HESI MED SURG 55 QUESTIONS ANSWERS 2018 RN V1-Clinical Complex Med Surg (Updated)

Space heater 18.C.K.D lab to report Potassium 6.5 19. Client with gullain barre is not blinking. Administer lubricant 20. Taking prednisone PO 5mg. What symptom? rapid weight gain 21. Succinylcholine. High Temperature Ice pack axillary 22. The nurse drops a sterile package of supplies on the floor in the operating room (OR) suite. The ... impervious wrapper. Which action should the nurse implement? Open contents to sterile field package intact 23.Client with acute glomerulonephritis. restrict sodium Client ask about biopsy results from cancer cells well differentiated. What response? ask hcp to gather more information Right cataract and lens implant. Which intervention should the nurse do first? Provide an eye shield to be worn while sleeping The UAP reports to the nurse that a client who was admitted with abdominal pain has just had a large black tarry stool. What intervention should the nurse implement first? Test the stool for occult blood Which action is most important for the nurse to implement to reduce the risk for deep vein thrombosis in a postoperative client? advise the client to perform leg exercises regularly The nurse is preparing a client for a bronchoscopy. While obtaining consent, the client complains of thirst and admits to drinking a small amount of orange juice two hours ago. What action should the nurse take? Delay procedure for 6 hours A client uses triamcinolone (Kenalog), a corticosteroid ointment, to manage pruritis caused by a chronic skin rash. The client calls the clinic nurse to report increased erythema with purulent exudate at the site. What action should the nurse implement? Schedule an appointment for the client to see the healthcare provider The nurse learns in change of shift report that the x-ray report for a newly admitted client indicates consolidation in the left lower lung. What action should the nurse take? Administer a PRN dose of a bronchodilator. The nurse is monitoring the glucose q4h of an adult woman admitted with DKA. Two hours after receiving 10 units of regular insulin for glucose of 255, the client is perspring and complaining of shakiness. What intervention should the nurse implement? Check capillary glucose level The chest x-ray for a client who is admitted for pneumonia shows pleural effusion with decreased air flow in the entire left upper lobe. What breath sounds that verify the x-ray findings should the nurse document after auscultation of the left upper lobe? Diminished breath sounds Which food is most important for the nurse to encourage a male patient with osteomalacia to include in his daily diet? fortified milk and cereal An older adult woman is seen in the clinic 3 months following diagnosis of type 2 diabetes mellitus (DM). She tells the nurse that she has had a difficult time keeping her blood sugar in control. The nurse reviews the client's current finger stick and daily log of blood glucose levels. Which interventions is most important for the nurse to implement? Review the client's glycosylated hemoglobin (A1c) level. The nurse is taking a client's blood pressure and observes carpal spasm after the sphygmomanometer cuff is inflated. What action should the nurse implement next? Assess the client's recent serum calcium level A male client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about the dietary restriction he should follow. In discussing fluid intake, the nurse should include which type of fluid limitation? Tea and hot chocolate "During preoperative teaching for a male client scheduled for repair of an inguinal hernia, the client tells the nurse that he has had several surgeries and understands the need to perform coughing and deep breathing exercises after surgery. How should the nurse respond? Ask for demonstration of these exercises A pt suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in the patient's plan of care? Continuous cardiac monitoring After 3 days of persistent epigastric pain, a female pt presents to the clinic. She has been taking oral antacids w/o relief. Her vital signs are HR 122 beats/min, respirations 16 breaths/min, O2 96% and BP 116/70. The nurse obtains a 12-lead ECG. Which assessment finding is most critical? ST elevation in three leads A male client with an external fixation device for a fractured left femur is complaining of left foot pain. Which intervention should the nurse implement first? Administer PRN pain medication Two days following abdominal surgery a client begins to complain of cramping abdominal pain, and the nurse's inspection of the abdomen indicates slight distention. Which action should the nurse implement first? Auscultate abdomen quadrants A fair- skinned female client who is an avid runner is diagnosed with malignant melanoma, which is located on the lateral surface of the lower leg. After wide margin resection, the nurse provides discharge teaching. It is most important for the nurse to emphasize the need to observe for changes in which characteristic? Appearance of any moles Order of 8200 units. Each 1 mL of solution contains 10,000 units of alfa. How many mL? Simply, divide 8200/10,000 = 0.8 mL What instruction should the nurse include in the discharge teaching plan of a client who had a cataract extraction today? Light housekeeping is permitted, but avoid heavy lifting When a nurse is caring for a client with acute hypothyroidism, which serum laboratory value requires immediate intervention? Serum sodium 122 mEq/L A potential donor of corneal tissue for the eye bank has just died. The nurse enters the room prescribed antibiotic eye drops. What action should the nurse take next? Secure eye shields over the closed after instilling the eyedrops. 3 months following her diagnosis of type II diabetes...had a difficult time keeping her blood sugar is centered. The nurse reviews that..blood glucose levels. Which interventions in most important for the nurse to implement? Review the client's glycosylated hemoglobin (A1c) level. What to do to avoid risk of retina damage Retinal tear 2- year old boy is having health assessment. Which further assessment by nurse? He refuses to feed but I make him eat meals A nurse is caring for a patient and is unable to palpate a pedal pulse. What should the nurse do next? Obtain a doppler What's priority for a patient who is allergic to bananas? Replace latex A client with a history of COPD has established a walking program. How do we know what walking is effective? Cardiovascular improvement Order 100 units in 250ml to infuse at 12units/hr 12/100 *250= 30 A client complains of pain in the right calf. What is the nurse's priority? Remain in bed