Hesi Review - Med Surg
A purchaser admitted to the health center with a diagnosis of acute pancreatitis has blood
drawn for several serum laboratory tests. Which of the following serum amylase values, noted
by using the nurse reviewing the results, might be expected on this consumer at the moment? -
ANS-395 gadgets/L
Rationale: The normal serum amylase variety is 25 to 151 gadgets/L. In acute pancreatitis, the
amylase degree is significantly accelerated; the extent starts growing three to six hours after the
onset of ache, peaks at about 24 hours, and returns to normal in 2 to 3 days after the onset of
ache.
A patron has a chest drainage system in place. The fluid in the water seal chamber rises and
falls during concept and expiration. The nurse translates this finding as a demonstration that: -
ANS-The tube is patent
Rationale: With ordinary respiratory and a patent chest tube, the fluid degree in the water seal
chamber rises with suggestion and falls with expiration.
A customer has been given a diagnosis of a couple of myeloma. Which of the following results
does the nurse reviewing the purchaser's laboratory findings apprehend as being specially
associated with this prognosis? - ANS-Increased calcium degree
Rationale: Multiple myeloma is characterized by means of hypercalcemia, anemia, improved
BUN, and an extended quantity of plasma cells inside the bone marrow. Hypercalcemia is a
result of the release of calcium from deteriorating bone tissue.
A customer has been scheduled for magnetic resonance imaging (MRI). For which of the
subsequent conditions, a contraindication to MRI, does the nurse test the client's medical
history? - ANS-Pacemaker insertion
Rationale: The candidate for MRI should be freed from steel devices or implants. A cautious
records is carried out to determine whether this kind of steel gadgets, together with orthopedic
hardware, pacemakers, artificial heart valves, aneurysm clips, and intrauterine gadgets, are
inside the consumer. These may additionally heat up inside the magnetic area generated by the
MRI tool, come to be dislodged, or malfunction throughout the process.
A purchaser has just been scheduled for endoscopic retrograde cholangiopancreatography
(ERCP). What must the nurse tell the consumer approximately the manner? Select all that
practice. - ANS-That knowledgeable consent is required
That meals and fluids might be withheld earlier than the process
, That a couple of position modifications may be necessary to pass the tube
Rationale: The patron should signal informed consent earlier than the procedure, which takes
about an hour to carry out. Intravenous sedation is given to relax the purchaser, and an
anesthetic spray is used to assist maintain the consumer from gagging as the endoscope is
surpassed. Food and fluids are withheld earlier than the manner to prevent aspiration. Multiple
position modifications may be vital to facilitate the passage of the tube.
A customer has simply back to the nursing unit after computerized tomography (CT) with
assessment medium. Which of the following actions must the nurse plan to take as a part of
habitual after-take care of this consumer? - ANS-Encouraging fluid intake
Rationale: After CT scanning, the purchaser may resume all regular activities. The customer
ought to be encouraged to eat greater fluids to replace the ones lost at some point of diuresis of
the assessment dye.
A purchaser has just gone through a renal biopsy. Which intervention need to the nurse include
intervention within the put up-technique plan of care? - ANS-Periodically checking out the urine
for occult blood
Rationale: After renal biopsy, bed relaxation is maintained and the customer's important signs
and puncture website online are assessed often. Urine is tested periodically for occult blood to
hit upon bleeding as a hardship.
A client has just passed through insertion of a chest tube that is attached to a closed chest
drainage machine. Which movement must the nurse plan to take within the care of this
consumer? - ANS-Taping the connections among the chest tube and the drainage system
Rationale: The nurse tapes all device connections to save you unintentional disconnection.
Drainage is referred to and recorded each hour for the duration of the primary 24 hours after
insertion and each eight hours thereafter.
A purchaser has simply passed through lumbar puncture. Into which position does the nurse
assist the client after the technique? - ANS-Flat
Rationale: After lumbar puncture, the patron must stay flat for as long as 12 hours to help
prevent post-system spinal headache and leakage of cerebrospinal fluid. Therefore the
alternative alternatives are incorrect.
A customer has gone through pericardiocentesis to deal with cardiac tamponade. For which
signs need to the nurse examine the consumer to decide whether the tamponade is routine? -
ANS-Distant muffled coronary heart sounds
A purchaser admitted to the health center with a diagnosis of acute pancreatitis has blood
drawn for several serum laboratory tests. Which of the following serum amylase values, noted
by using the nurse reviewing the results, might be expected on this consumer at the moment? -
ANS-395 gadgets/L
Rationale: The normal serum amylase variety is 25 to 151 gadgets/L. In acute pancreatitis, the
amylase degree is significantly accelerated; the extent starts growing three to six hours after the
onset of ache, peaks at about 24 hours, and returns to normal in 2 to 3 days after the onset of
ache.
A patron has a chest drainage system in place. The fluid in the water seal chamber rises and
falls during concept and expiration. The nurse translates this finding as a demonstration that: -
ANS-The tube is patent
Rationale: With ordinary respiratory and a patent chest tube, the fluid degree in the water seal
chamber rises with suggestion and falls with expiration.
A customer has been given a diagnosis of a couple of myeloma. Which of the following results
does the nurse reviewing the purchaser's laboratory findings apprehend as being specially
associated with this prognosis? - ANS-Increased calcium degree
Rationale: Multiple myeloma is characterized by means of hypercalcemia, anemia, improved
BUN, and an extended quantity of plasma cells inside the bone marrow. Hypercalcemia is a
result of the release of calcium from deteriorating bone tissue.
A customer has been scheduled for magnetic resonance imaging (MRI). For which of the
subsequent conditions, a contraindication to MRI, does the nurse test the client's medical
history? - ANS-Pacemaker insertion
Rationale: The candidate for MRI should be freed from steel devices or implants. A cautious
records is carried out to determine whether this kind of steel gadgets, together with orthopedic
hardware, pacemakers, artificial heart valves, aneurysm clips, and intrauterine gadgets, are
inside the consumer. These may additionally heat up inside the magnetic area generated by the
MRI tool, come to be dislodged, or malfunction throughout the process.
A purchaser has just been scheduled for endoscopic retrograde cholangiopancreatography
(ERCP). What must the nurse tell the consumer approximately the manner? Select all that
practice. - ANS-That knowledgeable consent is required
That meals and fluids might be withheld earlier than the process
, That a couple of position modifications may be necessary to pass the tube
Rationale: The patron should signal informed consent earlier than the procedure, which takes
about an hour to carry out. Intravenous sedation is given to relax the purchaser, and an
anesthetic spray is used to assist maintain the consumer from gagging as the endoscope is
surpassed. Food and fluids are withheld earlier than the manner to prevent aspiration. Multiple
position modifications may be vital to facilitate the passage of the tube.
A customer has simply back to the nursing unit after computerized tomography (CT) with
assessment medium. Which of the following actions must the nurse plan to take as a part of
habitual after-take care of this consumer? - ANS-Encouraging fluid intake
Rationale: After CT scanning, the purchaser may resume all regular activities. The customer
ought to be encouraged to eat greater fluids to replace the ones lost at some point of diuresis of
the assessment dye.
A purchaser has just gone through a renal biopsy. Which intervention need to the nurse include
intervention within the put up-technique plan of care? - ANS-Periodically checking out the urine
for occult blood
Rationale: After renal biopsy, bed relaxation is maintained and the customer's important signs
and puncture website online are assessed often. Urine is tested periodically for occult blood to
hit upon bleeding as a hardship.
A client has just passed through insertion of a chest tube that is attached to a closed chest
drainage machine. Which movement must the nurse plan to take within the care of this
consumer? - ANS-Taping the connections among the chest tube and the drainage system
Rationale: The nurse tapes all device connections to save you unintentional disconnection.
Drainage is referred to and recorded each hour for the duration of the primary 24 hours after
insertion and each eight hours thereafter.
A purchaser has simply passed through lumbar puncture. Into which position does the nurse
assist the client after the technique? - ANS-Flat
Rationale: After lumbar puncture, the patron must stay flat for as long as 12 hours to help
prevent post-system spinal headache and leakage of cerebrospinal fluid. Therefore the
alternative alternatives are incorrect.
A customer has gone through pericardiocentesis to deal with cardiac tamponade. For which
signs need to the nurse examine the consumer to decide whether the tamponade is routine? -
ANS-Distant muffled coronary heart sounds
