Med Surg Final HESI Questions and answers, rated A. 2022/2023 updates

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Med Surg Final HESI Questions and answers, rated A. 2022/2023 updates A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the best initial nursing a... ction? A. Administer the first dose of antibiotic therapy B. Observe the color, consistency, and amount of sputum C. Encourage the client to consume plenty of warm liquids D. Send the specimen to the lab for analysis - ✔✔B. Observe the color, consistency, and amount of sputum A client is brought to the ED by ambulance in cardiac arrest with cardiopulmonary resuscitation (CPR) in progress. The client is intubated and is receiving 100% oxygen per self-inflating (ambu) bag. The nurse determines that the client is cyanotic, cold, and diaphoretic. Which assessment is most important for the nurse to obtain? A. Breath sounds over bilateral lung fields. B. Carotid pulsation during compressions C. Deep tendon reflexes D. Core body temperature - ✔✔A. Breath sounds over bilateral lung fields. After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a client develops pontine myselinolysis. Which intervention should the nurse implement first? A. Reorient client to his room B. Place a patch on one eye C. Evaluate client's ability to swallow D. Perform range of motion exercises - ✔✔A. Reorient client to his room A male client with heart failure (HF) calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain? A. What time did he take his last medications? B. Has his weight changed in the last several days? C. Is he still able to tighten his belt buckle? D. How many hours did he sleep last night? - ✔✔B. Has his weight changed in the last several days? An older adult woman with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. She is anxious and is complaining of a dry mouth. Which intervention should the nurse implement? A. Administer a prescribed sedative B. Encourage client to drink water C. Apply a high-flow venturi mask D. Assist her to an upright position - ✔✔D. Assist her to an upright position A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened tenacious mucous, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care? A. Increase the daily intake of oral fluids to liquefy secretions B. Avoid crowded enclosed areas to reduce pathogen exposure C. Call the clinic if undesirable side effects of mediations occur D. Teach anxiety reduction methods for feelings of suffocation - ✔✔A. Increase the daily intake of oral fluids to liquefy secretions A cardiac catherterization of a client with heart disease indicates the following blockages: 95% proximal left anterior descending (LAD), 99% proximal circumflex, and ? % proximal right coronary artery (RCA). The client later asks the nurse "what does all this mean for me?" What information should the nurse provide? A. Blood supply to the heart is diminished by artherosclerotic lesions, which necessitate lifestyle changes. B. Blood vessels supplying the pumping chamber have blockages indicating a past heart attack. C. Three main arteries have major blockages, with only 1 to 5% of blood flow getting through to the heart muscle. D. The heart is not receiving enough blood, so there is a risk of heart failure and fluid retention. - ✔✔C. Three main arteries have major blockages, with only 1 to 5% of blood flow getting through to the heart muscle. A client who weighs 175 pounds is receiving IV bolus dose of heparin 80 units/kg. The heparin is available in a 2 ml vial, labeled 10,000 units/ml. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.) - ✔✔0.6 ml What information should the nurse include in the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD)? A. Sleep without pillows at night to maintain neck alignment. B. Adjust food intake to three full meals per day and no snacks. C. Minimize symptoms by wearing loose, comfortable clothing D. Avoid participation in any aerobic exercise programs - ✔✔C. Minimize symptoms by wearing loose, comfortable clothing The nurse is caring for a client with a lower left lobe pulmonary abscess. Which position should the nurse instruct the client to maintain? A. left lateral B. Supine, knees flexed C. Dorsal recumbent D. Knee-chest - ✔✔A. left lateral A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider. A. Belching B. Amber urine C. Yellow sclera D. Flatulence - ✔✔C. Yellow sclera While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse? A. Inappropriate laughter B. Increasing anxiety C. Weakened cough effort D. Asymmetrical weakness - ✔✔C. Weakened cough effort The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client? A. Grafting increases the risk for bacterial infections B. The xenograft is taken from nonhuman sources C. Grafts are later removed by a debriding procedure D. As the burn heals, the graft permanently attaches - ✔✔B. The xenograft is taken from nonhuman sources A male client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning him, the wound dehiscences and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. What intervention should the nurse implement next? A. Bring additional sterile dressing supplies to the room B. Prepare the client to return to the operating room C. Obtain a sample of the drainage to send to the lab D. Auscultate the abdomen for bowel sound activity - ✔✔B. Prepare the client to return to the operating room A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117 mEq/L. Which nursing problem should the nurse include in this client's plan of care? A. Altered urinary elimination B. Impaired gas exchange C. Fluid volume excess D. Decreased cardiac output - ✔✔C. Fluid volume excess A female client enters the clinic and insists on being seen. She is weak, nervous, and reports a racing heart beat and recent weight loss of 15 pounds. After ruling out substance withdrawal, the healthcare provider suspects hyperthyroidism and admits her for further testing. Which action should the nurse implement? A. Begin preparing client for thyroidectomy procedure B. Space the client's care to provide periods of rest C. Assess the client for hyperactive bowel sounds D. Provide warm blankets to prevent heat loss - ✔✔B. Space the client's care to provide periods of rest The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendations should the nurse encourage the client to follow? A. Increase intake of high-fiber foods, such as bran cereal B. Restrict protein intake by limiting meats and other high-protein foods C. Limit oral fluid intake to 500 ml per day D. Increase intake of potassium-rich foods such as bananas or cantaloupe - ✔✔B. Restrict protein intake by limiting meats and other high-protein foods An overweight, young adult made who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions should the nurse implement? (Select all that apply.) A. Check his fingerstick glucose level B. Assess his skin temperature and moisture C. Measure his pulse and blood pressure D. Document anxiety on the surgical checklist E. Administer a PRN dose of regular insulin - ✔✔A. Check his fingerstick glucose level B. Assess his skin temperature and moisture C. Measure his pulse and blood pressure A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse? A. Irregular apical pulse B. Purple marks on the skin of the abdomen C. Quarter size blood spot on dressing D. Pitting ankle edema - ✔✔A. Irregular apical pulse An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red and the client reports a burning sensation. What action should the nurse take? A. Apply a cool compress to the affected fingers for 20 minutes B. Secure a pulse oximeter to monitor the client's oxygen saturation C. Report the finding to the healthcare provider as soon as possible D. Continue to monitor the fingers until color returns to normal - ✔✔D. Continue to monitor the fingers until color returns to normal A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 101F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to implement first? A. Obtain oxygen saturation level B. Encourage incentive spirometry C. Assess lower extremity circulation D. Administer PRN oral antipyretic - ✔✔D. Administer PRN oral antipyretic The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomy under general anesthesia. Which finding warrants notification of the healthcare provider prior to proceeding with the scheduled procedure? A. Light yellow coloring of the client's skin and eyes B. The client's blood pressure reading is 184/88 mm Hg. C. The client vomits 20 ml of clear yellowish fluid D. The IV insertion site is red, swollen, and leaking IV fluid - ✔✔B. The client's blood pressure reading is 184/88 mm Hg A client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse? A. Facial puffiness and periorbital edema B. Hematocrit of 30% C. Cold and dry skin D. Further decline in level of consciousness - ✔✔D. Further decline in level of consciousness Following surgical repair of the bladder, a female client is being discharged from the hospital to home with an indwelling urinary catheter. Which instruction is most important for the nurse to provide to this client? A. Avoid coiling the tubing and keep if free of kinks B. Cleanse the perineal area with soap and water twice daily C. Keep the drainage bag lower than the level of the bladder D. Drink 1,000 ml of fluids daily to irrigate catheter - ✔✔C. Keep the drainage bag lower than the level of the bladder Which client has the highest risk for developing skin cancer? A. A 16-year old dark-skinned female who tans in tanning beds once a week B. A 65 year-old fair-skinned male who is a construction worker C. A 25 year-old dark-skinned male whose mother had skin cancer D. A 70 year-old fair-skinned female who works as a secretary - ✔✔B. A 65 year-old fair-skinned male who is a construction worker When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain? A. Daily weight B. Vital signs C. Level of consciousness D. Bowel sounds - ✔✔A. Daily weight A female client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions should the nurse implement? (Select all that apply.) A. Offer ice chips and oral clear liquids B. Verify pedal pulses using a doppler pulse device C. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure D. Evaluate the application of the splint to the left leg E. Administer oral antispasmodics and narcotic analgesics - ✔✔B. Verify pedal pulses using a doppler pulse device C. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure D. Evaluate the application of the splint to the left leg A male client with Herpes zoster (shingles) on his thorax tells the nurse that he is having difficulty sleeping. What is the probable etiology of this problem? A. Pain B. Nocturia C. Dyspnea D. Frequent cough - ✔✔A. Pain When planning care for a client newly diagnosed with open angle glaucoma, the nurse identifies a priority nursing diagnosis of, "visual sensory/perceptual alterations." This diagnosis is based on which etiology? A. Limited eye movement B. Decreased peripheral vision C. Blurred distance vision D. Photosensitivity - ✔✔B. Decreased peripheral vision A client who is newly diagnosed with emphysema is being prepared for discharge. Which instruction is best for the nurse to provide the client to assist them with dyspnea self-management? A. Allow additional time to complete physical activities to reduce oxygen demand B. Practice inhaling through the nose and exhaling slowly through pursed lips C. Use a humidifier to increase home air quality humidity between 30-50% D. Strengthen abdominal muscles by alternating leg raises during exhalation - ✔✔B. Practice inhaling through the nose and exhaling slowly through pursed lips A client with cancer is receiving chemotherapy with a known vesicant. The client's IV has been in place for 72 hours. The nurse determines that a new IV site cannot be obtained, and leaves the present IV in place. What is the greatest clinical risk related to this situation? A. Impaired skin integrity B. Fluid volume excess C. Acute pain and anxiety D. Peripheral neurovascular dysfunction - ✔✔A. Impaired skin integrity A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the postanasthesia unit. Before selecting which medication to administer, which action should the nurse implement? A. Document the client's report of pain in the electronic medical record B. Determine which prescription will have the quickest onset of action C. Compare the client's pain scale rating with the prescribed dosing D. Ask the client to choose which mediation is needed for pain - ✔✔C. Compare the client's pain scale rating with the prescribed dosing While assisting a female client to the toilet, the client begins to have a seizure and the nurse eases her to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first? A. Document details of the seizure activity B. Observe for lacerations to the tongue C. Observe for prolonged periods of apnea D. Evaluate for evidence of incontinence - ✔✔C. Observe for prolonged periods of apnea [Show More]

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