HESI Med Surgical Practice (evolve) Questions and Answers

HESI Med Surgical Practice (evolve) Questions and Answers Which assessment is most important for the nurse to perform on a client who is hospitalized for Guillain-Barre syndrome that is rapidly progressing? a. Respiratory effort. b. Unsteady gait. c. Intensity of pain. d. Ability to eat. a. Respiratory effort. Guillain-Barre syndrome causes paralysis or weakness that typically starts at the feet and progresses upwards. As the condition progresses, the nurse must ensure that the client is able to breathe effectively. While caring for a client who has esophageal varices, which nursing intervention is most important for the nurse to implement? a. Monitor infusing IV fluids and any replacement blood products. b. Prepare for esophagogastroduodenoscopy (EGD). c. Maintain the client on strict bedrest. d. Insert a nasogastric tube (NGT) for intermittent suction. a. Monitor infusing IV fluids and any replacement blood products. Maintaining hemodynamic stability in a client with esophageal varices can precipitate a life-threatening crisis if esophageal varies leak or rupture and can result in hemorrhage. The priority is assessing and monitoring infusions of IV fluids and any replacement blood products. A client with chest pain, dizziness, and vomiting for the last 2 hours is admitted for evaluation for Acute Coronary Syndrome (ACS). Which cardiac biomarker should the nurse anticipate to be elevated if the client experienced myocardial damage? a. Creatine Kinase (CK-MB). b. Serum troponin. c. Myoglobin. d. Ischemia-modified albumin. b. Serum troponin Troponin is the most sensitive and specific test for myocardial damage. Troponin elevation is more specific than CK-MB. A nurse is preparing a teaching plan for a client who is postmenopausal. Which measure is most important for the nurse to include to prevent osteoporosis? a. Take a multivitamin daily. b. Use only low fat milk products. c. Perform weight resistance exercises. d. Bicycle for at least 3 miles every day. c. Perform weight resistance exercises. Weight-bearing on the skeletal system stimulates bone formation, so recommending weight-resistance exercise is the most important in the prevention of osteoporosis in postmenopausal women. The unlicensed assistive personnel (UAP) reports that an 87-year-old female client who is sitting in a chair at the bedside has an oral temperature of 97.2 °F (36.2 °C). Which intervention should the nurse implement? a. Document the temperature reading on the vital sign graphic sheet. b. Report the temperature to the healthcare provider immediately. c. Instruct the UAP to take the client's temperature again in 30 minutes. d. Advise the UAP to assist the client in returning to her bed. a. Document the temperature reading on the vital sign graphic sheet. A subnormal temperature of 97.2 °F (36.2 °C) (orally) is a common finding in older clients, so the nurse should document the findings and continue with the plan of care. Based on an analysis of the client's rhythm, atrial fibrillation, the nurse should prepare the client for which treatment protocol? a. Diuretic therapy. b. Pacemaker implantation. c. Anticoagulation therapy. d. Cardiac catheterization. c. Anticoagulation therapy. The client is experiencing atrial fibrillation, and the nurse should prepare the client for anticoagulation therapy which should be prescribed before rhythm control therapies to prevent cardioembolic events which result from blood pooling in the fibrillating atria. Which dietary assessment finding is most important for the nurse to address when caring for a client with diabetic nephropathy? a. Drinks a six-pack of beer every day. b. Enjoys a hamburger once a month. c. Eats fortified breakfast cereal daily. d. Consumes beans and rice every day. a. Drinks a six-pack of beer every day. Drinking six beers every day is the dietary assessment finding most important for the nurse to address when caring for a client with diabetic nephropathy. The usual can of beer is 12 ounces (360 mL). Clients with diabetes are recommended to drink no more than 12 ounces of beer per day because beer contains carbohydrates that can create unhealthy fluctuations in blood glucose and promote poor glucose control. Nephropathy is exacerbated by poor blood glucose control. When planning care for a client with right renal calculi, which nursing problem has the highest priority? a. Acute pain related to movement of the stone. b. Impaired urinary elimination related to the obstructed flow of urine. c. Risk for infection related to urinary stasis. d. Deficient knowledge related to the need for prevention of recurrence of calculi. a. Acute pain related to movement of the stone. The nursing problem of the highest priority is "Acute pain related to the renal calculi's movement". The nurse is caring for a client scheduled to undergo the insertion of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks the nurse to explain how a PEG tube differs from a gastrostomy tube (GT). Which explanation best describes how they are different? a. Method of insertion. b. Location of the tubes. c. Diameter of the tubes. d. Procedure for feedings. a. Method of insertion. The best explanation of how a PEG tube differs from a GT is by the method of insertion. GT insertion involves making an incision in the wall of the abdomen and suturing the tube to the gastric wall. A PEG tube is more commonly used due to the fact it does not require general anesthesia and is less invasive due to being inserted with endoscopic visualization through the esophagus into the stomach and then pulled through a small incision in the abdominal wall and held in place by a tiny plastic device called a "bumper" that holds the tube in place inside the stomach and a small water-filled balloon which keeps the stomach in place against the abdominal wall. A client with a chronic infection of Hepatitis C virus (HCV) is scheduled for a liver biopsy. Which intervention should the nurse perform after the procedure? a. Progress activity as soon as possible. b. Assess for signs of bleeding and hypovolemia. c. Place the client in the left lateral position. d. Monitor blood pressure, pulse and breathing every 4 hours. b. Assess for signs of bleeding and hypovolemia. Assessment for signs of bleeding should be implemented because internal bleeding is the greatest risk following a liver biopsy. A client with acute osteomyelitis has undergone surgical debridement of the diseased bone and asks the nurse how long will antibiotics have to be administered. Which information should the nurse communicate? a. Oral antibiotics for 2 to 4 months, then for dental procedure prophylaxis. b. Parenteral antibiotics for 4 to 6 weeks, then oral antibiotics for up to 1 year. c. Parenteral antibiotics for 4 to 8 weeks, then oral antibiotics for 4 to 8 weeks. d. Parenteral antibiotics for 2 to 3 weeks, then oral antibiotics for 4 weeks. c. Parenteral antibiotics for 4 to 8 weeks, then oral antibiotics for 4 to 8 weeks. Treatment of acute osteomyelitis requires the administration of high doses of parenteral antibiotics for 4 to 8 weeks, followed by oral antibiotics for another 4 to 8 weeks. The nurse should explain to a client with lung cancer that pleurodesis is performed to achieve which expected outcome? a. Prevent the formation of effusion fluid. b. Remove fluid from the intrapleural space. c. Debulk tumor to maintain patency of air passages. d. Relieve empyema after pneumonectomy. a. Prevent the formation of effusion fluid. Instillation of a sclerosing agent to create pleurodesis is aimed at preventing the formation of a pleural effusion by causing the pleural spaces to be sealed together, thereby preventing the accumulation of pleural fluid. A client, who speaks very little English, is being discharged following surgery. Which nurse should the nurse manager assign to provide the discharge instructions for the client? a. A graduate registered nurse (RN) with three weeks of experience. b. The registered nurse (RN) case manager for the unit with 1 year's experience. c. A "floating" registered nurse (RN) with five years of nursing experience. d. A Korean-American practical nurse (PN) with six years of nursing experience. b. The registered nurse (RN) case manager for the unit with 1 year's experience. The RN case manager is the best-qualified nurse to assess and provide discharge educational needs, obtain resources for the client, enhance coordination of care, and prevent fragmentation of care. Which is the priority nursing action while caring for a client on a ventilator when an electrical fire occurs in the intensive care unit? a. Tell another staff member to bring extinguishing equipment to the bedside. b. Close the doors to the client's area when attempting to extinguish the fire. c. Use a bag-valve-mask resuscitator while removing the client from the area. d. Implement an emergency protocol to remove the client from the ventilator. c. Use a bag-valve-mask resuscitator while removing the client from the area. A client on a ventilator should have respirations maintained with a manual bag-valve-mask resuscitator while being moved away from the oxygen wall outlet and fire source. Which client should be further assessed for an ectopic pregnancy? a. A 24-year-old with shoulder and lower abdominal quadrant pain. b. A 33-year-old with intermittent lower abdominal cramping. c. A 20-year-old with fever and right lower abdominal colic. d. A 40-year-old with jaundice and right lower abdominal pain. a. A 24-year-old with shoulder and lower abdominal quadrant pain. A 24-year-old with sudden onset of lower abdominal quadrant pain should be assessed for an ectopic pregnancy. The pain can also be referred to the shoulder and may be associated with vaginal bleeding. A female client with type 2 diabetes mellitus reports dysuria. Which assessment finding is most important for the nurse to report to the healthcare provider? a. Suprapublic pain and distention. b. Bounding pulse at 100 beats/minute. c. Fingerstick glucose of 300 mg/dL. d. Small vesicular perineal lesions. c. Fingerstick glucose of 300 mg/dL. Elevated fingerstick glucose levels need to be reported to the healthcare provider, so a plan of care can be adjusted to treat the elevated glucose level. Also, elevated glucose levels spill into the urine and provide a medium for bacterial growth. The nurse is providing postoperative instructions for a female client after a mastectomy. Which information should the nurse include in the teaching plan? (Select all that apply.) a. Empty surgical drains once a week using procedure gloves. b. Report inflammation of the incision site or the affected arm. c. Wear clothing with snug sleeves over the arm on the operative side. d. Avoid lifting more than 4.5 kg (10 pounds) or reaching above her head. b. Report inflammation of the incision site or the affected arm. d. Avoid lifting more than 4.5 kg (10 pounds) or reaching above her head. Part of a client's s/p mastectomy teaching plan should include reporting evidence of inflammation at the incision site or the affected arm, and avoiding lifting or reaching above their head. Which assessment finding should the nurse identify that indicates a client with an acute asthma exacerbation is beginning to improve after treatment? a. Wheezing becomes louder. b. Cough remains unproductive. c. Vesicular breath sounds decrease. d. Bronchodilators stimulate coughing. a. Wheezing becomes louder. In an acute asthma attack, airflow may be so significantly restricted that breath sounds and wheezing is diminished. If the client is successfully responding to bronchodilators and respiratory treatments, wheezing should become louder as the airflow increases in the airways. As the airways open and mucous is mobilized in response to treatment, the cough should become more productive. The nurse is caring for a client with peptic ulcer disease (PUD). Which assessment should the nurse identify and document that is consistent with PUD? (Select all that apply). a. Hematemesis. b. Gastric pain on an empty stomach. c. Colic-like pain with fatty food ingestion. d. Intolerance of spicy foods. e. Diarrhea and stearrhea. a. Hematemesis. b. Gastric pain on an empty stomach. d. Intolerance of spicy foods. Manifestations of PUD include hematemesis, gastric pain, and spicy food intolerance. A college student who is diagnosed with a vaginal infection and vulva irritation describes the vaginal discharge as having a "cottage-cheese" appearance. Which prescription should the nurse implement first? a. Cleanse the perineum with warm soapy water 3 times per day. b. Instill the first dose of nystatin vaginally per applicator. c. Perform glucose measurement using a capillary blood sample. d. Obtain a blood specimen for sexually transmitted diseases (STDs). b. Instill the first dose of nystatin vaginally per applicator. Candidiasis, also known as a yeast infection, is characterized by a white, vaginal discharge with a "cottage-cheese" appearance, and vaginal nystatin should be implemented first to initiate treatment to provide relief of symptoms. A female client is recently diagnosed with Sarcoidosis. The client tells the nurse that she does not understand why she has this. When teaching about the occurrence of sarcoidosis, the nurse should include that sarcoidosis most commonly occurs in which ethnic group of women? a. Black women. b. Caucasian women. c. Asian women. d. Hispanic women. a. Black women. Sarcoidosis, an autoimmune inflammatory disease affecting multiple organs, has shown familial tendency due to multiple genes that together increase the susceptibility of developing the disease. In the United States, sarcoidosis more commonly affects Black Americans than white Americans and is twice as common in Black-American women as in Black-American men. The nurse is assessing a client who is bedfast and refuses to turn or move from a supine position. How should the nurse assess the client for possible dependent edema? a. Compress the flank and upper buttocks. b. Measure the client's abdominal girth. c. Gently palpate the lower abdomen. d. Apply light pressure over the shins. a. Compress the flank and upper buttocks. Dependent edema collects in dependent areas, such as the flank and upper buttocks of the client who is persistently flat in bed. By compressing these areas, the nurse can determine if any pitting edema is present. A client in the preoperative holding area receives a prescription for midazolam IV. The nurse determines that the surgical consent form needs to be signed by the client. Which action should the nurse implement? a. Give the drug and allow the client to read and sign the consent form. b. Counter-sign the client's initials on the consent form after giving the drug. c. Withhold the drug until the client validates understanding of the surgical procedure and signs the consent form. d. Call the healthcare provider to explain the surgical procedure before the client signs the consent. c. Withhold the drug until the client validates understanding of the surgical procedure and signs the consent form. Midazolam, a benzodiazepine sedative, is commonly used for conscious sedation intraoperatively and interferes with the client's cognition and level of consciousness, so the consent form should be signed before the drug is administered. Which preexisting diagnosis places a client at the greatest risk of developing superior vena cava syndrome? a. Carotid stenosis. b. Steatosis hepatitis. c. Metastatic cancer. d. Clavicular fracture. c. Metastatic cancer. Superior vena cava syndrome occurs when the superior vena cava (SVC) is compressed by outside structures, such as a growing tumor that impedes the return of blood flow to the heart. Superior vena cava syndrome is likely to occur with metastatic cancer from a primary tumor in the upper lobe of the right lung that compresses the superior vena cava. A young adult female reports that she is experiencing a lack of appetite, hypersomnia, stress incontinence, and irritability. Which symptom is not frequently associated with PMS? a. Heart palpitations. b. Anorexia. c. Hypersomnia. d. Stress incontinence. a. Heart palpitations. Characteristic features of premenstrual syndrome include behavioral changes/irritability, sleeplessness, increased appetite and food cravings, and oliguria or enuresis. While heart palpitations can occur at times with PMS, it is not a characteristic finding. The nurse is caring for a young adult who is having an oral glucose tolerance test (OGTT). Which laboratory result should the nurse assess as a normal value for the two-hour postprandial result? a. 140 mg/dL. b. 160 mg/dL. c. 180 mg/dL. d. 200 mg/dL. a. 140 mg/dL. The two-hour postprandial level should be less than 140 mg/dL for a young adult client. Which finding should the nurse report to the healthcare provider for a client with a circumferential extremity burn? a. Full thickness burns rather than partial thickness. b. Supinates extremity but is unable to fully pronate the extremity. c. Slow capillary refill in the digits with absent distal pulse points. d. Inability to distinguish sharp versus dull sensations in the extremity. c. Slow capillary refill in the digits with absent distal pulse points. A circumferential burn can form an eschar that results from burn exudate fluid that dries and acts as a tourniquet as fluid shifts occur in the interstitial tissue. As edema increases tissue pressure, blood flow to the distal extremity is compromised, which is manifested by slow capillary refill and absent distal pulses, so the healthcare provider should be notified about any compromised circulation that requires escharotomy. A male client comes into the clinic with a history of penile discharge with painful, burning urination. Which action should the nurse implement? a. Collect a culture of the penile discharge. b. Palpate the inguinal lymph nodes gently. c. Observe for scrotal swelling and redness. d. Express the discharge to determine color. a. Collect a culture of the penile discharge. Penile discharge with painful urination is commonly associated with gonorrhea. The nurse should collect a culture of the penile discharge to determine the cause of these symptoms. The cause must be determined or confirmed through culture to identify the organism and ensure effective treatment. A client with rheumatoid arthritis is prescribed piroxicam, a nonsteroidal antiinflammatory drug (NSAID). Which effect is characteristic of NSAIDs used for treating rheumatoid arthritis? a. Production of replacement cartilage is stimulated. b. Further destruction of the articular cartilage is prevented. c. Inflammation is reduced by inhibiting prostaglandin synthesis. d. Bradykinin is inhibited, thereby reducing acute and chronic pain. c. Inflammation is reduced by inhibiting prostaglandin synthesis. Nonsteroidal antiinflammatory drugs (NSAIDs) are used for treating rheumatoid arthritis by inhibiting the synthesis of prostaglandins and providing relief from the associated pain. The nurse completes a visual inspection of a client's abdomen. Which technique should the nurse perform next in the abdominal examination? a. Percussion. b. Auscultation. c. Deep palpation. d. Light palpation. b. Auscultation. Auscultation of the client's abdomen is performed next because manual manipulation of the abdomen can stimulate peristalsis and create an inaccurate assessment of bowel sounds heard during auscultation. The nurse is caring for a male client who had an inguinal herniorrhaphy 3 hours ago. The nurse determines the client's lower abdomen is distended and assesses dullness to percussion. Which is the priority nursing action? a. Assessment of the client's vital signs. b. Document the finding as the only action. c. Determine the time the client last voided. d. Insert a rectal tube for the passage of flatus. c. Determine the time the client last voided. Swelling at the surgical site in the immediate postoperative period can impact the bladder and prostate area causing the client to experience difficulty voiding due to pressure on the urethra. To provide additional data supporting bladder distention, the last time the client voided should be determined next. A man who smokes two packs of cigarettes a day wants to know if smoking is contributing to the difficulty that he and his wife are having getting pregnant. Which information is best for the nurse to provide? (Select all that apply.) a. Only marijuana cigarettes affect sperm count. b. Smoking can decrease the quantity and quality of sperm. c. The first semen analysis should be repeated to confirm sperm counts. d. Cessation of smoking improves general health and fertility. e. Sperm specimens should be collected in 2 subsequent days. b. Smoking can decrease the quantity and quality of sperm. c. The first semen analysis should be repeated to confirm sperm counts. d. Cessation of smoking improves general health and fertility. The use of tobacco, alcohol, and marijuana may affect a man's sperm counts. A nurse is preparing to insert an IV catheter after applying a eutectic mixture of lidocaine and prilocaine (EMLA), a topical anesthetic cream. Which action should the nurse take to maximize its therapeutic effect? a. Rub a liberal amount of cream into the skin thoroughly. b. Cover the skin with a gauze dressing after applying the cream. c. Leave the cream on the skin for 1 to 2 hours before the procedure. d. Use the smallest amount of cream necessary to numb the skin surface. c. Leave the cream on the skin for 1 to 2 hours before the procedure. Topical anesthetic creams, such as EMLA, should be applied to the puncture site at least 60 minutes to 2 hours before the insertion of an IV catheter. A client with a recent history of blood in his stools is scheduled for a proctoscopy/sigmoidoscopy. The nurse should implement which protocols to prepare the client for this procedure? (Select all that apply.) a. Obtain consent for the procedure. b. Initiate preoperative sedation. c. Begin fast the morning of the procedure. d. Administer an enema before the procedure. e. Provide a clear-liquid diet 48 hours before the procedure. a. Obtain consent for the procedure. c. Begin fast the morning of the procedure. d. Administer an enema before the procedure. e. Provide a clear-liquid diet 48 hours before the procedure. The usual preoperative preparation for proctoscopy/sigmoidoscopy entails obtaining the client's consent to the procedure, a clear liquid diet for 24 to 48 hours prior to the procedure, administration of an enema, and fasting on the morning of the procedure. A client with sickle cell anemia is admitted with severe abdominal pain and the diagnosis is sickle cell crisis. Which is the most important nursing action to implement? a. Limit the client's intake of oral fluids and food. b. Evaluate the effectiveness of narcotic analgesics. c. Encourage the client to ambulate as tolerated. d. Teach the client about the prevention of crises. b. Evaluate the effectiveness of narcotic analgesics. Pain management is the priority for a client during sickle cell crisis. Continuous narcotic analgesics are the mainstay of pain control, which should be evaluated frequently to determine if the client's pain is adequately controlled. A client who is admitted to the coronary care unit with a myocardial infarction (MI) begins to develop increased pulmonary congestion, an increase in heart rate from 80 to 102 beats per minute, and cold, clammy skin. Which action should the nurse implement? a. Notify the healthcare provider. b. Increase the IV flow rate. c. Place the client in the supine position. d. Prepare the client for emergency echocardiography. a. Notify the healthcare provider. Increased pulmonary congestion, increased heart rate, and cold, clammy skin in a client with a myocardial infarction indicate impending cardiogenic shock related to heart failure, a common complication of MI. The healthcare provider should be notified immediately for emergency interventions for this life-threatening complication. A client who returns to the unit after having a percutaneous coronary intervention (PCI) with balloon angioplasty, complains of acute chest pain. Which action should the nurse implement next? a. Inform the healthcare provider. b. Obtain a 12-lead electrocardiogram. c. Give a sublingual nitroglycerin tablet. d. Administer prescribed analgesic. c. Give a sublingual nitroglycerin tablet. After a percutaneous coronary intervention (PCI) with balloon angioplasty, a client who experiences acute chest pain may be experiencing cardiac ischemia related to re-stenosis, stent thrombosis, or acute coronary syndrome involving any coronary artery. The first action is to administer nitroglycerin to dilate the coronary arteries and increase myocardial oxygenation. The nurse is caring for a client with human immunodeficiency virus (HIV) infection who develops Mycobacterium avium complex (MAC). Which is the most significant desired outcome for this client? a. Free from injury of drug side effects. b. Return to pre-illness weight. c. Adequate oxygenation. d. Maintenance of intact perineal skin. b. Return to pre-illness weight. MAC is an opportunistic infection that presents as a tuberculosis-like pulmonary process. MAC is a major contributing factor to the development of wasting syndrome, so the most significant desired outcome is the client's return to a pre-illness weight using oral, enteral, or parenteral supplementation as needed. A client with type II diabetes arrives at the clinic with a blood glucose of 50 mg/dL. The nurse provides the client with 6 ounces of orange juice. In 15 minutes the client's capillary glucose is 74 mg/dL. Which action should the nurse take? a. Obtain a specimen for a serum glucose level. b. Administer insulin per sliding scale. c. Provide cheese and bread to eat.' d. Collect a glycosylated hemoglobin specimen. c. Provide cheese and bread to eat.' Once blood glucose is greater than 70 mg/dl, the client should eat a regularly scheduled meal or a snack that contains protein and carbohydrates to help prevent hypoglycemia from recurring. The nurse is caring for a client after transurethral resection of the prostate (TURP) and determines the client's urinary catheter is not draining. What should the nurse implement? a. Reposition the catheter drainage tubing. b. Encourage the client to drink oral fluids. c. Irrigate the catheter. d. Change drainage unit tubing. c. Irrigate the catheter. Obstruction of urinary flow after a TURP is most often due to blood clots, and sterile irrigation should be implemented to remove the clots that are blocking the catheter. Which assessment finding should most concern the nurse who is monitoring a client two hours after a thoracentesis? a. New onset of coughing. b. Low resting heart rate. c. Distended neck veins. d. Decreased shallow respirations. a. New onset of coughing. A pneumothorax (partial or complete lung collapse) is the potential complication of a thoracentesis. Manifestations of a pneumothorax include the new onset of a nagging cough, tachycardia, and an increased shallow respiration rate. A client with heart failure is prescribed digoxin 0.125 mg PO. The client's apical heart rate is 70 beats per minute, respirations are 18 breaths per minute and blood pressure is 125/75 mmHg. Which action should the nurse implement next? a. Administer the medication. b. Inform the healthcare provider. c. Review the vital sign flowsheet. d. Reassess the apical heart rate. a. Administer the medication. Obtaining the apical heart rate is a common parameter prior to administering digoxin, which may indicate early digoxin toxicity if the heart rate is less than 60 beats per minute, so the dose should be administered since the client is not demonstrating any signs of toxicity. A client with osteoarthritis requests information from the nurse about which type of exercise regimen would be most beneficial for him. The nurse should communicate which information? a. Low-impact exercise, walking, swimming, and water aerobics. b. Repetitive strength-building exercises with weights or resistance bands. c. Circuit training alternating with frequent rest periods. d. High-impact aerobic exercise. a. Low-impact exercise, walking, swimming, and water aerobics. Low-impact exercises such as walking or swimming, that do not put additional pressure and strain or cause further harm to damaged joints, are most beneficial to clients with osteoarthritis. Strength-building exercises, circuit training, and high-impact aerobics may cause too much stress on the joint areas and subsequently increase inflammation and damage. The nurse is assessing common complications related to a client's recent diagnosis, systemic lupus erythematosus (SLE). Which symptom should the nurse instruct the client to report immediately? a. Fever related to infection. b. Weight loss and anorexia. c. Depressed mood. d. Break in tissue integrity. a. Fever related to infection. Secondary infections are a major concern with SLE clients due to the use of corticosteroids and chemotherapeutic agents, which suppresses the immune system, so reporting fever and infections should be reported immediately. A client who has a chronic cough with blood-tinged sputum returns to the unit after a bronchoscopy. Which nursing interventions should be implemented in the immediate postprocedural period? a. Keep the client on bed rest for eight hours. b. Check vital signs every 15 minutes for two hours. c. Allow the client nothing by mouth until the gag reflex returns. d. Encourage fluid intake to promote the elimination of the contrast media. c. Allow the client nothing by mouth until the gag reflex returns. The nasal pharynx and oral pharynx are anesthetized with local anesthetic spray prior to bronchoscopy, and the bronchoscope is coated with lidocaine gel to inhibit the gag reflex and prevent laryngeal spasm during insertion. The client should be NPO until the client's gag reflex returns to prevent aspiration from any oral intake or secretions. An older female client is admitted with atrophic vaginitis and perineal cutaneous candidiasis. Which is the priority nursing problem for this client? a. Risk for injury. b. Impaired comfort. c. Disturbed body image. d. Ineffective health maintenance. b. Impaired comfort. In menopausal women, the vaginal mucous membrane responds to low estrogen levels causing the vaginal walls to become thinner, drier, and susceptible to infection which leads to atrophic vaginitis. Perineal cutaneous candidiasis contributes to other manifestations of vaginal infections, such as vaginal irritation, burning, pruritus, increased leukorrhea, bleeding, and dyspareunia, which supports the primary nursing problem, "Impaired comfort". A client arrives at the emergency department for treatment of injuries sustained in a motor vehicle collision. The nurse notes the asymmetrical expansion of the chest wall during respiration. Which action should the nurse implement next? a. Auscultate the lungs bilaterally. b. Inspect the overall skin color. c. Palpate for tactile fremitus. d. Percuss the chest for resonance. a. Auscultate the lungs bilaterally. Chest trauma may result in the development of pneumothorax. After noting the asymmetric expansion of the chest wall, the nurse should auscultate the lungs to determine if the client can move air through all of the lung fields. Which instruction should the nurse include in the discharge teaching for a client who needs to perform the self-catheterization technique at home? a. Catheterize every 4 to 6 hours. b. Maintain sterile technique. c. Use the Crede maneuver before catheterization. d. Drink 500 mL of fluid within 2 hours of catheterization. a. Catheterize every 4 to 6 hours. The average interval between catheterizations for adults is every 4 to 6 hours. Although the sterile technique is indicated in healthcare facilities, the clean technique is often followed by the client when performing self-catheterization at home. The nurse is preparing a client for orthopedic surgery on the left leg and completing a safety checklist before transport to the operating room. Which items should the nurse remove from the client? (Select all that apply.) a. Nail polish. b. Hearing aids may be left in place so the client can hear all instructions but should be removed prior to induction. c. Wedding band. d. Left leg brace. e. Contact lenses. f. Partial dentures. a. Nail polish. b. Hearing aids may be left in place so the client can hear all instructions but should be removed prior to induction. e. Contact lenses. f. Partial dentures. The removal of nail polish provides more accurate pulse oximetry readings and evaluation of capillary refill. Hearing aids, contact lenses, and partial dentures are removed to prevent damage, loss or misplacement, or injury during surgery. Ideally, give the client's significant other the contact lenses if they are not disposable ones, hearing aids, and partial dentures once placed in an appropriately labeled container to hold for safekeeping. If no significant other is able to hold onto the items, then secure them in an appropriate and safe place. During the initial outbreak of genital herpes simplex for a female client, which should be the nurse's primary focus in planning care? a. Promotion of comfort. b. Prevention of pregnancy. c. Instruction in condom use. d. Information about transmission. a. Promotion of comfort. The initial outbreak of genital herpes simplex in a woman causes severe discomfort. The promotion of comfort is the first priority. The nurse is teaching a client about precautions for a new prescription for lovastatin. Which symptom should the nurse instruct the client to report to the healthcare provider immediately? a. Terrible nightmares. b. Increased nocturia. c. Severe muscle pain. d. Visual disturbances. c. Severe muscle pain. A potential, serious side effect of statin therapy that is used to lower both LDL-C and triglyceride levels is rhabdomyolysis, which is manifested by severe muscle pain and aching. The nurse is preparing a teaching plan for a client with newly diagnosed glaucoma and a history of allergic rhinitis. Which information is most important for the nurse to provide the client about using over-the-counter (OTC) medications for allergies? a. Notify your healthcare provider if there is an increase in heart rate. b. Increase fluid intake while taking an antihistamine or decongestant. c. Avoid allergy medications that contain pseudoephedrine or phenylephrine. d. Ophthalmic lubricating drops may be used for eye dryness due to allergy medications. c. Avoid allergy medications that contain pseudoephedrine or phenylephrine. OTC allergy medications may contain ephedrine, phenylephrine, or pseudoephedrine, which can cause adrenergic side effects, such as increased intraocular pressure, so a client with glaucoma should avoid using these OTC medications.