Med surg HESI EXIT EXAM Updated (June 2022) Test Bank.pdf

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Med surg HESI EXIT EXAM Updated (June 2022) Test Bank.pdf 1. Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk,... to help coat and protect his ulcer. What is the best follow-up action by the nurse? • Review with the client the need to avoid foods that are rich in milk and cream 2. A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him “feel bad”. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition? 3. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? 4. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? 5. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? 6. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? • Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows. 7. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up? • Describes life without purpose 8. A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client’s teaching plan? • Further evaluation involving surgery may be needed 9. A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan? • Teach tracheal suctioning techniques 10. In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client’s respiratory rate is 14 breaths / minute. What action should the nurse implement? • Document the assessment data • Rational: reservoir bag should not deflate completely during inspiration and the client’s respiratory rate is within normal limits. 11. During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate firs?• Respiratory apnea of 30 seconds 12. During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should the nurse take first? • Check the client for lacerations or fractures 13. At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first? • Inform the anesthesia care provider 14. After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first? • Listen with the bell at the same location 15. A 66-year-old woman is retiring and will no longer have a health insurance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs? • Medicare 16. A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline? • Toasted wheat bread and jelly 17. Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse that the client is experiencing a complication? • “I have a headache that gets worse when I sit up” • “I am having pain in my lower back when I move my legs” • “My throat hurts when I swallow” • “I feel sick to my stomach and am going to throw up” 18. An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement? • Obtain a clean catch mid-stream specimen 19. The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child’s dietary restrictions. Which foods are contraindicated for this child? • Foods sweetened with aspartame 20. Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide? • Direct the nurse to continue the surgical hand scrub for a 5 minute duration 21. Which breakfast selection indicates that the client understands the nurse’s instructions about the dietary management of osteoporosis? • Bagel with jelly and skim milk22. The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse (RN)? • An 82-year-old client with Alzheimer’s disease newly-fractures femur who has a Foley catheter and soft wrist restrains applied 23. A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician’s office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child’s foot. Which action should the nurse implement first? • Cleanse the foot with soap and water and apply an antibiotic ointment • Provide teaching about the need for a tetanus booster within the next 72 hours. • have the mother check the child's temperature q4h for the next 24 hours • transfer the child to the emergency department to receive a gamma globulin injection 24. The mother of an adolescent tells the clinic nurse, “My son has athlete’s foot, I have been applying triple antibiotic ointment for two days, but there has been no improvement.” What instruction should the nurse provide? • Stop using the ointment and encourage complete drying of the feet and wearing clean socks. 25. A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences • Bradycardia and constipation • Lethargy and lack of appetite • Muscle cramping and dry, flushed skin • Palpitations and shortness of breath 26. A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to assess to the client? • Obtain a list of medications taken for cardiac history 27. The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only.) • 75 • Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour / 1,000 mcg x 250 ml = 3/1 x 25 = 75 ml/hour 28. The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply) • Fluid shifts from intravascular to interstitial area due to decreased serum protein • Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen • Increased circulating aldosterone levels that increase sodium and water retention 29. The nurse is auscultating a client’s heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies) • Murmur• Rationale: A murmur is auscultated as a swishing sound that is associated with the blood turbulence created by the heart or valvular defect. 30. The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant. The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration of 100 mg/ml. How many ml should the nurse administered for each dose? (Enter numeric value only. If rounding is required, round to the nearest tenth) • 0.4 • rationale: 35mg/100mg x 1 = 0.35 = 0.4 ml 31. The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete? • Auscultate the client's bowel sounds • Observe for edema around the ankles • Measure the client’s capillary glucose level • Count the apical and radial pulses simultaneously • Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and frequently causes constipation, so it is most important to Auscultate the client's bowel sounds 32. A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of shortness of breath. The client tells the nurse that she wants “no heroic measures” taken if she stops breathing, and she asks the nurse to document this in her medical record. What action should the nurse implement? • Ask the client to discuss “do not resuscitate” with her healthcare provider 33. A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement? • Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour 34. A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the nurse to ask? • Have you noticed any changes in your fingernails? • Rationale: The pattern of reported manifestations is suggestive of hypothyroidism 35. After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse? • Capillary refill of 8 seconds • bruises on arms and legs • round and tight abdomen • pitting edema in lower legs 36. After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs the form as a witness. What are the legal implications of the nurse’s signature on the client’s surgical consent form? (Select all that apply)• The client voluntarily grants permission for the procedure to be done • The client is competent to sign the consent without impairment of judgment • The client understands the risks and benefits associated with the procedure 37. Following surgery, a male client with antisocial personality disorder frequently requests that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the charge nurse implement? • Advise the client that assignments are not based on clients requests 38. A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take? • Place the implant in a lead container using long-handled forceps 39. The client with which type of wound is most likely to need immediate intervention by the nurse? • Laceration • Abrasion • Contusion • Ulceration • Rationale: A laceration is a wound that is produced by the tearing of soft body tissue. This type of wound is often irregular and jagged. A laceration wound is often contaminated with bacteria and debris from whatever object caused the cut. 40. The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client’s plan of care? • Monitor blood pressure frequently • Rationale: A pheochromocytoma is a rare, catecholamine-secreting tumor that may precipitate life-threatening hypertension. The tumor is malignant in 10% of cases but may be cured completely by surgical removal. Although pheochromocytoma has classically been associated with 3 syndromes—von Hippel-Lindau (VHL) syndrome, multiple endocrine neoplasia type 2 (MEN 2), and neurofibromatosis type 1 (NF1)—there are now 10 genes that have been identified as sites of mutations leading to pheochromocytoma. 41. When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention? • To reduce abdominal pressure on the diaphragm • to promote retraction of the intercostal accessory muscle of respiration • to promote bronchodilation and effective airway clearance • to decrease pressure on the medullary center which stimulates breathing • Rationale: a semi-sitting position is the best position for matching ventilation and perfusion and for decreasing abdominal pressure on the diaphragm, so that the client can maximize breathing. 42. When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely explanation for failure to locate the gallbladder by palpation? • The client is too obese • Palpating in the wrong abdominal quadrant• Deeper palpation technique is needed • The gallbladder is normal • Rationale: a normal healthy gallbladder is not palpable 43. A woman with an anxiety disorder calls her obstetrician’s office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman? • describe the transmission of drugs to the infant through breast milk • encourage her to use stress relieving alternatives, such as deep breathing exercises • Inform her that some antianxiety medications are safe to take while breastfeeding • Explain that anxiety is a normal response for the mother of a 3-week-old. • Rationale: there are several antianxiety medications that are not contraindicated for breastfeeding mothers. 44. An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first? • Start an intravenous (IV) infusion of normal saline • obtain a serum potassium level • administer the client's usual dose of insulin • assess pupillary response to light • Rationale: the nurse should first start an intravenous infusion of normal saline to replace the fluids and electrolytes because the client has been vomiting, and it is unclear when he last ate or took insulin. The symptoms of confusion, lethargy, vomiting, and abdominal cramping are all suggestive of hyperglycemia, which also contributes to diuresis and fluid electrolyte imbalance. 45. A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse’s decision to hold the client’s scheduled antihypertensive medication? • increased urinary clearance of the multiple medications has produced diuresis and lowered the blood pressure • the antagonistic interaction among the various blood pressure medications has reduced their effectiveness • The additive effect of multiple medications has caused the blood pressure to drop too low • the synergistic effect of the multiple medications has resulted in drug toxicity and resulting hypotension 46. Which client is at the greatest risk for developing delirium? • An adult client who cannot sleep due to constant pain. • an older client who attempted 1 month ago • a young adult who takes antipsychotic medications twice a day • a middle-aged woman who uses a tank for supplemental oxygen 47. Which intervention should the nurse include in a long-term plan of care for a client withChronic Obstructive Pulmonary Disease (COPD)? • Reduce risks factors for infection • Administer high flow oxygen during sleep • Limit fluid intake to reduce secretions • Use diaphragmatic breathing to achieve better exhalation 48. Which location should the nurse choose as the best for beginning a screening program for hypothyroidism? • A business and professional women's group. • An African-American senior citizens center • A daycare center in a Hispanic neighborhood • An after-school center for Native-American teens 49. A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling “very tired”. Which nursing intervention is most important for the nurse to implement? • Measure vital signs • Auscultate breath sounds • Palpate the abdomen • Observe the skin for bruising 50. A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab is important for the nurse to review before contacting the health care provider? • capillary glucose • urine specific gravity • Serum calcium • white blood cell count 51. What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning? • working together can decrease the risk for back injury • The technique is intended to maintain straight spinal alignment. • Using two or three people increases client safety. • turning instead of pulling reduces the likelihood of skin damage 52. A client receiving chemotherapy has severe neutropenia. Which snack is best for the nurse to recommend to the client? • Baked apples topped with dried raisins 53. Which action should the school nurse take first when conducting a screening for scoliosis? • Inspect for symmetrical shoulder height. 54. An unlicensed assistive personnel (UAP) assigned to obtain client vital signs reports to the charge nurse that a client has a weak pulse with a rate of 44 beat/ minutes. What action should the charge nurse implement? • Assign a practical nurse (LPN) to determine if an apical radial deficit is present 55. After a sudden loss of consciousness, a female client is taken to the ED and initial assessment indicate that her blood glucose level is critically low. Once her glucose level is stabilized, the client reports that was recently diagnosed with anorexia nervosa and is being treated at an outpatient clinic. Which intervention is more important to include in this client’s discharge plan?• Encourage a low-carbohydrate and high-protein diet 56. A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform? • Observe the antecubital fossa for inflammation. 57. The nurse administers an antibiotic to a client with respiratory tract infection. To evaluate the medication’s effectiveness, which laboratory values should the nurse monitor? Select all that apply • White blood cell (WBC) count • Sputum culture and sensitivity 58. A client is admitted to isolation with the diagnosis of active tuberculosis. Which infection control measures should the nurse implement? • Negative pressure environment • contact precautions • droplet precautions • protective environment 59. A school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In what position should the nurse place the child? • Sitting up and leaning forward 60. A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma? • Altered consciousness within the first 24 hours after injury. 61. A female client with breast cancer who completed her first chemotherapy treatment today at an out-patient center is preparing for discharge. Which behavior indicates that the client understands her care needs • Rented movies and borrowed books to use while passing time at home 62. Which instruction should the nurse provide a pregnant client who is complaining of heartburn? • Eat small meal throughout the day to avoid a full stomach. 63. A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely? • Hypokalemia • Ketonuria. • Peripheral edema • Elevated blood pressure • Rational: pituitary tumors that suppress antidiuretic hormone (ADH) result in diabetes insipidus, which causes massive polyuria and serum electrolyte imbalances, including hypokalemia, which can lead to lethal arrhythmias. 64. A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amount of liquid stool. Which action should the nurse implement? • Digitally check the client for a fecal impaction 65. After changing to a new brand of laundry detergent, an adult male reports that he has a fine itchy rash. Which assessment finding warrants immediate intervention by the nurse? • Bilateral Wheezing.66. The nurse should teach the parents of a 6 year-old recently diagnosed with asthma that the symptom of acute episode of asthma are due to which physiological response? • Inflammation of the mucous membrane & bronchospasm 67. A 10 year old who has terminal brain cancer asks the nurse, "What will happen to my body when I die?" How should the nurse respond? • "The heart will stop beating & you will stop breathing." 68. The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which findings? Select all that apply: • Restlessness • Clenched Fist • Increased pulse rate • Increased respiratory rate. • Increased temperature • Peripheral pallor of the skin 69. The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping and, aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication? • Determine which side of the body is weak. 70. The nurse who is working on a surgical unit receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse? • Gunshot wound three hours ago with dark drainage of 2 cm noted on the dressing. • Mastectomy 2 days ago with 50 ml bloody drainage noted in the Jackson-pratt drain. • Collapsed lung after a fall 8h ago with 100 ml blood in the chest tube collection container • Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills. • Rationale: the client with an abdominal- perineal resection is at risk for peritonitis and needs to be immediately assessed for other signs and symptoms for sepsis. 71. The nurse is caring for a client who had gastric bypass surgery yesterday. Which intervention is most important for the nurse to implement during the first 24 postoperative hours? • Measure hourly urinary output. • Rationale: a serious early complications of gastric bypass surgery is an anastomoses leak, often resulting in death. 72. When preparing to discharge a male client who has been hospitalized for an adrenal crisis, the client expresses concern about having another crisis. He tells the nurse that he wants to stay in the hospital a few more days. Which intervention should the nurse implement? • Schedule an appointment for an out-patient psychosocial assessment. 73. An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. What action should the nurse take first? • Explore client’s readiness to discuss the situation. 74. In caring for a client with Cushing syndrome, which serum laboratory value is mostimportant for the nurse to monitor? • Lactate • Glucose • Hemoglobin • Creatinine 75. Azithromycin is prescribed for an adolescent female who has lower lobe pneumonia and recurrent chlamydia. What information is most important for the nurse to provide to this client? • Use two forms of contraception while taking this drug. 76. A client in the emergency center demonstrates rapid speech, flight of ideas, and reports sleeping only three hours during the past 48h. Based on these finding, it is most important for the nurse to review the laboratory value for which medication? • Divalproex. • Rationale: divalproex is the first line of treatment for bipolar disorder BPD because it has a high therapeutic index, few side effects, and a rapid onset in controlling symptoms and preventing recurrent episodes of mania and depression. The serum value of divalproex should be determined since the client is exhibiting symptoms of mania, which may indicate non-compliance with the medication regimen. 77. A male client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider? • Serum lithium level of 1.6 mEq/L or mmol/l (SI) • Rationale: The therapeutic level of Serum lithium is 0.8 to 1.5 mEq/L or mmol/l (SI). Slurred speech and ataxia are sign of lithium toxicity. 78. A client was admitted to the cardiac observation unit 2 hours ago complaining of chest pain. On admission, the client’s EKG showed bradycardia, ST depression, but no ventricular ectopy. The client suddenly reports a sharp increase in pain, telling the nurse, “I feel like an elephant just stepped on my chest” The EKG now shows Q waves and ST segment elevations in the anterior leads. What intervention should the nurse perform? • Administer prescribed morphine sulfate IV and provide oxygen at 2 L/min per nasal cannula. 79. The nurse is developing a teaching program for the community. What population characteristic is most influential when choosing strategies for implementing a teaching plan? • Literacy level 80. A client is being discharged with a prescription for warfarin (Coumadin). What instruction should the nurse provide this client regarding diet? • Eat approximated the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent. 81. A client who had a small bowel resection acquired methicillin resistant staphylococcus aureus (MRSA) while hospitalized. He treated and released, but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention. • Maintain contact transmission precaution82. A postoperative female client has a prescription for morphine sulfate 10 mg IV q3 hours for pain. One dose of morphine was administered when the client was admitted to the post anesthesia care unit (PACU) and 3 hours later, the client is again complaining of pain. Her current respiratory rate is 8 breaths/minute. What action should the nurse take? • Administer Naxolone IV 83. Which intervention is most important for the nurse to include in the plan of care for an older woman with osteoporosis? • Place the client on fall precautions 84. Based on the information provided in this client’s medical record during labor, which should the nurse implement? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client’s medical record.) • Continue to monitor the progress of labor. 85. An unlicensed assistive personnel UAP leaves the unit without notifying the staff. In what order should the unit manager implement this intervention to address the UAPs behavior? (Place the action in order from first on top to last on bottom.) 1. Note date and time of the behavior. 2. Discuss the issue privately with the UAP. 3. Plan for scheduled break times. 4. Evaluate the UAP for signs of improvement. 86. A client with intestinal obstructions has a nasogastric tube to low intermittent suction and is receiving an IV of lactated ringer’s at 100 ml/H. which finding is most important for the nurse to report to the healthcare provider? • Serum potassium level of 3.1 mEq/L or mmol/L (SI) • Rationale: The normal potassium level in the blood is 3.5-5.0 milliEquivalents per liter (mEq/L). 87. Which type of Leukocyte is involved with allergic responses and the destruction of parasitic worms? • Neutrophils • Lymphocytes • Eosinophils • Monocytes • Rationale: Eosinophils are involved in allergic responses and destruction of parasitic worms. 88. The healthcare provider prescribes the antibiotic cephradine 500mg PO every 6 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat? • Yogurt and/or buttermilk. 89. Several months after a foot injury, and adult woman is diagnosed with neuropathic pain. The client describes the pain as severe and burning and is unable to put weight on her foot. She asks the nurse when the pain will “finally go away.” How should the nurse respond? • Assist the client in developing a goal of managing the pain 90. One day following an open reduction and internal fixation of a compound fracture of theleg, a male client complains of “a tingly sensation” in his left foot. The nurse determines the client’s left pedal pulses are diminished. Based on these finding, what is the client’s greatest risk? • Neurovascular and circulation compromise related to compartment syndrome. 91. The nurse is completing a head to be assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the nurse? • Clear fluid leaking from the nose. 92. A client with multiple sclerosis (MS) has decreased motor function after taking a hot bath (Uhthoff’s sign). Which pathophysiological mechanism supports this response? • Temporary vasodilation 93. While assessing a radial artery catheter, the client complains of numbness and pain distal to the insertion site. What interventions should the nurse implement? • Promptly remove the arterial catheter from the radial artery. 94. A client is admitted with an epidural hematoma that resulted from a skateboarding accident. To differentiate the vascular source of the intracranial bleeding, which finding should the nurse monitor? • Rapid onset of decreased level of consciousness. 95. The nurse finds a client at 33 weeks gestation in cardiac arrest. What adaptation to cardiopulmonary resuscitation (CPR) should the nurse implement? • Position a firm wedge to support pelvis and thorax at 30 degree tilt. 96. When preparing a client for discharge from the hospital following a cystectomy and a urinary diversion to treat bladder cancer, which instruction is most important for the nurse to include in the client’s discharge teaching plan? • Report any signs of cloudy urine output. 97. For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a bedridden, older client with infectious gastroenteritis. Which finding requires the nurse to take further action? • Tented skin turgor. 98. After repositioning an immobile client, the nurse observes an area of hyperemia. To assess for blanching, what action should the nurse take? • Apply light pressure over the area. 99. The nurse enters a client’s room and observes the client’s wrist restraint secured as seen in the picture. What action should the nurse take? • Reposition the restraint tie onto the bedframe. 100. A female client with acute respiratory distress syndrome (ARDS) is chemically paralyzed and sedated while she is on as assist-control ventilator using 50% FIO2. Which assessment finding warrants immediate intervention by the nurse? • Diminished left lower lobe sounds • Rationale: Diminished lobe sounds indicate collapsed alveoli or tension pneumothorax, which required immediate chest tube insertion to re-inflate the lung [Show More]

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