med surg hesi v1
The nurse obtains a fingerstick glucose level utilizing bedside lancet/glucose meter equipment
from a client with prescribed sliding scale insulin protocol. The meter indicates 56 mg/dl (3.12
mmol/l). At this time which intervention should the nurse implement first?
A. Collect a blood specimen by venipuncture to send to the laboratory for serum glucose
analysis.
B. Prepare the prescribed dose of rapid acting insulin from the sliding scale instructions.
C. Give the client six ounces of non-diet carbonated soda and instruct to drink it entirely.
D. Document the glucose reading in the electronic medical record as the only action needed.
C
To achieve maximum mobility and independence for a client with multiple sclerosis (MS), which
intervention is most important for the nurse to implement?
A. Provide a walker for ambulation
B. Frequently assist the client to the bathroom
C. Apply alternating patches over eyes
D. Teach strengthening exercises
D
Brainpower
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A client is admitted to the hospital with symptoms consistent with a right hemisphere stroke.
Which neurovascular assessment requires immediate intervention by the nurse?
A. Pupillary changes to ipsilateral dilation
, B. Orientation to person and place only
C. Left- sided drooping and dysphagia
D. Unequal bilateral hand grip strengths
C
The nurse is teaching a client with glomerulonephritis about self care. Which dietary
recommendations should the nurse encourage the client to follow?
A. Limit oral fluid intake to 500 ml per day
B. Restrict protein intake by limiting meats and other high-protein foods
C. Increase intake of potassium-rich foods such as bananas and cantaloupe.
D. Increase intake of high fiber foods such as bran cereal
B
The nurse is caring for a client with Herpes zoster who reports painful, red, blisters that align
from the back along the chest's curvature to the anterior chest. Which intervention is the highest
priority for the nurse?
A. Place the client on contact precautions
B. Administer antiviral medications
C. Place wet compresses to ruptured vesicles
D. Administer narcotic analgesics
B
A young adult who suffered a severe brain injury in an automobile collision has been
mechanically ventilated for the past three days and has no spontaneous respiratory effort. After
serial electroencephalograms (EEG) reveal no brain activity, the healthcare provider discusses
end-of-life options with the family who agree to discontinue life support. Which intervention
should the nurse implement?
A. Ask the family if they wish to remain at the bedside during withdrawal
B. Request a living will be placed in the clients medical record
C. Discuss the withdrawal procedure with the family and offer support
D. Turn off mechanical ventilator and note time of death
C
The nurse obtains a fingerstick glucose level utilizing bedside lancet/glucose meter equipment
from a client with prescribed sliding scale insulin protocol. The meter indicates 56 mg/dl (3.12
mmol/l). At this time which intervention should the nurse implement first?
A. Collect a blood specimen by venipuncture to send to the laboratory for serum glucose
analysis.
B. Prepare the prescribed dose of rapid acting insulin from the sliding scale instructions.
C. Give the client six ounces of non-diet carbonated soda and instruct to drink it entirely.
D. Document the glucose reading in the electronic medical record as the only action needed.
C
To achieve maximum mobility and independence for a client with multiple sclerosis (MS), which
intervention is most important for the nurse to implement?
A. Provide a walker for ambulation
B. Frequently assist the client to the bathroom
C. Apply alternating patches over eyes
D. Teach strengthening exercises
D
Brainpower
Read More
Previous
Play
Next
Rewind 10 seconds
Move forward 10 seconds
Unmute
0:00
/
0:15
Full screen
A client is admitted to the hospital with symptoms consistent with a right hemisphere stroke.
Which neurovascular assessment requires immediate intervention by the nurse?
A. Pupillary changes to ipsilateral dilation
, B. Orientation to person and place only
C. Left- sided drooping and dysphagia
D. Unequal bilateral hand grip strengths
C
The nurse is teaching a client with glomerulonephritis about self care. Which dietary
recommendations should the nurse encourage the client to follow?
A. Limit oral fluid intake to 500 ml per day
B. Restrict protein intake by limiting meats and other high-protein foods
C. Increase intake of potassium-rich foods such as bananas and cantaloupe.
D. Increase intake of high fiber foods such as bran cereal
B
The nurse is caring for a client with Herpes zoster who reports painful, red, blisters that align
from the back along the chest's curvature to the anterior chest. Which intervention is the highest
priority for the nurse?
A. Place the client on contact precautions
B. Administer antiviral medications
C. Place wet compresses to ruptured vesicles
D. Administer narcotic analgesics
B
A young adult who suffered a severe brain injury in an automobile collision has been
mechanically ventilated for the past three days and has no spontaneous respiratory effort. After
serial electroencephalograms (EEG) reveal no brain activity, the healthcare provider discusses
end-of-life options with the family who agree to discontinue life support. Which intervention
should the nurse implement?
A. Ask the family if they wish to remain at the bedside during withdrawal
B. Request a living will be placed in the clients medical record
C. Discuss the withdrawal procedure with the family and offer support
D. Turn off mechanical ventilator and note time of death
C
