HESI EXIT MED-SURGE EXAM TEST-BANK WITH RATIONALES PERFECT QUESTIONS & ANSWERS RATED A+

HESI EXIT MED-SURGE EXAM TEST-BANK WITH RATIONALES PERFECT QUESTIONS & ANSWERS RATED A+ The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care? (ANS- Monitor blood pressure frequently Rationale: A pheochromocytoma is a rare, catecholamine-secreting tumor that may precipitate life-threatening hypertension. The tumor is malignant in 10% of cases but may be cured completely by surgical removal. Although pheochromocytoma has classically been associated with 3 syndromes—von Hippel-Lindau (VHL) syndrome, multiple endocrine neoplasia type 2 (MEN 2), and neurofibromatosis type 1 (NF1)—there are now 10 genes that have been identified as sites of mutations leading to pheochromocytoma. When caring foraclient who has acute respiratory distresssyndrome (ARDS), thenurse elevates the head of the bed 30 degrees. What is the reason for this intervention? To reduce abdominal pressure on the diaphragm To promote retraction of the intercostalaccessory muscle ofrespirationTo promote bronchodilation and effective airway clearance To decrease pressure on the medullarycenter which stimulates breathing (ANS- Toreduce abdominal pressure on the diaphragm Rationale:asemi-sitting position is the best position for matching ventilation andperfusion and for decreasing abdominal pressure on the diaphragm, so that the client can maximize breathing. When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral borderof the rectus abdominal muscle. What isthe most likely explanation for failure tolocate the gallbladder by palpation? The client istoo obese Palpating in the wrong abdominal quadrantDeeper palpation technique is needed The gallbladder is normal (ANS- The gallbladder is normal Rationale:a normal healthy gallbladder is not palpable A woman with an anxiety disordercalls her obstetrician's office and tells the nurseof increased anxiety since the normal vaginal delivery of her son three weeks ago.Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman? Describe the transmission of drugs to the infant through breast milk Encourage her to use stress relieving alternatives,such as deep breathing exercisesInform her that some antianxiety medications are safe to take while breastfeeding Explain that anxiety is a normal response for the mother of a 3-week-old. (ANS- Inform her thatsome antianxiety medications are safe to take while breastfeeding Rationale: there are severalantianxiety medications thatare notcontraindicated forbreastfeeding mothers. An older male client with a history of type 1 diabetes has not felt well the past fewdays and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first? Start an intravenous (IV) infusion of normalsalineObtain a serum potassium level Administer the client's usual dose of insulin Assess pupillaryresponse to light (ANS- Startan intravenous (IV) infusion ofnormal saline Rationale: the nurse should first start an intravenous infusion of normal saline toreplace the fluids and electrolytes because the client has been vomiting,and it is unclear when he last ate or took insulin. The symptoms of confusion, lethargy, vomiting, and abdominal cramping are all suggestive of hyperglycemia, which alsocontributes to diuresis and fluid electrolyte imbalance. Following discharge teaching,a male client with duodenal ulcertells the nurse thehe will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best followup action bythe nurse? (ANS- Review with the client the need to avoid foods thatare rich in milkandcream A male client with hypertension, who received new antihypertensive prescriptionsat his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him "feel bad". In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition? (ANS- Stroke secondary to hemorrhage The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? (ANS- Instruct the UAP to obtain soft blankets to secure to the side rails instead ofpillows. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediatefollow-up? (ANS- Describes life without