Med Surg Hesi 2024, Questions and Answers Verified 100%

A client is admitted with rapid atrial flutter is receiving amiodarone 1mg/min via a peripheral line. The UAP reports to the nurse that the client's HR is 90 BPM, and BP is 110/50. Which intervention should the nurse implement? 1. tell the uap to turn off the amiodarone 2. restart the IV infusion in another site 3. Determine the regularity of the peripheral pulses 4. Evaluate the rhythm of the heart rate - CORRECT ANSWER-$. Evaluate the rhythm of the heart rate The nurse notes there is bloody drainage trickling from under a client who had a thyroidectomy yesterday. Which action should the nurse take? 1. Apply pressure to client's incision. 2. reinforced the dressing with sterile gauze 3. Remove the dressing and apply steri strips 4. Assess the client's ability to swallow - CORRECT ANSWER-4. Assess the client's ability to swallow A client tells the nurse that her biopsy results indicate that the cancer cells were well differentiated. How should the nurse respond? 1. Offer the client reassurance that this indicates the cancer cells are benign 2. explain that these tissue cells often respond more effectively to radiation than chemo 3. help the client make plans to begin immediate treatment since her cancer is likely to spread 4. Ask the client if the healthcare provider has given her any information about the classification of her cancer - CORRECT ANSWER-4. the nurse is teaching a client recently diagnosed with SLE about self-care. Which instruction should be included in this client's teaching plan? 1. Encourage use of a cromolyn inhaler prior to activity 2. use tanning beds in place of sun bathing 3, remove tags, curtains, and other dust collection items in the home 4. avoid large crowds and people with infections - CORRECT ANSWER-4, avoid large crowds and people with infections a client is being treated for SIADH. On examination the client has a weight gain of 4.4lbs. In 24 hours, and an elevated HR. Which intervention should the nurse implement first? 1. Record usual eating patterns 2. Measure ankle circumference 3. Review ABG's 4. Enurse the client takes a diuretic every morning - CORRECT ANSWER-4. Ensure the client takes a diuretic every morning A client recently diagnosed with DM is admitted with watery diarrhea, deep rapid respirations, and reports having a sever headache for the past week. VS 80/40, HR 134 bpm, RR 36. Which interventions should the nurse implement first 1. Rapidly infused bolus of NS 2. Obtain the clietns admission weight 3. Check the urine for ketones 4. Assess for evidence of fruity breath - CORRECT ANSWER-!. Rapidly infused bolus of NS A client with DM seems confused and parents with onset of headache, polyuria, fatigue, and blurry vision. What action should the nurse implement. 1. Arrange for a vision consultation 2. Request a urine culture 3. Provide the client with a cup of juice 4. check the client's blood glucose - CORRECT ANSWER-4. check the client's blood glucose After 3 days of nausea, vomiting, and fatigue a client with adrenal insufficiency presents to the ED. Which findings attained during the admission assessment warrants immediate intervention by the nurse 1. Postural hypotension 2. extremity weakness 3. Signs of dehydration 4. Increased HR - CORRECT ANSWER-3. Signs of Dehydration A client with HF is admitted to the medical surgical unit with pneumonia. To reduce cardiac workload, which interventions should the nurse include in the plan of care 1. assist with ambulation in the hallway 2. teach to sleep in a side lying position 3. provide a bedside commode for toileting 4. encourage active range of motion exervcises - CORRECT ANSWER-3. Provide a bedside commonde for toileting A client with hyperthyroidism tells the nurse " I stopped taking my anti-thyroid medication and now I feel anxious. I can feel my heart pounding. Which assessment is most important for the nurse to obtain 1. VS 2. Peripheral pulses 3. Emotional status 4. Presence of goiter - CORRECT ANSWER-1. VS An older client with a history of anemia presents to the clinic with weakness and general fatigue. Which assessment should the nurse perform to evaluate the client's tissue perfusion 1. observe for bruising on the arms and legs 2. note the presence of nailbed cyanosis 3. palpate the volume of the pedal pulses 4. determine elasticity of skin turgor - CORRECT ANSWER-B. Note the presence of nail bed cyanosis A client is being treated for AKI. On exam the client has generalized edema and changes in mental status. Which intervention should the nurse include in the client's plan of care 1. measure the ankle circumference e 2. auscultate for irregular HR 3. Review ABG results 4. Measure and document urine output - CORRECT ANSWER-4. measure and document urine output An older male client is brought to the ED by his daughter. He is complaining of abdominal pain and the inability to urine, except for small amounts of incontinence, what action should the nurse implement first? 1. scan bladder to determine amount of urine in bladder 2. insert an indwelling catheter to drain bladder of retained urine 3. obtain a urine sample from incontinnce for culture and sensivity 4. administer IV pain medication for the abd pain - CORRECT ANSWER-1. scan bladder The HCP prescribes an IV fluid bolus for a client in adrenal crisis who is confused and unncooperative. The RN has attempted to obtain IV access twice without success. The client's VS are temp 103, BP 88/50, HR 132 and RR 30. Which intervention should the nurse implement first 1. insert a temporary intraosseous access 2. Have a family remain at bedside 3. ask charge nurse to assist with access 4. Ask HCP to obtain central line access - CORRECT ANSWER-3. Ask charge nurse to assist with access an adult male is admitted with dyspnea on exertion, persistent cought, and palpitations. The telemetry revels a-fib. Which additional findings warrants the most immediate interventions by the nurse. 1. Production of frothy, pink tinged sputum. 2. Pitting edema of the ankles bilaterally 3. RR of 22 breaths/min 4. Irregular apical heart rhythm - CORRECT ANSWER-1. Production of frothy pink tinged sputum A client with AIDS has impaird gas exchange from a respiratory infection. Which assessment finding warrants immediate intervention by the RN 1. Generalized weakness 2. Pain when swallowing 3. Diminished lung sounds 4. Elevated temperature - CORRECT ANSWER-2. Pain when swallowing