Question

An older adult client recently diagnosed with chronic obstructive pulmonary disease (COPD) is admitted with shortness of breath. The nurse observes the client sitting upright and leaning over the bedside table, using accessory muscles to assist in breathing. Which action should the nurse take?

Answer 1

Correct Answers:

Instruct the client in pursed lip breathing techniques.

Rationale :

🔷 The client is assuming the tripod position, which is a common spontaneous posture used by clients with COPD to improve chest expansion and reduce the work of breathing.

🔷 Pursed lip breathing helps keep the airways open longer during exhalation, which reduces air trapping and improves the exchange of oxygen and carbon dioxide.

🔷 This technique is especially effective for clients with COPD because it promotes more complete exhalation and decreases dyspnea.

🔷 Teaching the client this breathing method is an immediate, noninvasive intervention that supports the client’s current effort to breathe more effectively.

🔷 Because the client is already demonstrating increased respiratory effort with accessory muscle use, instructing in pursed lip breathing is the most appropriate nursing action to improve ventilation.

Prepare to transfer the client to a critical care unit.

🔷 The information given does not indicate that the client requires immediate transfer to a critical care unit.

🔷 The nurse should first provide supportive respiratory interventions and further assess the client’s response before assuming a need for higher-level care.

Observe the client for the presence of a barrel chest.

🔷 A barrel chest is a common chronic assessment finding in clients with COPD, but identifying it does not address the client’s immediate breathing difficulty.

🔷 The priority is to support airflow and ease of breathing, not simply gather additional expected physical findings.

Assist the client to a high Fowler's position in bed.

🔷 The client is already sitting upright and leaning forward in a position that helps maximize breathing effort.

🔷 Moving the client back into bed may actually interfere with the client’s self-selected position of comfort and respiratory effectiveness.

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Answer 2

Correct Highlights :

unable to remember being transported and wants to go home.
weak left-hand grasp and unable to bear weight on left leg
unable to feel palpation of the left upper arm and upper and lower left leg
She informs had a mild headache around the eyes was present upon waking up

Rationale :

Unable to remember being transported and wants to go home

🔶This finding requires follow-up because sudden confusion, impaired awareness, and poor judgment are important neurologic warning signs of acute stroke.

🔶The client’s inability to recall recent events suggests an acute change in mental status, not simple forgetfulness.

🔶Wanting to go home despite clear left-sided deficits also reflects decreased insight and unsafe decision-making, which can occur with anterior circulation stroke syndromes.

🔶With stroke, new confusion and impaired orientation require immediate nursing attention because they may indicate ongoing cerebral injury.

🔶This is not a minor symptom; it is a priority neurologic finding that supports the seriousness of the client’s acute event.

Weak left-hand grasp and unable to bear weight on left leg

🔶 Sudden unilateral weakness is one of the most important hallmark findings of stroke and always requires prompt follow-up.

🔶 This client has both left arm weakness and significant left leg motor impairment, which fit an acute right-sided brain lesion.

🔶 The CT perfusion study showing an area of opacity in the right anterior cerebral artery supports contralateral motor deficits, especially involving the leg.

🔶 In anterior cerebral artery stroke syndromes, contralateral leg weakness is especially characteristic and may be accompanied by some arm involvement.

🔶 Because weakness affects mobility and safety immediately, this finding requires urgent nursing follow-up and ongoing stroke-focused assessment.

Unable to feel palpation of the left upper arm and upper and lower left leg

🔶Sudden numbness or sensory loss on one side of the body is another classic warning sign of stroke and requires immediate follow-up.

🔶The client’s inability to feel palpation over the left arm and leg shows a significant left-sided sensory deficit.

🔶This sensory loss is consistent with a right hemisphere/anterior circulation neurologic event because stroke deficits usually occur on the side opposite the brain lesion.

🔶Sensory changes, combined with weakness, increase the risk for falls, injury, and worsening functional impairment.

🔶This is a high-priority abnormal finding because it helps confirm the presence and extent of the client’s acute neurologic deficit.

Reports a mild headache around the eyes was present upon waking up

🔶A sudden headache with no known cause is recognized as a stroke warning sign and should be followed up, even if it has improved or resolved.

🔶In a client with new neurologic deficits, a recent headache can be clinically important because it may have been part of the acute cerebrovascular event.

🔶The headache does not need to be severe at the moment of assessment to matter; the history still contributes to the overall stroke picture.

🔶Because the client also has confusion, weakness, and sensory loss, the earlier headache should not be dismissed as insignificant.

🔶This finding requires follow-up as part of the complete neurologic assessment and stroke evaluation.

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Answer 3

Correct Answers

Headache [ ruptured cerebral aneurysm ]
Left-sided weakness, paralysis [ ischemic stroke ]
Elevated blood pressure [ ruptured cerebral aneurysm ]
Treatment for atherosclerosis [ ischemic stroke ]
Confusion [ ischemic stroke ]
CT scan results (area of opacity) [ ischemic stroke ]

Rationale :

Left-sided weakness, paralysis → associated with an ischemic stroke

🔹 Sudden unilateral weakness or paralysis is one of the classic hallmark findings of an ischemic stroke because interruption of cerebral blood flow causes loss of neurologic function on the opposite side of the body.

🔹 In this case, the client’s left arm and left leg weakness match a right-sided brain event, which is supported by the imaging result involving the right anterior cerebral artery.

🔹 An anterior cerebral artery stroke commonly causes contralateral motor deficits, especially involving the lower extremity.

🔹 This pattern fits the client’s inability to bear weight on the left leg and weak left-hand grasp.

🔹 These findings strongly support ischemic stroke, not a nonspecific complaint.

Treatment for atherosclerosis → associated with an ischemic stroke

🔶 Atherosclerosis is a major risk factor and common underlying cause of ischemic stroke because plaque buildup can narrow or block cerebral blood vessels.

🔶 The client is taking rosuvastatin, which reflects treatment for dyslipidemia and vascular disease risk reduction.

🔶 This history supports an ischemic mechanism, since arterial plaque disease commonly contributes to thrombotic or embolic stroke.

🔶 In contrast, a ruptured cerebral aneurysm is more strongly linked to weakened vessel walls and hemorrhage than to atherosclerotic plaque occlusion.

🔶 This makes treatment for atherosclerosis more closely associated with ischemic stroke.

Confusion → associated with an ischemic stroke

💎 Confusion, disorientation, and altered awareness can occur with ischemic stroke because reduced brain perfusion affects cognition and neurologic processing.

💎 This client is unable to communicate the date, is not aware of surroundings, and cannot recall being transported, all of which reflect an acute change in neurologic status.

💎 Such changes are consistent with stroke-related brain dysfunction and require urgent follow-up.

💎 Although confusion can appear in other neurologic emergencies, in this case it aligns with the confirmed vascular lesion on brain imaging.

💎 The overall presentation supports ischemic stroke as the source of the confusion.

CT scan results (area of opacity) → associated with an ischemic stroke

✅ A brain imaging finding showing an area of opacity in the right anterior cerebral artery territory supports an ischemic stroke, because infarcted brain tissue appears abnormal in the affected vascular distribution.

✅ The key feature here is that the abnormality is localized to a specific arterial territory, which is consistent with cerebral ischemia.

✅ This imaging result matches the client’s left-sided neurologic deficits and helps confirm the diagnosis.

✅ The client’s symptoms began about an hour before emergency care, which also fits the urgent evaluation pathway for suspected ischemic stroke.

✅ In this scenario, the CT perfusion finding is most consistent with ischemic stroke, not aneurysmal rupture.

Headache → associated with a ruptured cerebral aneurysm

🟣 A sudden headache is a classic warning sign of ruptured cerebral aneurysm and other hemorrhagic stroke presentations.

🟣 Headache is especially important in aneurysmal rupture because bleeding into the subarachnoid space often causes abrupt head pain.

🟣 Even though this client’s headache was described as mild and had resolved, headache as a general finding is more strongly associated with aneurysmal rupture than with typical ischemic stroke pattern questions.

🟣 This is why headache is grouped under ruptured cerebral aneurysm in this comparison.

🟣 The finding is still clinically significant and should never be ignored in neurologic assessment.

Elevated blood pressure → associated with a ruptured cerebral aneurysm

🟡 Elevated blood pressure is commonly seen with hemorrhagic stroke and ruptured cerebral aneurysm because bleeding in the brain can trigger a significant physiologic stress response.

🟡 Very high blood pressure is often noted in intracranial bleeding presentations and may worsen the risk of continued hemorrhage.

🟡 Although hypertension is also a general stroke risk factor, in this type of matching question it is more closely linked to ruptured cerebral aneurysm/hemorrhagic presentation.

🟡 The client’s blood pressure of 168/96 mm Hg is abnormal and important to monitor closely.

🟡 For classification purposes here, elevated blood pressure best fits ruptured cerebral aneurysm.

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Answer 4

Correct Answers

Blank 1 Correct Option: Perfusion

Rationale :

🔷 The priority problem is perfusion because the client has findings of an acute ischemic stroke, including sudden left-sided weakness, left-sided sensory loss, confusion, and CT perfusion results showing an area of opacity in the right anterior cerebral artery.

🔷 These findings indicate impaired cerebral blood flow, which means brain tissue is not receiving adequate oxygen and nutrients.

🔷 In an acute stroke, restoring or preserving perfusion to the brain is the most urgent concern because prolonged ischemia can lead to irreversible neurologic damage.

🔷 The laboratory results are within normal limits, and the onset of symptoms was about 1 hour ago, which makes rapid attention to cerebral perfusion especially critical.

🔷 Although the client also has problems with cognition, mobility, and sensory perception, those are secondary to the more immediate life- and tissue-threatening issue of decreased cerebral perfusion.

Cognition

🔷 The client does have altered cognition, including confusion and poor awareness of the situation.

🔷 However, the cognitive changes are most likely a result of the impaired cerebral perfusion, so cognition is not the first priority.

Sensory perception

🔷 The client has impaired sensory perception as shown by inability to feel palpation on the left side.

🔷 This is important, but it is a consequence of the stroke and is not the most immediate threat compared with reduced blood flow to the brain.

Mobility

🔷 The client also has impaired mobility because of left-sided weakness and inability to bear weight.

🔷 Even though mobility affects safety, it is not the top priority over the need to address the underlying perfusion problem causing the neurologic deficits.

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Answer 5

Correct Answers:

Administer antihypertensive medication
Prepare for alteplase therapy
Monitor neurological status every hour

Rationale :

Prepare for alteplase therapy

🔷 The client’s findings are highly consistent with an acute ischemic stroke, including sudden left-sided weakness, sensory loss, confusion, and a CT perfusion result showing an area of opacity in the right anterior cerebral artery.

🔷 The spouse reports symptom onset was about 1 hour ago, which places the client within the treatment window for alteplase if no contraindications are present.

🔷 The coagulation studies are within expected limits, with PT 11.5 seconds, aPTT 33 seconds, and INR 0.9, which supports possible eligibility for thrombolytic therapy.

🔷 Rapid preparation for alteplase is appropriate because early restoration of cerebral perfusion can reduce the extent of neurologic damage.

🔷 Based on the symptoms, timing, imaging, and lab results, preparing for alteplase is an anticipated and priority intervention.

Monitor neurological status every hour

🔷This client has an evolving acute neurologic event, so frequent reassessment is essential to detect improvement, deterioration, or complications.

🔷Ongoing monitoring of level of consciousness, orientation, motor strength, sensation, and speech helps the nurse identify any change in cerebral status quickly.

🔷The client already shows persistent deficits at 1145, including unchanged left-hand weakness and unchanged left leg motor and sensory loss, making continued surveillance necessary.

🔷Hourly neurologic assessment is consistent with priority stroke care because early changes in status can indicate worsening ischemia or response to treatment.

🔷For this reason, monitoring neurological status every hour should be included in the plan of care.

Administer antihypertensive medication

🔷The client’s blood pressure remains elevated, rising from 168/96 mm Hg to 172/92 mm Hg, and blood pressure management is an important part of stroke care.

🔷In clients being considered for alteplase, the nurse should anticipate interventions to keep blood pressure within the safe treatment range ordered by the provider or stroke protocol.

🔷Even though hypertension can be protective in some ischemic stroke situations, uncontrolled elevation can increase the risk of complications, especially if thrombolytic therapy is planned.

🔷Because the client is being evaluated for urgent reperfusion treatment, antihypertensive therapy may be needed if the provider determines it is necessary to maintain treatment eligibility or safety.

🔷For that reason, administration of antihypertensive medication is a reasonable anticipated intervention in this plan of care.

Administer antibiotics

🔷 There is no evidence in the data of an acute bacterial infection requiring antibiotic therapy.

🔷 The client’s WBC is 6,000/mm³ and temperature is normal, so antibiotics are not the priority intervention here.

Apply oxygen via nasal cannula

🔷 The client’s oxygen saturation is 97% on room air, so routine oxygen administration is not indicated based on the current assessment.

🔷 Oxygen is usually reserved for clients with hypoxemia or respiratory compromise, which is not present here.

Ambulate in the hallway

🔷 This client has left-sided weakness and inability to bear weight on the left leg, making hallway ambulation unsafe.

🔷 The priority is stabilization and neurologic management, not activity progression.

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Answer 6

Correct Answers

Limit venipunctures when possible [ Appropriate ]
Monitor vital signs every 15 minutes [ Appropriate ]
Prepare for a CT scan after alteplase therapy [ Appropriate ]
Provide the total alteplase dose over 5 minutes [ Not Appropriate ]
Prepare for discharge in 24 hours [ Not Appropriate ]
Conduct neurological assessment at 2-hour intervals [ Not Appropriate ]

Rationale :

Limit venipunctures when possible — Appropriate

🔶Alteplase is a fibrinolytic therapy, which places the client at a significantly increased risk for bleeding.

🔶Because of this bleeding risk, the nurse should avoid unnecessary venipunctures, injections, and invasive procedures whenever possible.

🔶Repeated needle sticks can cause bleeding that is harder to control after thrombolytic administration.

🔶Limiting venipunctures is an important nursing safety intervention to reduce the risk of hemorrhage while the client is receiving and recovering from alteplase therapy.

🔶This action is appropriate because it directly supports safe care during post-fibrinolytic monitoring.

Monitor vital signs every 15 minutes — Appropriate

🔶 Clients receiving alteplase require very close monitoring because changes in blood pressure, heart rate, and neurologic status can signal serious complications such as intracranial bleeding.

🔶 Frequent vital sign assessment is especially important early in therapy, when the risk of adverse effects is highest.

🔶 Monitoring every 15 minutes is appropriate during the acute phase of fibrinolytic treatment and helps the nurse respond quickly to deterioration.

🔶 This client has already demonstrated elevated blood pressure readings, so close surveillance is especially important.

🔶 For these reasons, monitoring vital signs every 15 minutes is an appropriate intervention for a client receiving alteplase.

Prepare for a CT scan after alteplase therapy — Appropriate

🔶A follow-up CT scan of the head is appropriate after alteplase therapy to evaluate for complications such as hemorrhagic transformation or other changes in the brain.

🔶The provider’s day 2 orders specifically include “CT scan of the head today,” confirming that repeat imaging is part of the planned care.

🔶Neuroimaging after fibrinolytic therapy helps determine whether bleeding has occurred before antiplatelet therapy such as aspirin is started.

🔶This is especially important because aspirin is ordered to begin on day 3, after post-thrombolytic monitoring and imaging are completed.

🔶Preparing for a CT scan after alteplase therapy is therefore an appropriate and expected nursing action.

Provide the total alteplase dose over 5 minutes — Not Appropriate

🔶The order states to infuse alteplase 63.7 mg IV over 1 hour, not over 5 minutes.

🔶Giving the total dose over 5 minutes would be unsafe and inconsistent with the prescribed administration plan.

Prepare for discharge in 24 hours — Not Appropriate

🔶 The client is being admitted to the stroke unit 4 hours after initiation of alteplase therapy if no complications occur, which shows ongoing inpatient monitoring is planned.

🔶 A client receiving fibrinolytic therapy requires continued observation and is not automatically prepared for discharge in 24 hours.

Conduct neurological assessment at 2-hour intervals — Not Appropriate

🔶The order specifies NIH Stroke Scale every 2 hours x 24 hours, but during and immediately after alteplase therapy, neurologic assessment is typically monitored more closely than every 2 hours alone.

🔶Relying only on 2-hour intervals as the nursing action during fibrinolytic therapy is not appropriate because the client requires more frequent acute monitoring for complications.

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Answer 7

Correct Answers:

Bends left leg at the knee
Swallows sips of water
Oriented to person, place, and time
Moving fingers on the left hand
Blood pressure 132/88 mm Hg
NIH stroke scale rating 4

Rationale :

Bends left leg at the knee

🔷 This finding indicates improvement because the client initially had left leg weakness with limited knee flexion and was unable to bear weight on that leg.

🔷 Being able to bend the left knee shows return of motor function on the affected side after fibrinolytic therapy.

🔷 In an ischemic stroke, improvement in movement is an important sign that cerebral perfusion may be improving.

🔷 Recovery of leg movement also suggests that the neurologic deficit is becoming less severe.

🔷 This is a positive post-alteplase finding because it reflects better neuromuscular control than the client had on admission.

Swallows sips of water

🔷The client was placed NPO until swallow screen, which means safe swallowing was a major concern after the stroke.

🔷Being able to swallow sips of water indicates improved swallowing ability and reduced risk for aspiration.

🔷Stroke can impair the muscles needed for swallowing, so this ability is an important sign of neurologic recovery.

🔷A successful swallow response also supports progression toward oral intake and medication administration by mouth when appropriate.

🔷This finding shows improvement because it reflects safer and more effective cranial nerve and motor function.

Oriented to person, place, and time

🔷On admission, the client was unable to communicate the date, was not aware of surroundings, and later was only oriented to person and place.

🔷Becoming oriented to person, place, and time shows improvement in cognition and neurologic status.

🔷Increased orientation suggests better cerebral function and improved awareness of the environment.

🔷In a client recovering from stroke, improvement in mental status is a meaningful sign that treatment is effective.

🔷This is a positive finding because it shows the client’s confusion is resolving.

Moving fingers on the left hand

🔷The client initially had a weak left-hand grasp, which reflected impaired motor function from the stroke.

🔷Being able to move the fingers of the left hand indicates improvement in fine motor activity on the affected side.

🔷Even small returns in movement after fibrinolytic therapy are clinically important because they suggest reperfusion of previously ischemic tissue.

🔷Improvement in hand movement also supports better function for grasping and performing tasks.

🔷This finding reflects recovery of left upper extremity motor strength, so it indicates improvement.

Blood pressure 132/88 mm Hg

🔷The client’s blood pressure was previously elevated at 168/96 mm Hg, 164/92 mm Hg, and 172/92 mm Hg, then later decreased to 132/88 mm Hg.

🔷A blood pressure of 132/88 mm Hg reflects better hemodynamic control than the earlier readings.

🔷Improved blood pressure after stroke care can support safer recovery and reduce strain on cerebral vessels.

🔷Stable blood pressure is especially important after alteplase therapy because uncontrolled hypertension increases the risk for bleeding complications.

🔷This finding indicates improvement because it shows the client is becoming more physiologically stable.

NIH stroke scale rating 4

🔷The NIH Stroke Scale is used to measure the severity of stroke deficits, and a lower score indicates less neurologic impairment.

🔷A rating of 4 suggests a relatively mild residual deficit compared with a more severe stroke presentation.

🔷Since the client initially had multiple significant deficits, including weakness, sensory loss, and confusion, a low NIHSS score is a positive sign of recovery.

🔷This means the client is demonstrating improvement in overall neurologic functioning after fibrinolytic therapy.

🔷Therefore, an NIH stroke scale rating of 4 indicates an improved condition.

Reports having a frontal headache

🔷A new or worsening headache after fibrinolytic therapy is concerning because it can indicate intracranial bleeding.

🔷 This is not a sign of improvement and requires prompt follow-up.

Blood oozing from the intravenous site

🔷Oozing blood from an IV site suggests a bleeding complication, which is a known risk after alteplase administration.

🔷This finding indicates possible harm from therapy, not improvement.

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Answer 8

Correct Answers:

Wear braces on both wrists during the night.

Rationale :

🔷 Carpal tunnel syndrome is caused by compression of the median nerve within the carpal tunnel, and symptoms often worsen at night because the wrists may become flexed during sleep.

🔷 Wearing wrist braces or splints at night helps keep the wrists in a neutral position, which reduces pressure on the median nerve.

🔷 This intervention is a common conservative treatment that can decrease pain, tingling, and numbness, especially during rest.

🔷 Night splinting is often one of the first teaching points because it directly targets the cause of the client’s nocturnal symptoms.

🔷 For this reason, teaching the client to wear braces on both wrists during the night is the most appropriate instruction.

Notify the healthcare provider (HCP) as soon as possible.

🔷 Worsening symptoms at night are common in carpal tunnel syndrome and do not by themselves require immediate provider notification.

🔷 The nurse should first reinforce appropriate symptom-management measures such as night splinting.

Apply cold compresses for 30 minutes before bedtime.

🔷 Cold therapy may provide temporary comfort, but it does not address the main problem of wrist positioning during sleep.

🔷 Also, 30 minutes is longer than usually recommended for cold application and may irritate tissue.

Elevate the hands on two pillows at night.

🔷 Elevating the hands is not the primary intervention for reducing median nerve compression in carpal tunnel syndrome.

🔷 Keeping the wrists in neutral alignment with braces is more effective than pillow positioning.

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Answer 9

Correct Answers:

Monitor urinary stream for decrease in output.

Rationale :

🟢 After transurethral needle ablation (TUNA) for benign prostatic hyperplasia, the client should be taught to monitor for decreased urinary output or a weakening urinary stream, which may indicate obstruction or urinary retention.

🟢 The procedure reduces prostatic tissue, but swelling or postoperative complications can temporarily interfere with urine flow.

🟢 Early recognition of decreased output is important because urinary retention can lead to bladder distention, discomfort, and renal complications.

🟢 Monitoring urinary function is one of the most important discharge instructions after this type of urologic procedure.

🟢 For this reason, the nurse should instruct the client to monitor the urinary stream for decrease in output.

Use incentive spirometer.

🟢 An incentive spirometer is mainly used to prevent postoperative pulmonary complications after surgeries that affect respiratory status or involve prolonged immobility.

🟢 It is not a priority discharge instruction after a TUNA procedure.

Restrict physical activities.

🟢 Clients are usually advised to avoid strenuous activity temporarily, but the broad statement restrict physical activities is too vague and not the best key teaching point here.

🟢 Monitoring urinary function is more directly related to detecting complications of the procedure.

Report when hematuria becomes pink tinged.

🟢 Mild pink-tinged urine may be expected for a short time after the procedure.

🟢 The client should report bright red bleeding, clots, or worsening hematuria, not urine that is merely pink tinged.

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Answer 10

Correct Answers:

Weight gain of 2 lb (0.91 kg) in one day.

Rationale :

💎 SIADH causes excessive release of antidiuretic hormone (ADH), leading to water retention and dilution of serum sodium.

💎 Because the body retains fluid, the client often develops sudden weight gain, decreased urine output, and dilutional hyponatremia.

💎 A weight gain of 2 lb in one day is an important indicator of acute fluid retention and is consistent with SIADH.

💎 Closed head injury is a known cause of SIADH because neurologic trauma can disrupt the normal regulation of ADH secretion.

💎 Therefore, rapid daily weight gain is an expected finding in a client with SIADH.

Fremitus over the chest wall.

💎 Fremitus is a respiratory assessment finding and is not related to the fluid-balance changes seen in SIADH.

💎 SIADH primarily affects water retention and sodium balance, not tactile chest vibrations.

Serum sodium of 150 mEq/L (150 mmol/L).

💎 SIADH usually causes hyponatremia, not hypernatremia.

💎 A sodium level of 150 mEq/L would be more consistent with dehydration or diabetes insipidus rather than SIADH.

Urine specific gravity of 1.004.

💎 SIADH causes the kidneys to retain water and produce concentrated urine, so the urine specific gravity is usually elevated, not low.

💎 A urine specific gravity of 1.004 suggests very dilute urine, which is inconsistent with SIADH.

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assessment findings	ischemic stroke	ruptured cerebral aneurysm
Headache
Left-sided weakness, paralysis
Elevated blood pressure
Treatment for atherosclerosis
Confusion
CT scan results (area of opacity)

Laboratory Test	Result	Reference Range
Prothrombin time (PT)	11.5 seconds	11 to 12.5 seconds
Activated partial thromboplastin time (aPTT)	33 seconds	30 to 40 seconds
International Normalized Ratio (INR)	0.9	0.8 to 1.1

Laboratory Test	Result	Reference Range
White blood cells (WBC)	6,000/mm³ (6 * 10 ^ 9 / L)	5,000 to 10,000/mm³ (5 to 10 * 10 ^ 9 / L )
Red blood cells (RBC)	4.6 * 10 ^ 6 / mu * L (4.6 * 10 ^ 12 / L)	4.2 to 5.4 * 10 ^ 6 / mu * L (4.2 to 5.4 * 10 ^ 12 / L )
Hemoglobin	14 g/dL (140.0 g/L)	12 to 16 g/dL (120 to 160 g/L)
Hematocrit	41% (0.41 volume fraction)	37% to 47% (0.37 to 0.47 volume fraction)
Platelet count	325,000 (325 * 10 ^ 9 / L)	150,000 to 400,000/mm3 (150 to 400 * 10 ^ 9 / L )

Laboratory Test	Result	Reference Range
Sodium	140 mEq/L (140 mmol/L)	136 to 145 mEq/L (136 to 145 mmol/L)
Potassium	4.2 mEq/L (4.2 mmol/L)	3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)
Chloride	101 mEq/L (101 mmol/L)	98 to 106 mEq/L (98 to 106 mmol/L)
Calcium	9.4 mg/dL (3.25 mmol/L)	9 to 10.5 mg/dL (2.25 to 2.62 mmol/L)
Carbon dioxide	27 mEq/L (27 mmol/L)	23 to 30 mEq/L (23 to 30 mmol/L)
Blood urea nitrogen (BUN)	14 mg/dL (5 mmol/L)	10 to 20 mg/dL (3.6 to 7.1 mmol/L)
Creatinine	0.7 mg/dL (61.66 µmol/L)	0.5 to 1.1 mg/dL (44 to 97 µmol/L)
Glucose	101 mg/dL (5.61 mmol/L)	70 to 110 mg/dL (3.9 to 6.1 mmol/L)

Laboratory Test	Result	Reference Range
Prothrombin time (PT)	11.5 seconds	11 to 12.5 seconds
Activated partial thromboplastin time (aPTT)	33 seconds	30 to 40 seconds
International Normalized Ratio (INR)	0.9	0.8 to 1.1

HESI exam

No.

1 :
An older adult client recently diagnosed with chronic obstructive pulmonary disease (COPD) is admitted with shortness of breath. The nurse observes the client sitting upright and leaning over the bedside table, using accessory muscles to assist in breathing. Which action should the nurse take?

2 :
Patient Data.

Correct Highlights :

3 :
Patient Data.

Correct Answers

4 :
Patient Data.

Correct Answers

5 :
Patient Data .

Answer Options

6 :
Patient Data .

Correct Answers

7 :
Patient Data.

Answer Options

8 :
A client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling experienced worsens at night. Which client teaching should the nurse provide?

9 :
A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?

10 :
A client with a closed head injury demonstrates signs of syndrome of inappropriate antidiuretic hormone (SIADH). Which additional finding should the nurse expect to obtain? (Reference Range: Sodium [136 to 145 mEq/L (136 to 145 mmol/L)] Urine Specific Gravity [1.005 to 1.03])

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Interventions	Appropriate	Not Appropriate
Limit venipunctures when possible
Monitor vital signs every 15 minutes
Prepare for a CT scan after alteplase therapy
Provide the total alteplase dose over 5 minutes
Prepare for discharge in 24 hours
Conduct neurological assessment at 2-hour intervals

HESI exam

No.

1 : An older adult client recently diagnosed with chronic obstructive pulmonary disease (COPD) is admitted with shortness of breath. The nurse observes the client sitting upright and leaning over the bedside table, using accessory muscles to assist in breathing. Which action should the nurse take?

2 : Patient Data.

Correct Highlights :

3 : Patient Data.

Correct Answers

4 : Patient Data.

Correct Answers

5 : Patient Data .

Answer Options

6 : Patient Data .

Correct Answers

7 : Patient Data.

Answer Options

8 : A client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling experienced worsens at night. Which client teaching should the nurse provide?

9 : A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?

10 : A client with a closed head injury demonstrates signs of syndrome of inappropriate antidiuretic hormone (SIADH). Which additional finding should the nurse expect to obtain? (Reference Range: Sodium [136 to 145 mEq/L (136 to 145 mmol/L)] Urine Specific Gravity [1.005 to 1.03])

1 :
An older adult client recently diagnosed with chronic obstructive pulmonary disease (COPD) is admitted with shortness of breath. The nurse observes the client sitting upright and leaning over the bedside table, using accessory muscles to assist in breathing. Which action should the nurse take?

2 :
Patient Data.

3 :
Patient Data.

4 :
Patient Data.

5 :
Patient Data .

6 :
Patient Data .

7 :
Patient Data.

8 :
A client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling experienced worsens at night. Which client teaching should the nurse provide?

9 :
A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?

10 :
A client with a closed head injury demonstrates signs of syndrome of inappropriate antidiuretic hormone (SIADH). Which additional finding should the nurse expect to obtain? (Reference Range: Sodium [136 to 145 mEq/L (136 to 145 mmol/L)] Urine Specific Gravity [1.005 to 1.03])