HESI MED-SURG practice exam Questions and Answers

HESI MED-SURG practice exam Questions and Answers Which description of pain is consistent with a diagnosis of rheumatoid arthritis? Joint pain is worse in the morning and involves symmetric joints. Joint pain is better in the morning and worsens throughout the day. Joint pain is consistent throughout the day and is relieved by pain medication. Joint pain is worse during the day and involves unilateral joints. Joint pain is worse in the morning and involves symmetric joints. Rheumatoid arthritis (RA) is an autoimmune disease that causes joint pain and swelling. RA is characterized by pain that is worse when arising and involves symmetric joints. Jarvis. (2016), Physical Examination and Health Assessment, 7th Ed., Chapter 22; p. 586 Which physical assessment finding should the nurse anticipate in a client with long-term gastroesophagealreflux disease (GERD)? Hoarseness. Dry mouth. Mouth ulcers. Weight loss. Hoarseness. Dyspepsia and regurgitation are the main symptoms of gastroesophageal reflux disease (GERD); however, hoarseness is one of the most common long-term symptoms of GERD due to the irritation of the reflux of gastric secretions. Ignatavicius, (2016). Medical-surgical nursing: Patient-centered collaborative care, eight edition., Ch. 49, p. 1111. A client presents with chronic venous insufficiency. Which assessment finding should the nurse anticipate? Bilateral lower leg stasis dermatitis. Clubbing of fingers and toes. Intermittent claudication. Peripheral cyanosis. Bilateral lower leg stasis dermatitis. Clients who suffer from chroninc venous insufficiency often develop statsis dermatitis in the lower extremities. Statis dermatitis appear as brownish-red discoloration on the lower extremities at the ankles which can develop into stasis ulcers due to the pooling of the venous blood flow back to the heart. Ignatavicius, (2013). Medical-surgical nursing: Patient-centered collaborative care, 7th ed.., Ch. 33, p. 803. A client has been hospitalized with a femur fracture and is being treated with traction. Which action by the nurse is the priority when caring for this client? Assess neurovascular status. Change the client's position. Inspect the traction equipment. Review pain medication orders. Assess neurovascular status. The use of traction for long bone fractures reduces the potential for damage to the surrounding tissues. Reports of increased pain may indicate circulatory compromise or tissue damage (compartment syndrome). Assessing the client's neurovascular status is the nurse's highest priority. Ignatavicius, (2016). Medical-surgical nursing: Patient-centered collaborative care, eight edition., Ch. 51, pp. 1051-80. Which statement made by a client with chronic pancreatitis indicates that further education is needed? I will cut back on smoking cigarettes daily. I will avoid drinking caffeinated beverages. I will rest frequently and avoid vigorous exercise. I will eat a bland, low-fat, high-protein diet. I will cut back on smoking cigarettes daily. To prevent exacerbations of chronic pancreatitis, clients should be instructed to avoid nicotine entirely. Additional teaching includes avoiding caffeinated beverages, resting frequently as needed, and eating a bland diet low fat and high in protein.Ignatavicius, (2016). Medical-surgical nursing: Patient-centered collaborative care, 8th ed., Ch. 59, pp. 1084-98. The nurse is teaching a female client who uses a contraceptive diaphragm about reducing the risk for toxic shock syndrome (TSS). Which information should the nurse include? (Select all that apply.) Remove the diaphragm immediately after intercourse. Wash the diaphragm with an alcohol solution. Use the diaphragm to prevent conception during the menstrual cycle. Do not leave the diaphragm in place longer than 8 hours after intercourse. Replace the old diaphragm every 3 months. Do not leave the diaphragm in place longer than 8 hours after intercourse. Replace the old diaphragm every 3 months. The diaphragm needs to remain against the cervix for 6 to 8 hours to prevent pregnancy but should not remain for longer than 8 hours to avoid the risk of toxic shock syndrome. The diaphragm should be replaced every 3 months to maintain integrity. A male client who smokes two packs of cigarettes a day states he understands that smoking cigarettes is contributing to the difficulty that he and his wife are having in getting pregnant and wants to know if other factors could be contributing to their difficulty. What information is best for the nurse to provide? (Select all that apply.) Marijuana cigarettes do not affect sperm count. Alcohol consumption can cause erectile dysfunction. Low testosterone levels affect sperm production. Cessation of smoking improves general health and fertility. Obesity has no effect on sperm production. Alcohol consumption can cause erectile dysfunction. Low testosterone levels affect sperm production. Cessation of smoking improves general health and fertility. Use of tobacco, alcohol, and marijuana may affect sperm counts. Sperm count is also negatively affected by low testerone levels and obesity. Twenty four hours after a client returns from surgical gastric bypass, the registered nurse (RN) observes large amounts of blood in the nasogastric tube (NGT) cannister. Which assessment finding should the RN report as early signs of hypovolemic shock? Faint pedal pulses. Decrease in blood pressure. Lethargy. Slow breathing. Lethargy. One of the early signs of hypovolemic shock is changes in the client's level of consciousness due to the decrease perfusion to the brain which can manifests as lethargy or confusion. The registered nurse (RN) is assessing a male client who arrives at the clinic with severe abdominal cramping, pain, tenesmus, and dehydration. The RN discovers that the client has had 14 to 20 loose stools with rectal bleeding. When taking the client's medical history, which information is most for the nurse to obtain? Irritable bowel syndrome. Diverticulitis. Crohn's disease. Ulcerative colitis. Ulcerative colitis. The RN should ask the client if he has a history of ulcerative colitis, which is characterized by severe abdominal cramping, pain, tenesmus, and dehydration . A client is newly diagnosed with diverticulosis. The registered nurse (RN) is assessing the client's basic knowledge about the disease process. Which statement by the client conveys an understanding of the etiology of diverticula? Over use of laxatives for bowel regularity result in loss of peristaltic tone. Inflammation of the colon mucosa cause growths that protrude into the colon lumen. Diverticulosis is the result of high fiber diet and sedentary life style. Chronic constipation causes weakening of colon wall which result in out-pouching sacs. Chronic constipation causes weakening of colon wall which result in out-pouching sacs. A client who has chronic constipation often strains to pass constipated stool which increases intestinal pressure that weakens the intestinal walls and causes out-pouching sacs, called diverticula which commonly occur in the sigmoid. The registered nurse (RN) is assessing a client who was discharged home after management of chronic hypertension. Which equipment should the RN instruct the client to use at home? Exercise bicycle. Sphygmomanometer. Blood glucose monitor. Weekly medication box. Sphygmomanometer. Self-awareness is the best way for a client to manage chronic hypertension, so the client should obtain a sphygmomanometer and learn how to monitor blood pressure daily and maintain a record. A young adult male is diagnosed with Stage 4 Hodgkin's lymphoma in the abdominopelvic region and is scheduled for radiation therapy (RT). The client expresses concern about becoming infertile. How should the nurse respond? Propose sperm banking before RT then artificial insemination is an option. Suggest adoption when the client is in remission or ready for parenting. Tell the client that infertility is a non-reversible side effect of radiotherapy. Explain that sperm production will be suppressed after radiotherapy is over. Propose sperm banking before RT then artificial insemination is an option. Radiation at high doses kills the stem cells that produce sperm. While infertility after radiotherapy often occurs, the nurse should be supportive and offer alternatives that address the client's concerns and treatment decisions. Suggesting sperm banking is the most sensitive and supportive response. A client's susceptibility to ulcerative colitis is most likely due to which aspect in the client's history? Jewish European ancestry. H. pylori bowel infection. Family history of irritable bowel syndrome. Incorrect Age between 25 and 55 years. Jewish European ancestry. Ulcerative colitis is 4 to 5 times more common among individuals of Jewish European or Ashkenazi ancestry. Small bowel obstruction is a condition characterized by which finding? Severe fluid and electrolyte imbalances. Metabolic acidosis. Ribbon-like stools. Intermittent lower abdominal cramping. Severe fluid and electrolyte imbalances. Among the findings characteristic of a small bowel obstruction is the presence of severe fluid and electrolyte imbalances. Which client should the nurse recognize as most likely to experience sleep apnea? Middle-aged female who takes a diuretic nightly. Obese older male client with a short, thick neck. Adolescent female with a history of tonsillectomy. School-aged male with a history of hyperactivity disorder. Obese older male client with a short, thick neck. Sleep apnea is characterized by lack of respirations for 10 seconds or more during sleep and is due to the loss of pharyngeal tone which allows the pharynx to collapse during inspiration and obstructs air flow through the nose and mouth. Risk factors which increase the condition of sleep apnea include: excessive weight, increases the risk 4 times more than normal weighing individuals; neck circumference, thicker necks have narrower airways; individuals with inherited narrower airways; males in general are more prone to sleep apnea; females risk increase with being overweight and post-menopausal; increased age (geriatrics); family history; use of alcohol, sedatives or tranquilizers; smokers and those who suffer from nasal allergies. Which milestone indicates to the nurse successful achievement of young adulthood? Demonstrates a conceptualization of death and dying. Completes education and becomes self-supporting. Creates a new definition of self and roles with others. Develops a strong need for parental support and approval. Completes education and becomes self-supporting. Transitioning through young adulthood is characterized by establishing independence as an adult, and includes developmental tasks such as completing education, beginning a career, and becoming self-supporting. A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L (2.9 mmol/L). Which action is most important for the nurse to implement? Give 20 mEq of potassium chloride. Initiate continuous cardiac monitoring. Arrange a consultation with the dietician. Teach about the side effects of diuretics. Initiate continuous cardiac monitoring. Hypokalemia (normal 3.5 to 5 mEq/L [3.5 to 5 mmol/L]) causes changes in myocardial irritability and ECG waveform, so it is most important for the nurse to initiate continuous cardiac monitoring to identify ventricular ectopy or other life-threatening dysrhythmias. After cardiac monitoring is initiated, then the potassium chloride should be given so that the effects of potassium replacement on the cardiac rhythm can be monitored. Which postmenopausal client's complaint should the nurse refer to the healthcare provider? Breasts feel lumpy when palpated. History of white nipple discharge. Episodes of vaginal bleeding. Excessive diaphoresis occurs at night. Episodes of vaginal bleeding. Postmenopausal vaginal bleeding may be an indication of endometrial cancer, which should be reported to the healthcare provider. The nurse is teaching a female client about the best time to plan sexual intercourse in order to conceive. Which information should the nurse provide? Two weeks before menstruation. Vaginal mucous discharge is thick. Low basal temperature. First thing in the morning. Two weeks before menstruation. Ovulation typically occurs 14 days before menstruation begins during a typical 28 day cycle. Sexual intercourse should occur within 24 hours of ovulation for an increase chance of conception to occur. High estrogen levels occur during ovulation and increase the vaginal mucous membrane characteristics to become more "slippery" and stretchy, along with a rise in basal temperature. The timing during the day is not as significant in determining conception as the day before and after ovulation. A postmenopausal client asks the nurse why she is experiencing discomfort during intercourse. Which response is best for the nurse to provide? Estrogen deficiency causes the vaginal tissues to become dry and thinner. Infrequent intercourse results in the vaginal tissues losing their elasticity. Dehydration from inadequate fluid intake causes vulva tissue dryness. Lack of adequate stimulation is the most common reason for dyspareunia. Estrogen deficiency causes the vaginal tissues to become dry and thinner. Estrogen deprivation decreases the moisture-secreting capacity of vaginal cells, so vaginal tissues tend to become thinner, drier, and the rugae become smoother which reduces vaginal stretching that contributes to dyspareunia. The discomfort during intercourse, primary cause can be contributed to the decrease in estrogen hormone levels. Which discharge instruction is most important for a client after a kidney transplant? Weigh weekly. Report symptoms of secondary Candidiasis. Use daily reminders to take immunosuppressants. Stop cigarette smoking. Use daily reminders to take immunosuppressants. After a renal transplantation, acute rejection is a high risk for several months. The organ recipient will have to take immunosuppressive therapy for the rest of their lives, such as corticosteroids and azathioprine, to prevent organ transplant rejection. Discharge instructions include measures such as daily reminders to ensure the client takes these medications regularly to prevent organ rejection from occurring. The nurse is assessing a client with chronic kidney disease (CKD). Which finding is most important for the nurse to respond to first? Potassium 6.0 mEq. Daily urine output of 400 ml. Peripheral neuropathy. Uremic fetor. Potassium 6.0 mEq. When assessing a client with chronic kidney disease (CKD), hyperkalemia (normal serum level, 3.5 to 5.5 mEq) is a serious electrolyte disorder that can cause fatal arrhythmias, so the elevation of the potassium level is a nursing priority. Which finding should the nurse identify as most significant for a client diagnosed with polycystic kidney disease (PKD)? Hematuria. 2 pounds weight gain. 3+ bacteria in urine. Steady, dull flank pain. 3+ bacteria in urine. Urinary tract infections (UTI) for a client with polycystic kidney disease (PKD) require prompt antibiotic therapy to prevent renal damage and scarring which may cause further progression of the disease so bacteria in the urine would be significant finding. The nurse is planning care for a client with newly diagnosed diabetes mellitus that requires insulin. Which assessment should the nurse identify before beginning the teaching session? Present knowledge related to the skill of injection. Intelligence and developmental level of the client. Willingness of the client to learn the injection sites. Financial resources available for the equipment. Willingness of the client to learn the injection sites. If a client is incapable or does not want to learn, it is unlikely that learning will occur, so motivation is the first factor the nurse should assess before teaching. When providing discharge teaching for a client with osteoporosis, the nurse should reinforce which home care activity? A diet low in phosphates. Skin inspection for bruising. Exercise regimen, including swimming. Elimination of hazards to home safety. Elimination of hazards to home safety. Discussion about fall prevention strategies is imperative for the discharged client with osteoporosis. Advice about safety measures in the home should be provided such as the elimination of throw rugs and proper lighting to minimize trip hazards and falls. A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client? Losing weight. Decreasing caffeine intake. Avoiding large meals. Raising the head of the bed on blocks. Raising the head of the bed on blocks. Raising the head of the bed on blocks (reverse Trendelenburg position) to reduce reflux and subsequent aspiration is the most non-pharmacological effective recommendation for a client experiencing severe gastroesophageal reflux during sleep. An older adult female client is brought to the clinic by her daughter for a flu shot. She has lost significant weight since the last visit. She has poor personal hygiene and inadequate clothing for the weather. The client states that she lives alone and denies problems or concerns. Which action should the nurse implement? Notify social services immediately of suspected elderly abuse. Discuss the need for mental health counseling with the daughter. Explain to the client that she needs to take better care of herself. Collect further data to determine whether self-neglect is occurring. Collect further data to determine whether self-neglect is occurring. Changes in weight and hygiene may be indicators of self-neglect or neglect by family members. Further assessment is needed before notifying social services or discussing a need for counseling. The nurse is assisting a client out of bed for the first time after surgery. Which action should the nurse do first? Place a chair at a right angle to the bedside. Encourage deep breathing prior to standing. Help the client to sit and dangle legs on the side of the bed. Allow the client to sit with the bed in a high Fowler's position. Allow the client to sit with the bed in a high Fowler's position. The first step in assisting a client out of bed for the first time after surgery is to raise the head of the bed to a high Fowler's position, which allows venous return to compensate from lying flat and the vasodilation effects of perioperative drugs. This helps prevent the client from becoming light-headed and decreases the chance of a client fall. After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 mL for the last 2 hours. Which priority nursing action should be implemented? Report the findings to the surgeon. Irrigate the indwelling urinary catheter. Apply manual pressure to the bladder. Increase the IV flow rate for 15 minutes. Report the findings to the surgeon. After surgery, an adult who weighs 132 pounds (60 kg) should produce about 60 mL of urine hourly (1 mL/kg/hour). Dark, concentrated, and low volume of urine output should be reported to the surgeon. A client who is fully awake after a gastroscopy asks the nurse for something to drink. After confirming that liquids are allowed, which assessment action should the nurse consider a priority? Listen to bilateral lung and bowel sounds. Obtain the client's pulse and blood pressure. Assist the client to the bathroom to void. Check the client's gag and swallow reflexes. Check the client's gag and swallow reflexes. Following gastroscopy, a client should remain nothing by mouth until the effects of local anesthesia have dissipated and the airway's protective gag and swallow reflexes have returned. During an interview with a client planning elective surgery, the client asks the nurse, "What is the advantage of having a preferred provider organization insurance plan?" Which response is best for the nurse to provide? Neither plan allows selections of healthcare providers or hospitals. There are fewer healthcare providers to choose from than in an HMO plan. An individual may select healthcare providers from outside of the PPO network. An individual can become a member of a PPO without belonging to a group. An individual may select healthcare providers from outside of the PPO network. The financial implication of selecting a provider from outside of the network is the feature most relevant to the average consumer. The nurse must have knowledge about preferred provider organizations (PPOs), which provides the option for the consumer to select a Healthcare Provider (HCP) from within the PPO network (in-network) at a reduced cost versus a higher cost for selecting an out-of-network HCP. The nurse is providing dietary instructions to a 68-year-old client who is at high risk for development of coronary heart disease (CHD). Which information should the nurse include? Limit dietary selection of cholesterol to 300 mg per day. Increase intake of soluble fiber to 10 to 25 grams per day. Decrease plant stanols and sterols to less than 2 grams/day. Ensure saturated fat is less than 30% of total caloric intake. Increase intake of soluble fiber to 10 to 25 grams per day. To reduce risk factors associated with coronary heart disease, the daily intake of soluble fiber should be increased to between 10 and 25 grams per day. According to the American Heart Association, soluble fibers helps reduce LDL cholesterol levels. A male client receives a local anesthetic during surgery. During the post-operative assessment, the nurse notices the client is slurring his speech. Which action should the nurse take? Determine the client is anxious and allow him to sleep. Evaluate his blood pressure, pulse, and respiratory status. Review the client's pre-operative history for alcohol abuse. Continue to monitor the client for reactivity to anesthesia. Evaluate his blood pressure, pulse, and respiratory status. Slurred speech in the post-operative client who received a local anesthetic is an atypical finding and may indicate neurological deficits that require further assessment, so obtaining the client's vital signs will provide information about possible cardiovascular complications, such as stroke. A client who is sexually active with several partners requests an intrauterine device (IUD) as a contraceptive method. Which information should the nurse provide? Using an IUD offers no protection against sexually transmitted diseases (STD), which increase the risk for pelvic inflammatory disease (PID). Getting pregnant while using an IUD is common and is not the best contraceptive choice. Relying on an IUD may be a safer choice for monogamous partners, but a barrier method provides a better option in preventing STD transmission. Selecting a contraceptive device should consider choosing a successful method used in the past. Using an IUD offers no protection against sexually transmitted diseases (STD), which increase the risk for pelvic inflammatory disease (PID). The use of an intrauterine device (IUD) provides the client with no protection from sexually transmitted diseases (STD). A female client requests information about using the calendar method of contraception. Which assessment is most important for the nurse to obtain? Amount of weight gain or weight loss during the previous year. An accurate menstrual cycle diary for the past 6 to 12 months. Skin pigmentation and hair texture for evidence of hormonal changes. Previous birth-control methods and beliefs about the calendar method. An accurate menstrual cycle diary for the past 6 to 12 months. The fertile period, which occurs 2 weeks prior to the onset of menses, is determined using an accurate record of the number of days of the menstrual cycles for the past 6 months, so it is most important to emphasize to the client that accuracy and being compliant in recording the menstrual diary is the basis of the calendar method. A 32-year-old female client complains of severe abdominal pain each month before her menstrual period, painful intercourse, and painful defecation. Which additional history should the nurse obtain that is consistent with the client's complaints? Frequent urinary tract infections. Inability to get pregnant. Premenstrual syndrome. Chronic use of laxatives. Inability to get pregnant. Dysmenorrhea, dyspareunia, and difficulty or painful defecation are common symptoms of endometriosis, which is the abnormal displacement of endometrial tissue in the dependent areas of the pelvic peritoneum. A history of infertility is another common finding associated with endometriosis. A 20-year-old female client calls the nurse to report a lump she found in her breast. Which response is the best for the nurse to provide? "Check it again in one month, and if it is still there schedule an appointment." "Most lumps are benign, but it is always best to come in for an examination." "Try not to worry too much about it, because usually, most lumps are benign." "If you are in your menstrual period it is not a good time to check for lumps." "Most lumps are benign, but it is always best to come in for an examination." The nurse advising the client to come in provides the best response because it addresses the client's anxiety most effectively and encourages prompt and immediate action for a potential problem. The nurse is working with a 71-year-old obese client with bilateral osteoarthritis (OA) of the hips. Which recommendation should the nurse make that is most beneficial in protecting the client's joints? Increase the amount of calcium intake in the diet. Apply alternating heat and cold therapies. Initiate a weight-reduction diet to achieve a healthy body weight. Use a walker for ambulation to lessen weight-bearing on the hips. Initiate a weight-reduction diet to achieve a healthy body weight. Achieving a healthy weight is critical to protect the joints of clients with osteoarthritis (OA). Weight loss for obese clients will take off the excess pressure that weight bearing joints such as the hips and knees are exposed to and reduce the wear and tear of the joints. A 58-year-old client who has been post-menopausal for five years is concerned about the risk for osteoporosis because her mother has the condition. Which information should the nurse offer? Osteoporosis is a progressive genetic disease with no effective treatment. Calcium loss from bones can be slowed by increasing calcium intake and exercise. Estrogen replacement therapy should be started to prevent the progression osteoporosis. Low-dose corticosteroid treatment effectively halts the course of osteoporosis. Calcium loss from bones can be slowed by increasing calcium intake and exercise. Post-menopausal females are at risk for osteoporosis due to the cessation of estrogen secretion, but a regimen including calcium, vitamin D, and weight-bearing exercise can help prevent further bone loss. During assessment of a client with amyotrophic lateral sclerosis (ALS), which finding should the nurse identify when planning care for this client? Muscle weakness. Urinary frequency. Abnormal involuntary movements. A decline in cognitive function. . Muscle weakness. Amyotrophic lateral sclerosis (ALS) is characterized by a degeneration of motor neurons in the brainstem and spinal cord and is manifested by muscle weakness and wasting The nurse formulates the nursing problem of urinary retention related to sensorimotor deficit for a client with multiple sclerosis. Which nursing intervention should the nurse implement? Teach the client techniques of intermittent self-catheterization. Decrease fluid intake to prevent over distention of the bladder. Use incontinence briefs to maintain hygiene with urinary dribbling. Explain that anticholinergic drugs will decrease muscle spasticity. Teach the client techniques of intermittent self-catheterization. Bladder control is a common problem for clients diagnosed with multiple sclerosis. A client with urinary retention should receive instructions about self-catheterization to prevent bladder distention. The nurse is caring for a client with a stroke resulting in right-sided paresis and aphasia. The client attempts to use the left hand for feeding and other self-care activities. The spouse becomes frustrated and insists on doing everything for the client. Based on this data, which nursing problem should the nurse document for this client? Situational low self-esteem related to functional impairment and change in role function. Disabled family coping related to dissonant coping style of significant person. Interrupted family processes related to shift in health status of family member. Risk for ineffective therapeutic regimen management related to complexity of care. Disabled family coping related to dissonant coping style of significant person. A stroke affects the whole family and in this case the spouse probably thinks that she is helping and needs to feel that she is contributing to the client's care. Her help is noted as being incongruent with attempts of self-care by the client thereby disabling family coping. A client with a completed ischemic stroke has a blood pressure of 180/90 mmHg. Which action should the nurse implement? Position the head of the bed (HOB) flat. Withhold intravenous fluids. Administer a bolus of IV fluids. Give an antihypertensive medication. Give an antihypertensive medication. Most ischemic strokes occur during sleep when baseline blood pressure declines or blood viscosity increases due to minimal fluid intake. Completed strokes usually produce neurologic deficits within an hour, and the client's current elevated blood pressure requires antihypertensive medication. A client with a 16-year history of diabetes mellitus is having renal function tests because of recent fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels. Which finding should the nurse conclude as an early symptom of renal insufficiency? Dyspnea. Nocturia. Confusion. Stomatitis. Nocturia. As the glomerular filtration rate decreases in early renal insufficiency, metabolic waste products, including urea, creatinine, and other substances, such as phenols, hormones, and electrolytes, accumulate in the blood. In the early stage of renal insufficiency, polyuria results from the inability of the kidneys to concentrate urine and contributes to nocturia. The nurse is caring for a client with a continuous feeding through a percutaneous endoscopic gastrostomy (PEG) tube. Which intervention should the nurse include in the plan of care? Flush the tube with 50 ml of water q 8 hours. Check for tube placement and residual volume q4 hours. Obtain a daily x- ray to verify tube placement. Position on left side with head of bed elevated 45 degrees. Check for tube placement and residual volume q4 hours. Percutaneous endoscopic gastrostomy (PEG) tube placement and residual volume should be checked every four hours for clients on continuous feeding. If the gastric residual is more than 200mL for an adult client; stop the feeding and re-check the gastric residual one hour later. If the residual still remains more than 200mL; continue to keep the feeding on hold and contact the client's health care provider. The nurse is planning care to prevent complications for a client with multiple myeloma. Which intervention is most important for the nurse to include? Safety precautions during activity. Incorrect Assess for changes in size of lymph nodes. Maintain a fluid intake of 3 to 4 L per day. Administer narcotic analgesic around the clock. Maintain a fluid intake of 3 to 4 L per day. Multiple myeloma is a malignancy of plasma cells that infiltrate bone causing demineralization and hypercalcemia, so maintaining a urinary output of 1.5 to 2 L per day requires an intake of 3 to 4 L to promote excretion of serum calcium. When teaching diaphragmatic breathing to a client with chronic obstructive pulmonary disease (COPD), which information should the nurse provide? Place a small book or magazine on the abdomen and make it rise while inhaling deeply. Purse the lips while inhaling as deeply as possible and then exhale through the nose. Wrap a towel around the abdomen and push against the towel while forcefully exhaling. Place one hand on the chest, one hand the abdomen and make both hands move outward. Place a small book or magazine on the abdomen and make it rise while inhaling deeply. Diaphragmatic or abdominal breathing uses the diaphragm instead of accessory muscles to achieve maximum inhalation and to slow the respiratory rate. The client should protrude the abdomen on inhalation and contract it with exhalation, so placing a book or magazine, helps the client visualize the rise and fall of the abdomen. During suctioning, a client with an uncuffed tracheostomy tube begins to cough violently and dislodges the tracheostomy tube. Which action should the nurse implement first? Notify the healthcare provider for reinsertion. Attempt to reinsert the tracheostomy tube. Position the client in a lateral position with the neck extended. Ventilate client's tracheostomy stoma with a manual bag-mask. Attempt to reinsert the tracheostomy tube. The nurse should attempt to reinsert the tracheostomy tube by using a hemostat to open the tracheostomy or by grasping the retention sutures (if present) to spread the opening and insert a replacement tube (with its obturator) into the stoma. Once in place, the obturator should immediately be removed. A client is admitted for further testing to confirm sarcoidosis. Which diagnostic test provides definitive information that the nurse should report to the healthcare provider? Lung tissue biopsy. Positive blood cultures. Magnetic resonance imaging (MRI). Computerized tomography (CT) of the thorax. Lung tissue biopsy. Sarcoidosis is an inflammatory condition that is characterized by the formation of widespread granulomatous lesions involving a pulmonary primary site. Although chest radiography identifies sarcoidosis, lung tissue biopsy obtained by bronchoscopy or bronchoalveolar lavage provides definitive confirmation. How should the nurse position the electrodes for modified chest lead one (MCL I) telemetry monitoring? Positive polarity right shoulder, negative polarity left shoulder, ground left chest nipple line. Positive polarity left shoulder, negative polarity right chest nipple line, ground left chest nipple line. Positive polarity right chest nipple line, negative polarity left chest nipple line, ground left shoulder. Negative polarity left shoulder, positive polarity right chest nipple line, ground left chest nipple line. Negative polarity left shoulder, positive polarity right chest nipple line, ground left chest nipple line. In MCL I monitoring, the positive electrode is placed on the client's mid-chest to the right of the sternum, and the negative electrode is placed on the upper left part of the chest. The ground may be placed anywhere, but is usually placed on the lower left portion of the chest. A 57-year-old male client is scheduled to have a stress-thallium test the following morning and is NPO after midnight. At 0130, he is agitated because he cannot eat and is demanding food. Which response is best for the nurse to provide to this client? "I'm sorry sir, you have a prescription for nothing by mouth from midnight tonight." "I will let you have one cracker, but that is all you can have for the rest of tonight." "What did the healthcare provider tell you about the test you are having tomorrow?" "The test you are having tomorrow requires that you have nothing by mouth tonight." "The test you are having tomorrow requires that you have nothing by mouth tonight." Being direct and explaining to the client that the test requires him to be NPO, is the most therapeutic statement because the nurse is responding to the client's question and providing him the reason why. The nurse working on a telemetry unit finds a client unconscious and in pulseless ventricular tachycardia (VT). The client has an implanted automatic defibrillator. Which action should the nurse implement? Prepare the client for transcutaneous pacemaker. Shock the client with 200 joules per hospital policy. Use a magnet to deactivate the implanted pacemaker. Observe the monitor until the onset of ventricular fibrillation. Shock the client with 200 joules per hospital policy. A client with an automatic defibrillator who is experiencing pulseless ventricular tachycardia (VT) must be externally shocked with 200 joules per hospital policy to restore an effective cardiac rhythm. The automatic defibrillator is obviously malfunctioning. In preparing to administer intravenous albumin to a client following surgery, which are the priority nursing interventions? (Select all that apply.) Set the infusion pump to infuse the albumin within four hours. Compare the client's blood type with the label on the albumin. Assign a UAP to monitor blood pressure q15 minutes. Administer through a large gauge catheter. Monitor hemoglobin and hematocrit levels. Assess for increased bleeding after administration. Set the infusion pump to infuse the albumin within four hours. Administer through a large gauge catheter. Monitor hemoglobin and hematocrit levels. Assess for increased bleeding after administration. Albumin should be infused within four hours because it does not contain any preservatives. Any fluid remaining after four hours should be discarded. A large gauge catheter allows for fast infusion rate, which may be necessary. Hemodilution may decrease hemoglobin (HgB) and hematocrit (HCT) levels, so the HgB and HCT levels should be monitored while monitoring for bleeding because of the increased blood volume and blood pressure. The nurse working in a postoperative surgical clinic is assessing a woman who had a left radical mastectomy for breast cancer. Which factor puts this client at greatest risk for developing lymphedema? She sustained an insect bite to her left arm yesterday. She has lost twenty pounds since the surgery. Her healthcare provider now prescribes a calcium channel blocker for hypertension. Her hobby is playing classical music on the piano. She sustained an insect bite to her left arm yesterday. A radical mastectomy interrupts lymph flow, and the increased lymph flow that occurs in response to the insect bite increases the risk for the occurrence of lymphedema. Which intervention should the nurse implement for a female client diagnosed with pelvic relaxation disorder? Describe proper administration of vaginal suppositories and cream. Encourage the client to perform Kegel exercises 10 times daily. Explain the importance of using condoms when having sexual intercourse. Discuss the importance of keeping a diary of daily temperature and menstrual cycle events. Encourage the client to perform Kegel exercises 10 times daily Pelvic relaxation disorders are structural disorders resulting from weakening support tissues of the pelvis. Kegel exercises help strengthen the surrounding muscles. Despite several eye surgeries, a 78-year-old client who lives alone has persistent vision problems. The visiting nurse is discussing home safety hazards with the client. The nurse suggests that the edges of the steps be painted which color? Black. White. Light green. Medium yellow. Medium yellow. The color yellow is the easiest for a person with failing vision to see What types of medications should the nurse expect to administer to a client during an acute respiratory distress episode? Vasodilators and hormones. Analgesics and sedatives. Anticoagulants and expectorants. Bronchodilators and steroids. Bronchodilators and steroids. Besides supplemental oxygen, a client with acute respiratory distress syndrome (ARDS) needs medications to widen air passages, increase air space, and reduce alveolar membrane inflammation, such as bronchodilators and steroids. A 46-year-old female client is admitted for acute renal failure secondary to diabetes and hypertension. Which test is the best indicator of adequate glomerular filtration? Serum creatinine. Blood Urea Nitrogen (BUN). Sedimentation rate. Urine specific gravity. Serum creatinine. Creatinine is a product of muscle metabolism that is filtered by the glomerulus, and blood levels of this substance are not affected by dietary or fluid intake. An elevated creatinine strongly indicates nephron loss, reducing filtration. Two days postoperative, a male client reports aching pain in his left leg. The nurse assesses redness and warmth on the lower left calf. Which intervention would be most helpful to this client? Apply sequential compression devices (SCDs) bilaterally. Assess for a positive Homan's sign in each leg. Pad all bony prominences on the affected leg. Advise the client to remain in bed with the leg elevated. Advise the client to remain in bed with the leg elevated. For a client exhibiting symptoms of deep vein thrombosis (DVT), a complication of immobility, the initial care includes bedrest and elevation of the extremity. Healthcare workers must protect themselves against becoming infected with HIV. The Center for Disease Control has issued guidelines for healthcare workers in relation to protection from HIV. These guidelines include which recommendation? Place HIV positive clients in strict isolation and limit visitors. Wear gloves when coming in contact with the blood or body fluids of any client. Conduct mandatory HIV testing of those who work with AIDS clients. Freeze HIV blood specimens at -70 F to kill the virus. Wear gloves when coming in contact with the blood or body fluids of any client. The CDC guidelines recommend that healthcare workers use gloves when coming in contact with blood or body fluids from any client since HIV is infectious before the client becomes aware of their exposure and/or symptomatic. A 51-year-old truck driver who smokes two packs of cigarettes a day and is 30 pounds overweight is diagnosed with having a gastric ulcer. Which content is most important for the nurse to include in the discharge teaching for this client? Information about smoking cessation. Diet instructions for a low-residue diet. Instructions on a weight-loss program. The importance of increasing milk in the diet. Information about smoking cessation. Smoking has been associated with ulcer formation, and stopping or decreasing the number of cigarettes smoked per day is an important aspect of ulcer management. In assessing cancer risk, the nurse identifies which woman as being at greatest risk of developing breast cancer? A 35-year-old multipara who never breastfed. A 50-year-old whose mother had unilateral breast cancer. A 55-year-old whose mother-in-law had bilateral breast cancer. A 20-year-old whose menarche occurred at age 9. A 50-year-old whose mother had unilateral breast cancer. The most predictive risk factors for development of breast cancer are over 40 years of age and a positive family history (occurrence in the immediate family, i.e., mother or sister). Other risk factors include nulliparity, no history of breastfeeding, early menarche and late menopause, but are not considered as predictive as a positive history of an immediate family member and over 40 years old. An adult client is admitted to the hospital burn unit with partial-thickness and full-thickness burns over 40% of the body surface area. In assessing the potential for skin regeneration, which should the nurse remember about full-thickness burns? Regenerative function of the skin is absent because the dermal layer has been destroyed. Tissue regeneration will begin several days following return of normal circulation. Debridement of eschar will delay the body's ability to regenerate normal tissue. Normal tissue formation will be preceded by scar formation for the first year. Regenerative function of the skin is absent because the dermal layer has been destroyed. Full-thickness burns destroy the entire dermal layer. Included in this destruction is the regenerative tissue. For this reason, tissue regeneration does not occur, and skin grafting is necessary. A client is admitted to the medical intensive care unit with a diagnosis of myocardial infarction. The client's history indicates the infarction occurred ten hours ago. Which laboratory test result would the nurse expect this client to exhibit? Elevated LDH. Elevated serum amylase. Elevated CK-MB. Elevated hematocrit. Elevated CK-MB. The cardiac isoenzyme CK-MB (C) is the one of the cardiac markers to indicate myocardial damage in the presence of MI symptoms and after a positive troponin. The troponin levels will elevate within 2-3 hours indicating myocardial ischemia, followed by the CK-MB cardiac markers within 6-9 hours, peaking within 12 to 20 hours after myocardial infarction (MI). The nurse is assessing a client who smokes cigarettes and has been diagnosed with emphysema. Which finding would the nurse expect this client to exhibit? A decreased total lung capacity. Normal arterial blood gases. Normal skin coloring. An absence of sputum. Normal skin coloring. The differentiation between the "pink puffer" and the "blue bloater" is a well-known method of differentiating clients exhibiting symptoms of emphysema (normal color but puffing respirations) from those exhibiting symptoms of chronic bronchitis (edematous, cyanotic, shallow respirations). Image: The nurse is assessing a client who smokes cigarettes and has been diagnosed with emphysema. Which finding would the nurse expect this client to exhibit? A decreased total lung capacity. Normal arterial blood gases. Normal skin coloring. An absence of sputum. pink puffer Image: pink puffer Blue bloater Image: Blue bloater A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which statement by the nurse provides the most accurate explanation for use of the splints? Prevention of deformities. Avoidance of joint trauma. Relief of joint inflammation. Improvement in joint strength. Prevention of deformities. Splints may be used at night by clients with rheumatoid arthritis to prevent deformities caused by muscle spasms and contractures. A client who was in a motor vehicle collision was admitted to the hospital and the right knee was placed in skeletal traction. The nurse has documented this nursing diagnosis in the client's medical record: "Potential for impairment of skin integrity related to immobility from traction." Which nursing intervention is indicated based on this diagnosis statement? Release the traction q4h to provide skin care. Turn the client for back care while suspending traction. Provide back and skin care while maintaining the traction. Give back care after the client is released from traction. Provide back and skin care while maintaining the traction. Maintaining skin integrity and providing back care is difficult when a client is in traction, but must be performed and is the correct intervention to maintain the client's skin integrity. The nurse assesses a client with advanced cirrhosis of the liver for signs of hepatic encephalopathy. Which finding would the nurse consider an indication of progressive hepatic encephalopathy? An increase in abdominal girth. Hypertension and a bounding pulse. Decreased bowel sounds. Difficulty in handwriting. Difficulty in handwriting. A daily record in handwriting may provide evidence of progression of hepatic encephalopathy leading to coma. A client taking furosemide, reports difficulty sleeping. Which question is important for the nurse to ask the client? "What dose of medication are you taking?" "Are you eating foods rich in potassium?" "Have you lost weight recently?" "At what time do you take your medication?" "At what time do you take your medication?" For a client taking a loop diuretic who complains of sleep issues, the nurse needs to first determine at what time of day the client takes the medication. Because of the diuretic effect of furosemide, clients should take the medication in the morning to prevent nocturia which may be the reason for the sleep difficulties. A client taking a thiazide diuretic for the past six months has a serum potassium level of 3. The nurse anticipates which change in prescription for the client? The dosage of the diuretic will be decreased. The diuretic will be discontinued. A potassium supplement will be prescribed. The dosage of the diuretic will be increased. A potassium supplement will be prescribed. A potassium level of 3 is considered low (normal is 3.5 to 5). Taking a thiazide diuretic often results in a loss of potassium, so a potassium supplement needs to be prescribed to restore a normal serum potassium level. A client experiencing uncontrolled atrial fibrillation is admitted to the telemetry unit. Which initial medication should the nurse anticipate administering to the client? Xylocaine. Procainamide. Phenytoin. Digoxin. Digoxin. Digoxin is administered for uncontrolled, symptomatic atrial fibrillation resulting in a decreased cardiac output. Digoxin slows the rate of conduction by prolonging the refractory period of the AV node, thus slowing the ventricular response, decreasing the heart rate, and effecting cardiac output. A client receiving cholestyramine for hyperlipidemia should be evaluated for which vitamin deficiency? K. B12. B6. C. K. Cholestyramine is administered to help lower the triglycerides levels. Side effects clients should be monitored for include increased prothrombin time and prolonged bleeding times which would alert the nurse to a vitamin K deficiency. These drugs reduce absorption of the fat soluble (lipid) vitamins A, D, E, and K. A client who is receiving chemotherapy asks the nurse, "Why is so much of my hair falling out each day?" Which response by the nurse best explains the reason for alopecia? "Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant." "Alopecia is a common side effect you will experience during long-term steroid therapy." "Your hair will grow back completely after your course of chemotherapy is completed." "The chemotherapy causes permanent alterations in your hair follicles that lead to hair loss." "Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant." The common adverse effects of chemotherapy (nausea, vomiting, alopecia, bone marrow depression) are due to chemotherapy's effect on the rapidly reproducing cells, both normal and malignant. The nurse is preparing a teaching plan for a client who is newly diagnosed with Type 1 diabetes mellitus. Which clinical cues should the nurse describe when teaching the client about hypoglycemia? Sweating, trembling, tachycardia. Polyuria, polydipsia, polyphagia. Nausea, vomiting, anorexia. Fruity breath, tachypnea, chest pain. Sweating, trembling, tachycardia. Sweating, dizziness, and trembling are signs of hypoglycemic reactions related to the release of epinephrine as a compensatory response to the low blood sugar. A female client taking oral contraceptives reports to the nurse that she is experiencing calf pain. Which action should the nurse implement? Determine if the client has also experienced breast tenderness and weight gain. Encourage the client to begin a regular, daily program of walking and exercise. Advise the client to notify the healthcare provider for immediate medical attention. Tell the client to stop taking the medication for a week to see if symptoms subside. Advise the client to notify the healthcare provider for immediate medical attention. Calf pain is indicative of thrombophlebitis, a serious, life-threatening complication associated with the use of oral contraceptives which requires further assessment and possibly immediate medical intervention. The healthcare provider prescribes aluminum and magnesium hydroxide, 1 tablet PO PRN, for a client with chronic kidney disease (CKD) who is complaining of indigestion. Which intervention should the nurse implement? Administer 30 minutes before eating. Evaluate the effectiveness 1 hour after administration. Instruct the client to swallow the tablet whole. Question the healthcare provider's prescription. Question the healthcare provider's prescription. Magnesium agents are not usually used for clients with CKD due to the risk of hypermagnesemia, so this prescription should be questioned by the nurse. A client has been taking oral corticosteroids for the past five days because of seasonal allergies. Which assessment finding is of most concern to the nurse? White blood count of 10,000 mm3. Serum glucose of 115 mg/dl. Purulent sputum. Excessive hunger. Purulent sputum. Steroids cause immunosuppression, and purulent sputum is an indication of infection, so this symptom is of greatest concern. A client with multiple sclerosis has experienced an exacerbation of symptoms, including paresthesias, diplopia, and nystagmus. Which instruction should the nurse provide? Stay out of direct sunlight. Restrict intake of high protein foods. Schedule extra rest periods. Go to the emergency room immediately. Schedule extra rest periods. Exacerbations of the symptoms of MS occur most commonly as the result of fatigue and stress. The client should be encouraged to schedule extra rest periods to help reduce the symptoms. The nurse is assessing a client with bacterial meningitis. Which assessment finding indicates the client may have developed septic emboli? Cyanosis of the fingertips. Bradycardia and bradypnea. Presence of S3 and S4 heart sounds. 3+ pitting edema of the lower extremities. . Cyanosis of the fingertips. Septic emboli secondary to meningitis commonly lodge in the small arterioles of the extremities, causing a decrease in circulation to the hands which may lead to gangrene A 58-year-old client, who has no health problems, asks the nurse about the Pneumovax vaccine. The nurse's response to the client should be based on which information? The vaccine is given annually before the flu season to those over 50 years of age. The immunization is administered once to older adults or persons with a history of chronic illness. The vaccine is for all ages and is given primarily to those persons traveling overseas to areas of infection. The vaccine will prevent the occurrence of pneumococcal pneumonia for up to five years. The immunization is administered once to older adults or persons with a history of chronic illness. It is recommended by the CDC (Dec 2016) that persons over 65 years of age and those with a history of chronic illness receive the vaccine once in a lifetime. An elderly client is admitted with a diagnosis of bacterial pneumonia. When observing the client for the first signs of decreasing oxygenation, the nurse should assess for which clinical cues? Abominal distention. Undue fatigue. Cyanosis of the lips. Confusion and tachycardia. Confusion and tachycardia. The onset of pneumonia in the elderly may be signaled by general deterioration, confusion, increased heart rate or increased respiratory rate due to the decreased oxygen- carbon dioxide exchange at the alveoli, known as the V-Q mismatch. Cyanosis is a very late sign. An older adult male client comes to the geriatric screening clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg which is warm to the touch and suspects it might be thrombophlebitis. Which type of pain would further confirm this suspicion? Pain in the calf awakening him from a sound sleep. Calf pain on exertion which stops when standing in one place. Pain in the calf upon exertion which is relieved by rest and elevating the extremity. Pain upon arising in the morning which is relieved after some stretching and exercise. pain in the calf upon exertion which is relieved by rest and elevating the extremity. Thrombophlebitis pain is relieved by rest and elevation of the extremity. It typically occurs with exercise at the site of the thrombus, and is aggravated by placing the extremity in a dependent position, such as standing in one place. An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that his tongue is somewhat cracked and his eyeballs are sunken into his head. Which nursing intervention is indicated? Help the client to determine ways to increase his fluid intake. Obtain an appointment for the client to see an ear, nose, and throat specialist. Schedule an appointment with an allergist to determine if the client is allergic to the cat. Encourage the client to slightly increase his use of oxygen at night and to always use humidified oxygen. Help the client to determine ways to increase his fluid intake. The nurse should suggest creative methods to increase the intake of fluids, such as having disposable fruit juices readily available. Clients with COPD should be encouraged to have at least three liters of fluids a day to help keep their mucus thin. As the disease progresses, these clients often reduce fluid intake because of shortness of breath experienced while drinking and due to the fact,that they may be on diuretics related to heart involvement with the disease and may purposely limit their fluid intake to decrease the need for elimination. A 77-year-old female client is admitted to the hospital. She is confused, has no appetite, is nauseated and vomiting, and is complaining of a headache. Her pulse rate is 43 beats per minute. It is most important for the nurse to assess for which finding? Wearing dentures. Use of aspirin prior to admit. Prescribed nitroglycerin for chest pain. Takes digitalis. Takes digitalis. Although it is important to obtain a complete medication history, the symptoms described are classic for digitalis toxicity, and assessment of this problem should be made promptly. Elderly persons are particularly susceptible to digitalis intoxication which manifests itself in such symptoms as anorexia, nausea, vomiting, diarrhea, headache, and fatigue. The nurse knows that lab values sometimes vary for the older client. Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old male? Increased WBC, decreased RBC. Increased serum bilirubin, slightly increased liver enzymes. Increased protein in the urine, slightly increased serum glucose levels. Decreased serum sodium, an increased urine specific gravity. Increased protein in the urine, slightly increased serum glucose levels. As older adults age, the protein found in urine slightly rises as a result of kidney changes, and the serum glucose increases slightly, also due to changes in the kidney. The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information would be most useful to the nurse when planning activities for the group? The length of time each group member has resided at the nursing home. A brief description of each resident's family life. The age of each group member. The usual activity patterns of each member of the group. The usual activity patterns of each member of the group. An older person's level of activity is a determining factor in adjustment to aging as described by the Activity Theory of Aging. The most useful information initially would be an assessment of each individual's adjustment to the aging process. While working in the emergency room, the nurse is exposed to a client with active tuberculosis. When should the nurse plan to obtain a tuberculin skin test? Immediately after the exposure. Within one week of the exposure. Four to six weeks after the exposure. Three months after the exposure. Four to six weeks after the exposure. A tuberculin skin test is effective 4 to 6 weeks after an exposure, so the individual with a known exposure should wait 4 to 6 weeks before having a tuberculin skin test. A client has taken steroids for 12 years to help manage chronic obstructive pulmonary disease (COPD). When making a home visit, which nursing assessment is of greatest importance to this client? pulse rate, both apically and radially. blood pressure, both standing and sitting. temperature. skin color and turgor. temperature. Long term use of steroids by COPD clients is effective in suppressing inflammation in their airways making it easier for them to breath, but at the same time suppresses the immune system, placing the client at risk for infection, so it is very important to obtain the client's temperature.