HESI CASE STUDY SUICIDE, A SENTINEL EVENT EXAM QUESTIONS AND ANSWERS|GUARANTEED SUCCESS

As the nurse documents Mr. Fearon's assessment, the nurse is correct to question which activity of a client with Type II Diabetes Mellitus? A. Client's frequency for checking blood glucose. B Quantity of Ensure taken per day. C. Reason for lack of appetite. D. Amount of water and other fluids taken daily. E. Last blood glucose result obtained by client. A. Client's frequency for checking blood glucose. -Too much glucose in the system can cause long-term complications such as heart disease. B Quantity of Ensure taken per day. -Helps the nurse discern if proper caloric intake is taking place C. Reason for lack of appetite. -If a person taking insulin fails to consume adequate carbohydrates, a drop in glucose levels is possible, causing hypoglycemia D. Amount of water and other fluids taken daily. -Clients with DM require more fluid intake to avoid dehydration Mr. Fearon mentions that he feels "blue" lately because his wife died one year ago, and his children live out of state and seldom visit. The nurse knows that the greatest risk for major depression includes which event? A. Being retired from the military. B. The realization of growing older. C. Inability to attend church regularly. D. Becoming widowed within the past year. D. Becoming widowed within the past year. -The combinations of sadness, loneliness from losing a loved one in widowhood, and hopelessness leads to social withdrawal. Those feelings place an older adult at greater risk of suffering from major depression because elderly are reluctant to adapt to changes. Brainpower 0:04 / 0:15 The HCP prescribes 1000 mL Dextrose 5% with Normal Saline 0.9% and 20 mEq/L Potassium Chloride (KCl) to infuse at 100 mL/hr. The nurse is correct to question which additive to this infusion prescription? A. Normal Saline (NS) and Potassium Chloride (KCl) B. Normal Saline (NS) C. Dextrose (D5) D. Potassium Chloride (KCl) C. Dextrose (D5) -Solutions that contain dextrose are not recommended for clients with DM because they can result in the rise of insulin, which will cause a decreased level of potassium in the blood. The HCP prescribes 1000 mL Normal Saline 0.45% with 20 mEq/L KCl to infuse at 125 mL/hr. The nurse calculates that it will take how many hours for the infusion to complete? 8 hours -Total volume infused/mL per hour = infusion time. 1000 mL/125 mL/hr = 8 hrs Mr. Fearon is febrile with temperature of 101.5F. Based on this information, which intervention should the nurse implement first? A. Contact the lab and request blood cultures be drawn. B. Administer acetaminophen (Tylenol) per hospital protocol. C. Contact the HCP for a prescription for an antibiotic. D. Retake temperature with a tympanic thermometer. A. Contact the lab and request blood cultures be drawn. -Blood culture specimens are always drawn before giving acetaminophen or starting antibiotic therapy because the antibiotic usually interferes with the organism's growth in the laboratory. The HCP prescribes clindamycin 900 mg in 100 mL over 30 minutes. The IV tubing drop factor is 15 gtt/mL. The nurse should regulate the IV to deliver how many drops per minute? 50 drops per minute -(volume/minutes)*the drop factor (100 mL/hr / 30 minutes)* 15 gtt/mL = 49.9 = 50 gtts/min The nurse knows that before drawing arterial blood gases, which interventions are the most important to be performed? (Select all that apply.) A. Perform Allen's Test B. Use sterile technique. C. Utilize clean technique. D. Check two client identifiers. E. Draw blood gas after applying oxygen. A. Perform Allen's Test -The Allen's test is performed prior to drawing an arterial blood test. It involves the nurse compressing both radial and ulnar arteries at the same time. B. Use sterile technique. -Sterile technique must be maintained during venipuncture D. Check two client identifiers. -The two client identifiers is part of the Joint Commission's National Patient Safety Goals and is required prior to performing any procedure. When monitoring Mr. Fearon's respiratory status, which symptom provides the nurse with the earliest indication of respiratory difficulty? A. Hypoxia B. Dusky nail beds and lips. C. Decreased pulse rate. D. Cyanosis. A. Hypoxia -Hypoxia is an early sign of respiratory distress. The nurse assesses respiratory depth, rate, and effort and listens for abnormal breath sounds that suggest breathing difficulty. The nurse prepares to contact the HCP with lab results, knowing that all lab information must be collected prior to reporting. Which lab results does the nurse need to report first to the HCP? A. ABGs, O2 saturation, WBC B. Potassium, Chloride, Creatinine C. Glucose, HCO3, BUN D. Platelets, Sodium, Hgb/Hct A. ABGs, O2 saturation, WBC -The labs for Mr. Fearon are abnormal and will assist the HCP in determining the effectiveness of the oxygen therapy. The nurse should interpret which finding as expected limits for the client with COPD? A. 87% O2 sat B. 96% O2 sat C. 100% O2 sat D. 75% O2 sat A. 87% O2 sat -A client with COPD who retains CO2 has adapted to high blood CO2 levels, and relies on low PaO2 to stimulate breathing. The HCP orders additional diagnostic tests. Which test would the nurse anticipate the HCP will order for Mr. Fearon? A. Magnetic Resonance Image (MRI) B. Positron Emission Tomography (PET) C. Computerized Tomography (CT) D. Diagnostic Imaging X-ray (DIX) C. Computerized Tomography (CT) -CT is the diagnostic imaging of choice during emergent situations because it produces accurate images of solid organs and bones that can reveal soft tissue masses. What are the nurse's responsibilities when preparing Mr. Fearon for the CT scan? (Select all that apply.) A. Verify the client's identity with two types of identifiers. B. Determine if the client has any known allergy to iodine or shellfish. C. Ask the client when his last dose of metformin was taken. D. Explain the post-procedure and the recovery time E. Instruct the client to remain NPO 4 to 8 hours before the procedure A. Verify the client's identity with two types of identifiers. -The client is identified with two types of identifiers before any procedure is performed. B. Determine if the client has any known allergy to iodine or shellfish. -It is the nurses responsibility to always assess the client for allergies to the iodine dye before it is administered. C. Ask the client when his last dose of metformin was taken. -If the client usually takes metformin, the drug is stopped at least 24 hours before contrast dye is used and is not restarted until adequate kidney function has been established. A client care tech arrives to transport Mr. Fearon to the CT scan. The nurse knows that communication breakdown can occur during transfer. Which statements about effective hand-off communication are true? (Select all the apply.) A. Background noise and interruption seldom affect the exchange of information because nurses can multitask. B. There is no need to give a verbal report if the SBAR tool is used. C. Communication and tradition differences between people of different backgrounds can be a barrier to hand-off. D. An SBAR tool form must be completed prior to the client's transfer. E. An SBAR tool is used only between the nurse and the HCP to obtain orders for client care. C. Communication and tradition differences between people of different backgrounds can be a barrier to hand-off. -To improve communication between staff members and healthcare agencies, procedures for hand-off communication were established. D. An SBAR tool form must be completed prior to the client's transfer. -SBAR is a formal method of communication between two or more members of the healthcare team.