NU371 HESI Case Study: Suicide, A Sentinel Event Test Questions and
Answers Rated A
Meet the Client - -The client has a 45-year c) Inability to attend church regularly.
history of smoking one pack a day of cigarettes. d) Becoming widowed within the past year. -
He admits he has had a productive cough, -d) Becoming widowed within the past
hoarseness, and a hard time breathing. He year.
attributes these symptoms to his age. He -
describes waking up three to four times at night The combinations of sadness, loneliness from
with coughing and difficulty breathing. He states losing a loved one in widowhood, and
that he has lost weight, but thinks it is because hopelessness leads to social withdrawal. Those
he isn't really hungry anymore. He talks about feelings place an older adult at greater risk of
being unusually tired lately and mentions that suffering from major depression because older
sometimes doesn't have enough energy to get adults are reluctant to adapt to changes.
from the bedroom to the kitchen. The client also
says he drinks nutrition shakes for meals
because they are easy to prepare and they taste Physical Assessment - -The client is alert
good. The client's medical history includes and oriented to time and place. He is a pale, thin
insulin-dependent type II diabetes mellitus. He male, with shallow respirations. He exhibits some
says that what bothers him the most is that he nasal flaring, mild intercostal retractions, and a
has difficulty concentrating. He compares it to productive cough. He leans forward as he sits in
"suffering from some sort of brain fog." a tripod position. Upon auscultation, the nurse
notices wheezing to the right side and diminished
breath sounds to the left side, and his heart rate
As the nurse documents the client's assessment, is slightly elevated. Visual inspection of the client
the nurse is correct to question which activity of a reveals a barrel chest, mild clubbing of the
client with type II diabetes mellitus? (Select all fingers, and cyanosis to the nail beds. His skin is
that apply. One, some, or all options may be very warm and dry to the touch, and an
correct.) examination reveals decreased skin turgor, and a
a) Client's frequency for checking blood glucose. stage II decubitus ulcer in the sacral area that
b) Quantity of Ensure taken per day. scored a 14 on the Braden scale. The client has
c) Reason for lack of appetite. mild swelling of the feet and he reports limited
d) Amount of water and other fluids taken daily. mobility related to feeling weak. He denies
e) Last blood glucose result obtained by client. - allergies to medication or food and denies any
-a) Client's frequency for checking blood pain. He does not have advance directives.
glucose.
b) Quantity of Ensure taken per day.
c) Reason for lack of appetite. VITAL SIGNS - -T 101.5° F (38.6° C), HR
d) Amount of water and other fluids taken daily. 110 beats/min, R 20 breaths/min, BP 150/90
mmHg, blood glucose 200, O2 saturation 88% on
room air
The client mentions that he feels "blue" lately
because his wife died one year ago, and his
children live out of state and seldom visit. The MEDICATIONS - -albuterol and ipratropium
nurse knows that the greatest risk for major bromide, meter dose inhalers
depression includes which event? diltiazem
a) Being retired from the military. furosemide
b) The realization of growing older. aspirin 81 mg
1/9
, NU371 HESI Case Study: Suicide, A Sentinel Event Test Questions and
Answers Rated A
metformin complete? (Enter numeric value only. If rounding
regular insulin (sliding scale) is required, round to the whole number.) - -
enoxaparin sodium 1 hr/125 mL X 1,000 = 1,000/125 = 8 hours
PRESCRIPTIONS - -The nurse follows the The client is febrile with temperature of 101.5°F
healthcare provider's (HCP) prescriptions for (38.6°C). Based on this information, which
treatment of exacerbation of chronic obstructive intervention should the nurse implement first?
pulmonary disease (COPD) a) Contact the lab and request blood cultures be
Obtain ABG, CBC with diff, chemistry 7, blood drawn.
cultures (BC), urinanalysis (UA) b) Administer acetaminophen per hospital
PA and lateral chest x-ray protocol.
Consult PT/OT for wound care c) Contact the HCP for a prescription for an
Start sequential compression device (SCD) antibiotic.
Establish intravenous access (saline lock) d) Retake temperature with a tympanic
thermometer. - -a) Contact the lab and
request blood cultures be drawn.
The HCP prescribes 1000 mL dextrose 5% with -
normal saline 0.9% and 20 mEq/L potassium Blood culture specimens are always drawn
chloride (KCl) to infuse at 100 mL/hr. The nurse before giving acetaminophen or starting antibiotic
is correct to question which additive to this therapy because the antibiotic usually interferes
infusion prescription? with the organism's growth in the laboratory.
a) Normal saline (NS) and Potassium chloride
(KCl).
b) Normal saline (NS). The HCP prescribes clindamycin 900 mg in 100
c) Dextrose (D5). mL over 30 minutes. The IV tubing drop factor is
d) Potassium chloride (KCl). - -c) Dextrose 15 gtt/mL. The nurse should regulate the IV to
(D5). deliver how many drops per minute? (Enter
- numeric value only. If rounding is required, round
Solutions that contain dextrose are not to the nearest whole number.) - -100 mL/30
recommended for client with diabetes because min= 3.33 mL/min
they can result in the rise of insulin, which will 3.33 ml/min x 15 gtt/mL= 50 gtt/min
cause a decreased level of potassium in the
blood. Dextrose may be prescribed for a client
with diabetes to prevent low blood sugar during The nurse knows that before drawing arterial
surgery. As a result of the many treatment and blood gases, which interventions are the most
approaches to diabetes, it is important for the important to be performed? (Select all that apply.
nurse to clarify the drug and intravenous fluid One, some, or all options may be correct.)
prescriptions with the HCP. a) Perform Allen's Test.
b) Use sterile technique.
c) Utilize clean technique.
The HCP prescribes 1000 mL normal saline d) Check two client identifiers.
0.45% with 20 mEq/L potassium chloride (KCl) to e) Draw blood gas after applying oxygen. -
infuse at 125 mL/hr. The nurse calculates that it -a) Perform Allen's Test.
will take how many hours for the infusion to be b) Use sterile technique.
2/9
Answers Rated A
Meet the Client - -The client has a 45-year c) Inability to attend church regularly.
history of smoking one pack a day of cigarettes. d) Becoming widowed within the past year. -
He admits he has had a productive cough, -d) Becoming widowed within the past
hoarseness, and a hard time breathing. He year.
attributes these symptoms to his age. He -
describes waking up three to four times at night The combinations of sadness, loneliness from
with coughing and difficulty breathing. He states losing a loved one in widowhood, and
that he has lost weight, but thinks it is because hopelessness leads to social withdrawal. Those
he isn't really hungry anymore. He talks about feelings place an older adult at greater risk of
being unusually tired lately and mentions that suffering from major depression because older
sometimes doesn't have enough energy to get adults are reluctant to adapt to changes.
from the bedroom to the kitchen. The client also
says he drinks nutrition shakes for meals
because they are easy to prepare and they taste Physical Assessment - -The client is alert
good. The client's medical history includes and oriented to time and place. He is a pale, thin
insulin-dependent type II diabetes mellitus. He male, with shallow respirations. He exhibits some
says that what bothers him the most is that he nasal flaring, mild intercostal retractions, and a
has difficulty concentrating. He compares it to productive cough. He leans forward as he sits in
"suffering from some sort of brain fog." a tripod position. Upon auscultation, the nurse
notices wheezing to the right side and diminished
breath sounds to the left side, and his heart rate
As the nurse documents the client's assessment, is slightly elevated. Visual inspection of the client
the nurse is correct to question which activity of a reveals a barrel chest, mild clubbing of the
client with type II diabetes mellitus? (Select all fingers, and cyanosis to the nail beds. His skin is
that apply. One, some, or all options may be very warm and dry to the touch, and an
correct.) examination reveals decreased skin turgor, and a
a) Client's frequency for checking blood glucose. stage II decubitus ulcer in the sacral area that
b) Quantity of Ensure taken per day. scored a 14 on the Braden scale. The client has
c) Reason for lack of appetite. mild swelling of the feet and he reports limited
d) Amount of water and other fluids taken daily. mobility related to feeling weak. He denies
e) Last blood glucose result obtained by client. - allergies to medication or food and denies any
-a) Client's frequency for checking blood pain. He does not have advance directives.
glucose.
b) Quantity of Ensure taken per day.
c) Reason for lack of appetite. VITAL SIGNS - -T 101.5° F (38.6° C), HR
d) Amount of water and other fluids taken daily. 110 beats/min, R 20 breaths/min, BP 150/90
mmHg, blood glucose 200, O2 saturation 88% on
room air
The client mentions that he feels "blue" lately
because his wife died one year ago, and his
children live out of state and seldom visit. The MEDICATIONS - -albuterol and ipratropium
nurse knows that the greatest risk for major bromide, meter dose inhalers
depression includes which event? diltiazem
a) Being retired from the military. furosemide
b) The realization of growing older. aspirin 81 mg
1/9
, NU371 HESI Case Study: Suicide, A Sentinel Event Test Questions and
Answers Rated A
metformin complete? (Enter numeric value only. If rounding
regular insulin (sliding scale) is required, round to the whole number.) - -
enoxaparin sodium 1 hr/125 mL X 1,000 = 1,000/125 = 8 hours
PRESCRIPTIONS - -The nurse follows the The client is febrile with temperature of 101.5°F
healthcare provider's (HCP) prescriptions for (38.6°C). Based on this information, which
treatment of exacerbation of chronic obstructive intervention should the nurse implement first?
pulmonary disease (COPD) a) Contact the lab and request blood cultures be
Obtain ABG, CBC with diff, chemistry 7, blood drawn.
cultures (BC), urinanalysis (UA) b) Administer acetaminophen per hospital
PA and lateral chest x-ray protocol.
Consult PT/OT for wound care c) Contact the HCP for a prescription for an
Start sequential compression device (SCD) antibiotic.
Establish intravenous access (saline lock) d) Retake temperature with a tympanic
thermometer. - -a) Contact the lab and
request blood cultures be drawn.
The HCP prescribes 1000 mL dextrose 5% with -
normal saline 0.9% and 20 mEq/L potassium Blood culture specimens are always drawn
chloride (KCl) to infuse at 100 mL/hr. The nurse before giving acetaminophen or starting antibiotic
is correct to question which additive to this therapy because the antibiotic usually interferes
infusion prescription? with the organism's growth in the laboratory.
a) Normal saline (NS) and Potassium chloride
(KCl).
b) Normal saline (NS). The HCP prescribes clindamycin 900 mg in 100
c) Dextrose (D5). mL over 30 minutes. The IV tubing drop factor is
d) Potassium chloride (KCl). - -c) Dextrose 15 gtt/mL. The nurse should regulate the IV to
(D5). deliver how many drops per minute? (Enter
- numeric value only. If rounding is required, round
Solutions that contain dextrose are not to the nearest whole number.) - -100 mL/30
recommended for client with diabetes because min= 3.33 mL/min
they can result in the rise of insulin, which will 3.33 ml/min x 15 gtt/mL= 50 gtt/min
cause a decreased level of potassium in the
blood. Dextrose may be prescribed for a client
with diabetes to prevent low blood sugar during The nurse knows that before drawing arterial
surgery. As a result of the many treatment and blood gases, which interventions are the most
approaches to diabetes, it is important for the important to be performed? (Select all that apply.
nurse to clarify the drug and intravenous fluid One, some, or all options may be correct.)
prescriptions with the HCP. a) Perform Allen's Test.
b) Use sterile technique.
c) Utilize clean technique.
The HCP prescribes 1000 mL normal saline d) Check two client identifiers.
0.45% with 20 mEq/L potassium chloride (KCl) to e) Draw blood gas after applying oxygen. -
infuse at 125 mL/hr. The nurse calculates that it -a) Perform Allen's Test.
will take how many hours for the infusion to be b) Use sterile technique.
2/9
