase norm - 60-160
51. Lichenification: Prolonged, intense scratching eventually
thickens the skin and produces tightly packed sets of papules;
looks like surface of moss (or lichen) seen with eczema or other
itchy skin disorders. to limit skin damage r/t scratching and
decrease the risk of bacterial superinfection, the nurse should
provide the child w pair of hand mittens. keep nails short.
-avoid hot baths as they dehydrate the skin and worsen symptoms.
-distraction is needed but exercising can cause sweating which
irritates the skin and worsens the eczema more.
-soap dries out the skin and should be avoided if possible
-keep skin moisturized
52. anabolic steroid use: elevated BP, acne, aggression
53. CVA experiencing right-sided hemiparesis. self care
activities?: PUTTING ON CLOTHES: weak side first before
dressing the strong side of body. this is to facilitate the
decreased range of motion and ability to wriggle and pull the
weak side. UNDRESSING: undress strong side first which
allows the pt to slide off the clothing
from the weak side without much extra movement
needed prevents over extension of the limbs and
joints on weak side
54. c. diff: contact precautions! gown and gloves. entire room
should be considered contaminated and contact w any object
in the room can result in transmission.
55. pulse deficit: the difference between the rate of an apical pulse
and the rate of a radial pulse
radial - apical`
56. school-age child normal red reflex?: presence of a redorange
glow when the light of the ophthalmoscope is shined
into the eyes is a normal red reflex
57. open angle glaucoma: the most common form of glaucoma,
where the trabecular meshwork gradually becomes blocked,
causing a buildup of pressure
58. Antidote for lead poisoning: Edetate calcium disodium,
succimer, or dimercaprol EDTA
-lead level b/w 25-69 tx w calcium disodium ethlenediamine
tetraacetate for 5-7 days followed by a rest and repeated
-EDTA and dimercaprol (BAL) is indicated for lead level >70
-penicillamine is used only when tx w other drugs is not effective
due to multisystem
SE
59. when should you take parenteral nutrition: non-healing
wound; renal failure; electrolyte imbalances; fluid restriction;
serum albumin level indicating malnutrition; and serum
prealbumin level indicating malnutrition and possible protein
malnutrition.
60. starting a marathon with glucose levels that are too: low is
dangerous. monitor BG level immediately after the event
-eat snacks rich in carbs during the race
-discuss decreasing routine insulin dose before the event with the
provider.
^ this can can high BG but it's fine bc glucose goes down while
running so its good to start off with high BG
61. NPH insulin: intermediate acting insulin and peaks 4-12 hrs
after providing!!!
62. immunocompromised pts use which solution:
chlorhexidine to start peripheral IV
63. capital budget: typically lists physical renovations, new
constructions and/or new replacement equipment for the care
area.
64. operating budget: budget for day-to-day expenses statement
of an organization's expected revenues and expenses for the
oncoming year
65. revenue budget: represents the pt's care income expected for
the budget period.
66. non-salary budget: pt care related to supplies and office
supplies, rental fees, maintenance costs and equipment
service contracts
67. flail chest: paradoxical chest wall movements (chest moves in
during inspiration and out during expiration) occur when part of
the chest wall becomes disconnected and separated from the
rest of the rib cage due to adjacent rib fractures.
-underlying pulmonary contusion which increases the risk for
intubation and ARDS 68. hypercyanotic spell with TOF: pt
should be placed in the knee-chest position to reduce the onset of
cerebral ischemia.
oxy after knee-chest position
69. pts with myelodysplastic syndrome -: group of cancers in
which immature blood cells in the bone marrow do not mature and
therefore do not become healthy blood cells.
may require frequent red blood cell transfusions to treat anemia.
since each unit of blood contains 250-300 mg of iron, the body is
not able to excrete the excess iron and it will accumulate. iron
chelation therapy is used to remove the excess iron from the
body.
70. septic shock manifestations: hypotension, tachycardia,
lethargy, rapid shallow respirations
71. indwelling catheter: -used if a catheter is to remin in place
for continuous drainage
-also called retention of Foley catheters
-designed so that it doesn't slip out of the bladder
-a balloon is inflated to ensure that the catheter remains in the
bladder
-used for the gradual decompression of an over distended bladder,
for intermittent bladder drainage &irrigation,
STRICT I&O
72. oral thrush or white plaques on the tongue and buccal
mucosa is an early indication of?: progression to AIDS.
73. PAWP: 8-12 mmhg normal.
15 indicates fluid volume overload and would need IV fluids to be
decreased.
74. when preparing an emergency spill response plan for a
chemical plant: the items needed for the safety of employees
includeL goggles, face shields, heavy neoprene gloves, corrosive
aprons, vinyl booties, MSDS sheets.