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NUR 2311 Med Surg version 1 Exit_Hesi_2020 - Southeastern College | NUR2311 Med Surg version 1 Exit_Hesi_2020

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NUR 2311 Med Surg version 1 Exit_Hesi_2020 - Southeastern College 1. The nurse is beginning the process of changing the central venous catheter dressing of a client receiving total parenteral nutriti... on. After applying sterile gloves, what action should the nurse take? 2. A nurse-manager is preparing an annual budget for the unit. Nursing salaries should be included in which component of the budget? 3. The wife of a client with terminal cancer gives the nurse a copy of her husband’s living will. What action should the nurse take? 4. A client with a fractured femur is placed in traction to immobilize the fracture. When transporting this client to another room, how should the nurse handle the traction? 5. The healthcare provider prescribed triazolam (Halcion) 500 mcg for a client with insomnia. The pharmacy supplies Halcion in 0.25 mg tablets. How many tablets should the nurse administer? (Enter numeric value only.) 2 6. A middle-aged female client is admitted to the hospital with a medical diagnosis of acute renal failure (ARF). The healthcare provider informs her that her treatment program will include hemodialysis. Which response demonstrates that this client understands what will occur with hemodialysis? 7. The mother of a 5-year-old boy calls the emergency room and reports that a pot of hot soup was pulled off the stove onto her child’s right arm and leg. What should the nurse tell this mother to do first? 8. A nurse is caring for a client with a diagnosis of acute renal failure who complains of shortness of breath, weakness, headache, and swelling of the lower legs and feet. What nursing intervention should be completed immediately? 9. A client with acute low back pain reports pain radiating down the buttock to below the knee. Initial nursing actions should be based on which interpretation of these symptoms? 10. The nurse is assigning rooms for four clients, each newly diagnosed and being admitted to the acute neuro unit for treatment. The client with which diagnosis should be assigned the only private room available? 11. A client who has been in active labor for 12 hours suddenly tells the nurse that she has a strong urge to have a bowel movement. What action should the nurse take? 12. A client who developed Syndrome of Inappropriate Antidiuretic Hormone (SIADH) associated with small cell carcinoma of the lung is preparing for discharge. When teaching the client about self-management with demeclocycline (Declomycin), the nurse should instruct the client to report which condition to the healthcare provider? 13. In determining the client position for insertion of an indwelling urinary catheter, it is most important for the nurse to recognize which client condition? 14. A male client with HIV, who is being admitted to a healthcare facility, tells the nurse that he is concerned about his right to have access to his records and explanations regarding his treatment and the cost of such treatment. Which resource should guide the nurse’s response to this client? 15. When assessing the oral temperature of an adult client at 6:00 pm, the nurse notes that the client’s temperature at 6:00 am was 97.2, and is now 98.8. Which intervention should the nurse implement? 16. It would be of greatest benefit for the client with which problem related to diabetes mellitus to change from the use of insulin syringes to using an insulin pen for medication administration? 17. In planning care for a client with a nursing diagnosis of “Impaired mobility”, the nurse instructs the unlicensed assistive personnel (UAP) to assist the client with ambulation. Because the healthcare provider has prescribed bed rest for the client, what action should the nurse take? 18. When assigning an unlicensed assistive personnel (UAP) to assist a client with personal care, which client information is most important for the nurse to provide the UAP? 19. Within four weeks of childbirth, a client is admitted to the hospital for disorganized speech, bizarre behavior, and strange thoughts about her infant being possessed by demons. The nurse identifies a nursing diagnosis of, “Altered thought processes, secondary to” what condition? A. Postpartum psychosis. 20. The nurse is preparing to discharge a client from the hospital who has aphasia secondary to a cerebrovascular accident (CVA). What instruction should the nurse provide the family to assist them in communicating with the client? 21. The intensive care department is full and short staffed, so the nursing supervisor informs the charge nurse in the medical department that one nurse must float to the ICU. Which nurse should the medical department charge nurse send to the intensive care department? 22. A mother brings her newborn infant to the well-baby clinic for the one-month check-up. The nurse reviews the infant’s records and identifies that the newborn received the first dose of the HBV immunization upon discharge from the newborn nursery. When should the nurse recommend the administration of the next booster for the HBV series? 23. When assessing a restless intubated client who is on a mechanical ventilator, the nurse auscultates breath sounds on the right side of the chest only. What action should the nurse implement next? 24. A male client taking several medications complains of sexual dysfunction. The nurse knows that this is a side effect commonly associated with which of his current medications? 25. The parents of two children with sickle cell disease ask the nurse to explain why both of their children have this disease. Which concept should the nurse use to provide an explanation? 26. A client with a cervical spinal cord injury is brought to the emergency center. What should be the nurse’s priority assessment? 27. A 13-year-old female client is evaluated at a mental health clinic because her parents suspect she is using an illicit substance. Symptoms reported to healthcare provider include sleep disturbances, slurred speech, mild hand tremors, and trouble hearing. Based on these symptoms, the nurse should screen for which substance? 28. The charge nurse is developing the nursing guidelines for a coronary care unit. Which reference is likely to be the most useful in developing these guidelines? 29. A male client who is in the day room becomes increasingly angry and aggressive when he is denied a day-pass. Which action should the nurse implement? 30. The nurse is assessing a client following a thoracotomy and left lung pneumonectomy. What assessment finding should the nurse anticipate? 31. A male client with Type 1 diabetes mellitus takes a combination of short-acting and intermediate-acting insulin drugs. The client complains of headaches when awakening and his blood glucose average for the past week has been 210 mg/dl. The nurse recognizes the client is experiencing a daily Somogyi, or rebound, effect. Which dosing method is likely to relieve these symptoms? 32. When obtaining a throat culture from a 6-year-old with possible streptococcal infection, which action is most important for the nurse to implement? 33. The nurse is caring for a 42-year-old male client who is excreting less sodium than he is consuming. If this condition continues, what complication can the nurse expect this client to exhibit? 34. Which condition would likely cause secondary polycythemia? A. High altitude exposure. 35. An infant is treated for intussusception with hydrostatic reduction. What instruction should the nurse include in the parents’ teaching plan? 36. The nurse is planning care for a 48-year-old client, diagnosed with schizophrenia at age 25, who has been taking antipsychotic drugs since diagnosis. Long-term use of these drugs is associated with which side effect? 37. What instruction is most important for the nurse to provide a client with neutropenia? 38. A client with acute laryngitis reports feeling “short of breath”. The nurse assesses that the client’s respiratory rate has increased from 16/minute to 28/minute. What intervention should the nurse implement? 39. When caring for a client who had a craniotomy yesterday for removal of a pituitary tumor, which finding indicates to the nurse that further information is needed? 40. The nurse is working with an interdisciplinary group to write procedures for assessment of clients from a multiracial inner city population. The guidelines include a statement that reads, “Remember that all Hispanic clients may not wish to give personal medical information to a stranger.” Which action should the nurse take? 41. What nursing action has the highest priority in preventing postoperative bleeding following a submucosal resection for a deviated septum? 42. A female client chooses to have a prophylactic mastectomy because she has a positive BRCA1 mutation, her mother died of breast cancer at age 30, and her cousin was diagnosed with breast cancer at age 28. Which intervention is most critical for the nurse to include in this client’s immediate postoperative plan of care? 43. The industrial health nurse who works in a mobile clinic is developing an exposure control plan for blood-borne pathogens. Which topics should be included in this plan? (Select all that apply.) 44. A male client awaiting surgery tells the nurse that he has some concerns about the surgical procedure that were never addressed. Which nursing intervention reflects the nurse’s role as a client advocate? 45. A client with pneumonia is admitted with severe shortness of breath and arterial blood gases of pH 7.30, PaO2 60 mm Hg, PaCO2 62 mm Hg, HCO2 35 mEq/liter. Which information should the nurse communicate immediately to the healthcare provider? 46. The nurse is teaching a primigravida, who describes herself as a lacto-vegetarian, about nutrition during pregnancy. Which foods should the nurse encourage this client to include in her diet? 47. In evaluating the effectiveness of a client’s nocturnal sleep patterns, what information is best for the nurse to obtain? 48. Four clients present to the Labor and Delivery unit at the same time. The nurse should assess the client with which complaint first? 49. The nurse is conducting discharge teaching about the antianxiety drug diazepam (Valium). Which instruction has the highest priority for inclusion in the teaching plan? 50. A male Muslin client with pneumonia is scheduled to receive a dose of an intravenous antibiotic but refuses to allow the nurse to begin the medication, stating he cannot allow fluids to enter his body once he is cleansed for prayer. Which action should the nurse implement? 51. After administering a medication through a nasogastric tube connected to suction, what action should the nurse take first? 52. Which of these women, all of whom have recently discovered a new breast lump, is at greatest risk for a diagnosis of breast cancer? 53. Which client situation requires the most immediate intervention by the nurse? 54. On admission, the healthcare provider prescribes a broad-spectrum antibiotic, ticarcillin (Ticar), for a client with a gram-negative infection. Before administering the first dose, it is important for the nurse to implement which prescription? 55. The nurse observes that a client receiving an aminoglycoside for an infection appears dizzy when ambulating. The nurse should consult with the healthcare provider regarding the need for which test? 56. The nurse is administering a continuous IV infusion of dopamine (Intropin) to a client. Which assessment finding indicates that the therapeutic effect has been achieved? 57. A client who is being prepared for discharge following a transurethral resection of the prostate (TURP) tells the nurse that he is concerned about becoming constipated. Which instruction should the nurse provide to this client? 58. A 3-year-old child visits the clinic with both parents for a well-child check-up. The nurse auscultates bronchovesicular breath sounds in the peripheral lung fields and assesses the child’s respiratory rate of 28 breaths/minute. Which interpretation of this finding is accurate? 59. The nurse is providing preoperative teaching to a female client scheduled for surgery tomorrow at an ambulatory surgery center. Which instruction is most important for the nurse to include? 60. In performing an initial assessment of an infant with cryptorchidism the nurse should also assess for which finding? 61. An unlicensed assistive personnel (UAP) reports to the nurse that a postoperative client is complaining of abdominal pain and has a respiratory rate of 32 breaths per minute. What action should the nurse implement? 62. A 4-year-old boy is admitted to the hospital for a urinary tract infection. Which statement made by the mother warrants further exploration by the nurse? 63. While assisting a postpartum client with perineal care, the nurse notes that her vaginal bleeding spurts rather than trickles from the vagina. The uterine fundus is firm, and the client’s vital signs are: pulse, 88 beats/minute; respiratory rate, 21 breaths/minute; and blood pressure, 104/68 mmHg. What action should the nurse take next? 64. An infant who weighs 22 pounds is receiving an IV solution at 96 ml/kg/24 hours. The nurse should program the infusion pump to deliver how many ml/hour? 40 65. The nurse determines that an intravenous infusion in a client’s right forearm is a stage 4 infiltration. After removing the intravenous catheter, what action should the nurse take? 66. In assessing a female client with Type 2 diabetes mellitus, the nurse notes that the client has gained five pounds since her last clinic visit six months ago. The client reports that she has been following her diet and that her glucose levels are under control. What indicator best reflects the client’s control of her diabetes? 67. The nurse is reviewing a client’s electrocardiogram and determines that the PR interval (PRI) is prolonged. What does this finding indicate? 68. The nurse is teaching a male client with multiple sclerosis how to empty his bladder using the Crede Method. When performing a return demonstration, the client applies pressure to the umbilical area of his abdomen. What instruction should the nurse provide? 69. A 35-year-old female client has just been admitted to the postanesthesia recovery unit following a partial thyroidectomy. Which statement reflects the nurse’s accurate understanding of the expected outcome for the client following this surgery? 70. When finding a client sitting on the floor, the nurse calls for help from the unlicensed assistive personnel (UAP). Which task should the nurse ask the UAP to do? 71. The nurse tests a client’s visual acuity and determines that the uncorrected vision is 20/100 in the right eye and 20/80 in the left eye. What does this finding indicate? 72. Identify the location of the pinnae that the nurse should pull upward and outward while instilling eardrops into an adult’s ear. 73. A client with hyperparathyroidism reports increasing lethargy and seems confused. It is most important for the nurse to obtain which serum lab test results? 74. The charge nurse is assessing the morning lab work on four clients. Which client’s laboratory findings should prompt the charge nurse to contact the healthcare provider immediately? 75. The nurse is assessing an adult who displays stagnation, boredom, and interpersonal impoverishment. Based on Erikson’s developmental model, which stage should the nurse develop interventions for this client? 76. The nurse obtains lying and standing blood pressure measurements for a female client who complains of dizziness every time she stands up from the computer at work. The nurse determines that her systolic pressure decreases 24 mmHg when she stands. What intervention is most important for the nurse to implement? 77. A client is receiving lidocaine IV at 3 mg/minute. The pharmacy dispenses a 500 ml IV solution of normal saline (NS) with 2 grams of lidocaine. The nurse should regulate the infusion pump to deliver how many ml/hr? 45 78. A school-age child with asthma is intubated and placed on a mechanical ventilator. The parents of the child are pale, holding onto each other, and have tears in their eyes. What statement by the nurse is most therapeutic when first interacting with these parents? 79. The nurse is conducting a community education program on osteoporosis prevention. Which physical activity would be best to recommend to women 65 years of age and older for prevention of osteoporosis? 80. A client is admitted to the nursing unit with a possible bowel obstruction. The nurse auscultates high-pitched bowel sounds in the upper quadrants of the client’s abdomen. What is the significance of this finding? 81. Which statement by a client would cause the nurse to suspect that the client may be experiencing a myocardial infarction? 82. The nurse is administering an intramuscular injection and performs the Z-track technique. At what point should the nurse release the tissue that is retracted laterally during the injection? 83. The nurse is caring for a 5-year-old with Reye’s syndrome. What goal has the highest priority in caring for this child? 84. While assessing a client with wrist restraints, the nurse first slides two fingers under the restraint, and then notes that the ties are secured to the side rails using a quick-release tie. What action should the nurse implement? 85. Which symptom in a client with fractured ribs indicates the presence of an abnormality warranting immediate intervention by the nurse? 86. A female client presents to the emergency department in the early evening complaining of abdominal cramping, watery diarrhea, and vomiting. She tells the nurse that she was at a picnic and ate barbeque that afternoon. What question is most important for the triage nurse to ask this client? 87. While drawing a blood sample from a 2-month-old diagnosed with Tetrology of Fallot (TOF), the nurse recognizes the onset of a hypercyanotic spell or “tet spell”. After positioning the infant in a knee-chest position, what should the nurse administer? 88. An adult male who admits to abusing IV drugs obtains the results of HIV testing. When informed that the results are positive, he states that he does not want his wife to know. What action should the nurse take? 89. When bathing an elderly client, the nurse notes that the client’s skin is very dry, flaky, and rough. Which nursing intervention should be added to this client’s plan of care? 90. A male client was admitted to the intensive care unit three days ago following a motor vehicle collision and is today being discharged to the medical unit. One hour before discharge, his blood pressure is 160/110 and his pulse is 120 beats/minute. He tells the nurse, “I feel like my skin is crawling.” Which lab value is most important for the nurse to assess? 91. A male client with diabetes and hypertension has begun to exhibit signs of diabetic retinopathy. To help decrease the retinopathy, the nurse should encourage the client to try and become more diligent in managing which situation? 92. The wife of a terminally ill client is concerned because her husband insists on talking about past events. Which response is best for the nurse to provide? 93. The nurse is caring for a toddler who has a medical diagnosis of coarctation of the aorta. Which assessment finding should the nurse report to the healthcare provider immediately? 94. A client’s case is being reviewed by the hospital’s multi-disciplinary ethics committee. What information could the nurse provide to the committee regarding this case? 95. A 16-year-old female client who attempted suicide that morning is admitted to the psychiatric unit. To determine the seriousness of the adolescent’s suicide attempt, which question is most important for the nurse to ask the family? 96. A high school football player comes to the clinic complaining of severe acne. The mother reports recent behavior changes, including irritability and suspiciousness of friends. The nurse’s assessment reveals an elevated blood pressure. Which intervention should the nurse implement first? 97. In caring for a client with a fracture of the femur, the nurse should be alert for compartment syndrome. What symptom is characteristic of this complication? 98. The nurse assesses a 78-year-old male client who has left sided heart failure. Which symptoms would the nurse expect this client to exhibit? 99. A child is admitted to the hospital with diarrhea and vomiting. Potassium chloride is prescribed for inclusion with rehydration IV fluids. Prior to administering the potassium, the nurse should ensure that which condition exists? 100. A client whose blood type is A, Rh negative is scheduled to receive a unit of blood. Two nurses verify the blood type and proceed with the transfusion. One of these nurses should stop the administration of the blood based on which data? 101. The nurse has not finished administering routine oral medication because one client experienced chest pain and another rectal bleeding. It is not dinnertime and two clients must be fed. The unlicensed assistive personnel (UAP) is filling water pitchers, and the practical nurse (PN) is charting vital signs. Which change in assignments is best for the team leader to make? 102. A postoperative client has developed an evisceration. Which nursing diagnosis should be added to the client’s plan of care? 103. The psychiatric nurse is called to a train derailment that was likely caused by a terrorist bomb. In triaging those in need of immediate care, what is the priority ranking for these cases? (Arrange these cases in order of priority, with the top item requiring the most immediate care and the bottom item requiring the least priority care.) 104. The nurse is caring for a male client who suffered a right cerebrovascular accident (CVA), resulting in left-sided hemiparesis. Which observation of the client indicates that he is experiencing homonymous hemianopsia? 105. While completing the admission assessment of a client at 24-weeks gestation who is contracting every 5 minutes, the nurse notes several bruises on her abdomen. The client reports that the bruises are a result of her boyfriend kicking her in the stomach. In what order should the nurse implement these nursing actions? 106. Following a transient ischemic attack (TIA) during which a male client experienced hemiparesis, he asks the nurse if he had a “stroke”. What is the best response by the nurse? 107. A male client returns to the acute care unit following surgery with sequential compression devices in place. The nurse observes that the client dorsiflexes his feet frequently. What action should the nurse implement? 108. A healthcare provider prescribes butorphanol (Stadol) 1 mg and promethazine (Phenergan) 12.5 mg IM for a 38-week primigravida who is in early labor. Stadol is available in 2 mg/l ml vials and Phenergan is available 50 mg/I ml ampules. The nurse plans to administer both drugs in one injection. How many ml should the injection contain? 109. A client who is immunosuppressed because of treatment for systemic lupus erythematosus (SLE) delivers a viable infant at 37-weeks gestation by cesarean section. Four days later she has a fever of 102.6 F and diarrhea. A stool specimen is positive for Clostridium difficile. What action should the nurse take? 110. Which statement by a client indicates to the nurse that the client understands how a newly prescribed transdermal medication will be administered? 111. Prior to administering digoxin (Lanoxin), two nurses assess the heart rate of a client with atrial fibrillation. They both obtain an apical pulse rate of 96 beats/minute and radial pulse of 77 beats/minute. Calculate the client’s pulse deficit. 19 112. A client diagnosed with a deep vein thrombus (DVT), followed by a diagnosis of pulmonary embolism (PE), is receiving heparin via an infusion pump at a rate of 1400 U/hr. The client tells the nurse, “I wish this medicine would hurry up and dissolve this clot in my lung so that I can go home.” What response is best for the nurse to provide? 113. A male translator is working with the nurse who is giving discharge instructions to a non-English speaking client. When the translator restates what he nurse is saying, it appears that he is saying much more than what the nurse said. What action should the nurse take? 114. A nurse is named as a defendant in a malpractice case. What action should the nurse take? 115. A female client admitted to a long-term care facility appears to be confused and frightened. She offers her belongings, including valuable jewelry, to members of the nursing staff if they promise to stay with her and not leave her alone. What action should the nurse implement? 116. The nurse is teaching a childbirth education class to prospective parents and describing possible signs of labor. Class participants should be taught that which sign should be reported to the healthcare provider immediately? 117. The nurse performs a series of heel sticks to obtain glucose levels on a large-for-gestational age (LGA) newborn. Because the glucose was 48 mg/dl on admission and 39 mg/dl one hour later, a venous specimen for laboratory analysis of serum glucose concentration is obtained. What action is most important for the nurse to implement? 118. A home health care agency set the goal: “Use informatics as a method for improving health care delivery.” What nursing action is directed toward achieving this goal? 119. A client with gestational diabetes, at 39-weeks gestation, is in the second stage of labor. After delivery of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first? 120. The nurse should observe most closely for drug toxicity when a client receives a medication that has which characteristic? 121. Following insertion of a LeVeen shunt in a client with cirrhosis of the liver, which assessment finding indicates to the nurse that the shunt is effective? 122. A female client with Type 1 diabetes mellitus is trying to lose weight, and recently started an exercise program. Which information is most important for the nurse to provide this client? 123. During the second treatment with IV antibiotic, the client develops a rash on the upper torso. What intervention should the nurse implement first? 124. A male client with moderate Alzheimer’s disease had abdominal surgery yesterday. Today, when the nurse begins to perform a dressing change, the client states, “I don’t want you to change my dressing.” What is the best initial action for the nurse to take? 125. The nurse is preparing a teaching plan for a 23-year-old female client who has had a kidney transplant. What should be the nurse’s focus in conducting this teaching? 126. What instruction should the nurse include in the discharge-teaching plan of a client with ulcerative colitis who has had a traditional ileostomy? 127. The community health nurse is planning a nutritional program that targets older adults who live alone and who may be in need of additional community services. Which intervention should the nurse implement first? 128. A family member contacts the nurse at the community mental health center and wishes to share concerns and ask questions about a client’s medications. What action is best for the nurse to take? 129. The nurse provided discharge teaching to a male client who was recently diagnosed with diabetes mellitus (DM). After receiving the instructions, the client states he understands when, how, and why to take his prescribed medications at home. Which intervention is most important or the nurse to implement? 130. A male client who has a serum potassium level of 5.9 mEq tells the nurse that he has decided to leave the hospital, even though his healthcare provider has not discharged him. He also states that he does not care if he is discharged, he is refusing all treatments. It is most important for the nurse to ensure that the client understands which fact prior to leaving the facility? 131. A 6-year-old boy was hit with a bat while playing at school. He has a splinter of wood imbedded in his eye. Which action should the school nurse take? 132. What is the rationale for the nurse to teach a client to compress the lacrimal duct after eye drop instillation? 133. Three days after surgery, a male client who had a laryngectomy has an elevated pulse and respiratory rates. His skin is dry to touch and he is beginning to thrash about in the bed. What intervention should the nurse implement first? 134. A client with chronic kidney disease (CKD) is scheduled for hemodialysis Monday and Wednesday mornings. Based on findings reported in the client’s medical record, which action should the nurse implement on Wednesday morning? 135. During the initial newborn assessment, the nurse finds that a newborn’s heart rate is irregular. Which intervention should the nurse implement? 136. A client is diagnosed with a frontal lobe glioma, which is a benign brain tumor. When teaching the client about the tumor, which information should the nurse consider? 137. A client who has suffered 3rd degree burns over 60% of the body is admitted to the emergency department. The healthcare provider writes a prescription for “IV Lactated Ringer’s 350 ml/hr”. Which intervention should the nurse implement? 138. A client just returned to the nursing unit after surgery, and initial assessment findings include a pulse rate of 120 beats/minute, restlessness, cyanosis, and gurgling sounds on inspiration and expiration. What action should the nurse take first? 139. A female client comes to the clinic complaining of fatigue and inability to sleep because she is the full-time caretaker for a 22-year-old son who was paralyzed by a motor vehicle collision. She adds that her husband left her because he says he can’t take her behavior anymore since all she does is care for their son. What intervention should the nurse implement? 140. The nurse plans to administer a scheduled dose of metoprolol (Toprol SR) at 0900 to a client with hypertension. At 0800, the nurse notes that the client’s telemetry pattern shows a second-degree heart block with a ventricular rate of 50. What action should the nurse take? 141. In shift report the charge nurse is told of several problems. Which problem should the nurse address first? 142. After receiving report on an inpatient acute care unit, which client should the nurse asses first? 143. A male client diagnosed with gastroesophageal reflux (GERD) often wakes up at night experiencing heartburn. He tells the nurse that he sleeps with the head of the bed on blocks, and always drinks a glass of milk at bedtime to help him fall asleep. How should the nurse respond? 144. A client with myelogenous leukemia is receiving an autologous bone marrow transplantation (BMT). What is the priority intervention that the nurse should implement when the bone marrow is repopulating? 145. A woman is transferred to the intensive care unit after hemorrhaging during childbirth, and a pulmonary artery catheter is inserted. Her PCWP is 3, PAP is 10/2, RAP is -4, and he blood pressure is 80/60. What is the highest priority intervention? 146. A 78-year-old client in a wheelchair wants to return to bed after eating breakfast. What assessment is most important for the nurse to consider before assisting this client? 147. A client who began a series of tests for infertility last month cries when telling the nurse, “I feel like such a failure. I don’t know if I can go through with all these tests.” Which response is best for the nurse to make at this time? 148. A child with diarrhea and dehydration is receiving an IV solution of half-strength saline at 100 ml/hour and is eating ice chips continuously throughout the day. Which laboratory finding is most important for the nurse to monitor? 149. An elderly male client is experiencing urinary incontinence. What is the best initial nursing action? 150. A male client develops oral candidiasis. He has MRSA-positive sputum, is dyspneic, and is receiving oxygen per facemask and linezolid (Zyvox) 600 mg BID IV. In planning care for this client, the nurse identifies which factor as the probable cause of the stomatitis? 151. A 38-year-old male client collapsed at his outside construction job in Texas in July. His admitting vital signs to ICU are: BP 82/70, heart rate 140 beats/minute, urine output 10 ml/hr, skin cool to the touch. Pulmonary artery (PA) pressures are: PAWP 1, PAP 8/2, RAP -1, SVR 1600. What nursing action has the highest priority? 152. A one-year-old child with neuroblastoma is crying continuously and is curled into a fetal position. What action is most important for the nurse to implement? 153. A client diagnosed with major depression is being allowed a weekend pass from the psychiatric unit. Which instruction should the nurse provide to the client’s family? 154. The nurse is evaluating an asthmatic client’s response to an inhaled corticosteroid medication. What assessment finding indicates that the medication has been effective in controlling the asthma symptoms? The client has increased 155. In reviewing the goals of “Healthy People”, the nurse determines that the community has a significant problem in preventing dental caries among children. To bring about change that addresses this identified community health problem, where is the best place to initiate a prevention program? 156. A client with a permanent pacemaker develops loss of capture resulting in symptomatic sinus bradycardia at a rate of 38/minute. Which intravenous medication should the nurse prepare to administer immediately? 157. A 25-year-old female client reports to the nurse that she has a throbbing headache over her left eye that began early yesterday right after experiencing dark spots in her vision. Movement makes her nauseous, but lying still in a dark room does provide some relief. Over-the-counter pain medications have not helped. This client is describing which type of headache? 158. A client is admitted to the emergency room because of an overdose of acetaminophen (Tylenol). Following gastric lavage, the nurse should expect to administer which medication? 159. The nurse is attempting to teach a male client newly diagnosed with diabetes how to administer insulin. When the nurse attempts to answer the client’s questions he becomes angry and tells the nurse that the entire process is just too much to learn. What action is best for the nurse to take? 160. The nurse plans to administer an IV heparin bolus of 80 units/kg to a client who weighs 210 pounds. How many units should the nurse administer? 7636 [Show More]

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By Martin Freeman , Uploaded: Aug 05, 2020

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 *NURSING> EXAM > NUR 2311 Critical_Care_Exit_Hesi_2_2020 - Southeastern College | NUR2311 Critical_Care_Exit_Hesi_2_2020 (All)

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NUR 2311 Critical_Care_Exit_Hesi_2_2020 - Southeastern College | NUR2311 Critical_Care_Exit_Hesi_2_2020

Critical Care Exit HESI Nurse plans to administer a dose of metoprolol at 0900 to a client with HTN. At 0800 nurse notes telemetry pattern shows second degree heart block with Ventricular rate of 50....

By Martin Freeman , Uploaded: Aug 05, 2020

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 *NURSING> EXAM > NUR 2311 Critical_Care_Exit_Hesi_1_2020 - Southeastern College | NUR 2311 Critical_Care_Exit_Hesi_1_2020 (All)

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NUR 2311 Critical_Care_Exit_Hesi_1_2020 - Southeastern College | NUR 2311 Critical_Care_Exit_Hesi_1_2020

NUR 2311 Critical_Care_Exit_Hesi_1_2020 - Southeastern College | NUR 2311 Critical_Care_Exit_Hesi_1_2020

By Martin Freeman , Uploaded: Aug 05, 2020

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 Health Care> EXAM > 2022 HESI Med Surg Version 1 exit exam Brand New Guaranteed Pass A+ Actual Screenshots Questions & Answers Included Exam Taken: 4/14/2022 I SCORED (1030) (All)

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2022 HESI Med Surg Version 1 exit exam Brand New Guaranteed Pass A+ Actual Screenshots Questions & Answers Included Exam Taken: 4/14/2022 I SCORED (1030)

2022 HESI Med Surg Version 1 exit exam Brand New Guaranteed Pass A+ Actual Screenshots Questions & Answers Included Exam Taken: 4/14/2022 I SCORED (1030)2022 HESI Med Surg Version 1 exit exam Bra...

By Otieno , Uploaded: Jan 04, 2023

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 NURSING.> EXAM > MED SURG VERSION 1 HESI MED SURG VERSION 1 HESI MED SURG VERSION 1 HESI MED SURG VERSION 1 HESI STUDY NOTES 2023 STUDY NOTES 2023 -2024 LATEST VERSION LATEST VERSION (All)

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MED SURG VERSION 1 HESI MED SURG VERSION 1 HESI MED SURG VERSION 1 HESI MED SURG VERSION 1 HESI STUDY NOTES 2023 STUDY NOTES 2023 -2024 LATEST VERSION LATEST VERSION

MED SURG VERSION 1 HESI MED SURG VERSION 1 HESI MED SURG VERSION 1 HESI MED SURG VERSION 1 HESI STUDY NOTES 2023 STUDY NOTES 2023 -2024 LATEST VERSION LATEST VERSION

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