EVOLVE ELSEVIER HESI MED SURG ACTUAL EXAM WITH 150 REAL
EXAM QUESTIONS AND CORRECT ANSWERS WITH WELL-
ELABORATED RATIONALES EVOLVE HESI MEDICAL SURGICAL
LATEST EXAM 2024-2025
Which |data |would |the |nurse |expect |to |find |when |reviewing |laboratory |values |of |an |80-year-old |man |who |is |in
|good |health |overall?
A. Complete |blood |count |reveals |increased |white |blood |cell |(WBC) |and |decreased |red |blood |cell |(RBC)
|counts.
B. Chemistries |reveal |an |increased |serum |bilirubin |level |with |slightly |increased |liver |enzyme |levels.
C. Urinalysis |reveals |slight |protein |in |the |urine |and |bacteriuria, |with |pyuria.
D. Serum |electrolytes |reveal |a |decreased |sodium |level |and |increased |potassium |level.
|C
Rationale: |In |older |adults, |the |protein |found |in |urine |slightly |rises, |probably |as |a |result |of |kidney |changes |or
|subclinical |urinary |tract |infections, |and |clients |frequently |experience |asymptomatic |bacteriuria |and |pyuria |as |a
|result |of |incomplete |bladder |emptying. |Laboratory |findings |in |options |A, |B, |and |D |are |not |considered |to |be
|normal |findings |in |an |older |adult.
The |nurse |witnesses |a |baseball |player |receive |a |blunt |trauma |to |the |back |of |the |head |with |a |softball. |What
|assessment |data |should |the |nurse |collect |immediately?
A. Reactivity |of |deep |tendon |reflexes, |comparing |upper |with |lower |extremities
B. Vital |sign |readings, |excluding |blood |pressure |if |needed |equipment |is |unavailable
C. Memory |of |events |that |occurred |before |and |after |the |blow |to |the |head
D. Ability |to |open |the |eyes |spontaneously |before |any |tactile |stimuli |are |given |D
Rationale: |The |level |of |consciousness |(LOC) |should |be |established |immediately |when |a |head |injury |has
|occurred. |Spontaneous |eye |opening |is |a |simple |measure |of |alertness |that |indicates |that |arousal |mechanisms
|are |intact. |Option |A |is |not |the |best |indicator |of |LOC. |Although |option |B |is |important, |vital |signs |are |not |the |best
|indicators |of |LOC |and |can |be |evaluated |after |the |client's |LOC |has |been |determined. |Option |C |can |be |assessed
|after |LOC |has |been |established |by |assessing |eye |opening.
A |client |diagnosed |with |angina |pectoris |complains |of |chest |pain |while |ambulating |in |the |hallway. |Which |action
|should |the |nurse |implement |first?
A. Support |the |client |to |a |sitting |position.
B. Ask |the |client |to |walk |slowly |back |to |the |room.
C. Administer |a |sublingual |nitroglycerin |tablet.
D. Provide |oxygen |via |nasal |cannula.
|A
Rationale: |The |nurse |should |safely |assist |the |client |to |a |resting |position |and |then |perform |options |C |and |D.
|The |client |must |cease |all |activity |immediately, |which |will |decrease |the |oxygen |requirement |of |the |myocardial
|muscle. |After |these |interventions |are |implemented, |the |client |can |be |escorted |back |to |the |room |via |wheelchair
|or |stretcher.
We |have |an |expert-written |solution |to |this |problem!
In |assessing |a |client |with |an |arteriovenous |(AV) |shunt |who |is |scheduled |for |dialysis |today, |the |nurse |notes |the
|absence |of |a |thrill |or |bruit |at |the |shunt |site. |What |action |should |the |nurse |take?
A. Advise |the |client |that |the |shunt |is |intact |and |ready |for |dialysis |as |scheduled.
B. Encourage |the |client |to |keep |the |shunt |site |elevated |above |the |level |of |the |heart.
,C. Notify |the |health |care |provider |of |the |findings |immediately.
D. Flush |the |site |at |least |once |with |a |heparinized |saline |solution. |C
Rationale: |Absence |of |a |thrill |or |bruit |indicates |that |the |shunt |may |be |obstructed. |The |nurse |should |notify |the
|health |care |provider |so |that |intervention |can |be |initiated |to |restore |function |of |the |shunt. |Option |A |is |incorrect.
|Option |B |will |not |resolve |the |obstruction. |An |AV |shunt |is |internal |and |cannot |be |flushed |without |access |using
|special |needles.
We |have |an |expert-written |solution |to |this |problem!
The |nurse |initiates |neurologic |checks |for |a |client |who |is |at |risk |for |neurologic |compromise. |Which |manifestation
|typically |provides |the |first |indication |of |altered |neurologic |function?
A. Change |in |level |of |consciousness
B. Increasing |muscular |weakness
C. Changes |in |pupil |size |bilaterally
D. Progressive |nuchal |rigidity
|A
Rationale: |A |decrease |or |change |in |the |level |of |consciousness |is |usually |the |first |indication |of |neurologic
|deterioration. |Options |B |and |C |may |also |occur |but |are |much |less |likely |to |be |the |first |sign |of |neurologic
|compromise. |Option |D |is |often |a |sign |of |meningitis.
What |is |the |most |important |nursing |priority |for |a |client |who |has |been |admitted |for |a |possible |kidney |stone?
A. Reducing |dairy |products |in |the |diet
B. Straining |all |urine
C. Measuring |intake |and |output
D. Increasing |fluid |intake
|B
Rationale: |Straining |all |urine |is |the |most |important |nursing |action |to |take |in |this |case. |Encouraging |fluid |intake
|is |important |for |any |client |who |may |have |a |kidney |stone, |but |it |is |even |more |important |to |strain |all |urine.
|Straining |urine |will |enable |the |nurse |to |determine |when |the |kidney |stone |has |been |passed |and |may |prevent
|the |need |for |surgery. |Option |C |is |not |the |highest |priority |action. |Option |A |is |usually |not |recommended |until |the
|stone |is |obtained |and |the |content |of |the |stone |is |determined. |Even |then, |dietary |restrictions |are |controversial.
We |have |an |expert-written |solution |to |this |problem!
During |the |shift |report, |the |charge |nurse |informs |a |nurse |that |she |has |been |assigned |to |another |unit |for |the
|day. |The |nurse |begins |to |sigh |deeply |and |tosses |about |her |belongings |as |she |prepares |to |leave, |making |it
|known |that |she |is |very |unhappy |about |being |floated |to |the |other |unit. |What |is |the |best |immediate |action |for
|the |charge |nurse |to |take?
A. Continue |with |the |shift |report |and |talk |to |the |nurse |about |the |incident |at |a |later | time.
B. Ask |the |nurse |to |call |the |house |supervisor |to |see |if |she |must |be |reassigned.
C. Stop |the |shift |report |and |remind |the |nurse |that |all |staff |are |floated |equally.
D. Inform |the |nurse |that |her |behavior |is |disruptive |to |the |rest |of |the |staff. |A
Rationale: |Continuing |with |the |shift |report |is |the |best |immediate |action |because |it |allows |the |nurse |who |was
|floated |some |cooling |off |time. |At |a |later |time |(after |the |nurse |has |cooled |off) |the |charge |nurse |should |discuss |the
|conduct |of |the |nurse |in |private. |Option |B |encourages |the |nurse |to |shirk |the |float |assignment. |Option |C |is
|disruptive. |Reprimanding |the |nurse |in |front |of |the |staff |would |increase |the |nurse's |hostility, |so |the |nurse |should
|be |counseled |in |private.
When |educating |a |client |after |a |total |laryngectomy, |which |instruction |would |be |most |important |for |the |nurse |to
|include |in |the |discharge |teaching?
,A. Recommend |that |the |client |carry |suction |equipment |at |all |times.
B. Instruct |the |client |to |have |writing |materials |with |him |at |all |times.
C. Tell |the |client |to |carry |a |medical |alert |card |that |explains |his |condition.
D. Caution |the |client |not |to |travel |outside |the |United |States |alone.
|C
Rationale: |Neck |breathers |carry |a |medical |alert |card |that |notifies |health |care |personnel |of |the |need |to |use
|mouth |to |stoma |breathing |in |the |event |of |a |cardiac |arrest |in |this |client. |Mouth |to |mouth |resuscitation |will |not
|establish |a |patent |airway. |Options |A |and |D |are |not |necessary. |There |are |many |alternative |means |of
|communication |for |clients |who |have |had |a |laryngectomy; |dependence |on |writing |messages |is |probably |the
|least |effective.
The |nurse |receives |the |client's |next |scheduled |bag |of |TPN |labeled |with |the |additive |NPH |insulin. |Which |action
|should |the |nurse |implement?
A. Hang |the |solution |at |the |current |rate.
B. Refrigerate |the |solution |until |needed.
C. Prepare |the |solution |with |new |tubing.
D. Return |the |solution |to |the |pharmacy.
|D
Rationale: |Only |regular |insulin |is |administered |by |the |IV |route, |so |the |TPN |solution |containing |NPH |insulin
|should |be |returned |to |the |pharmacy. |Options |A, |B, |and |C |are |not |indicated |because |the |solution |should |not
|be |administered.
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A |postoperative |client |receives |a |Schedule |II |opioid |analgesic |for |pain. |Which |assessment |finding |requires |the
|most |immediate |intervention |by |the |nurse?
A. Hypoactive |bowel |sounds |with |abdominal |distention
B. Client |reports |continued |pain |of |8 |on |a |10-point |scale
C. Respiratory |rate |of |12 |breaths/min, |with |O2 |saturation |of |85%
D. Client |reports |nausea |after |receiving |the |medication
|C
Rationale: |Administration |of |a |Schedule |II |opioid |analgesic |can |result |in |respiratory |depression, |which |requires
|immediate |intervention |by |the |nurse |to |prevent |respiratory |arrest. |Options |A, |B, |and |D |require |action |by |the
|nurse |but |are |of |less |priority |than |option |C.
A |client |is |placed |on |a |mechanical |ventilator |following |a |cerebral |hemorrhage, |and |vecuronium |bromide, |0.04
|mg/kg |every |12 |hours |IV, |is |prescribed. |What |is |the |priority |nursing |diagnosis |for |this |client?
A. Impaired |communication |related |to |paralysis |of |skeletal |muscles
B. High |risk |for |infection |related |to |increased |intracranial |pressure
C. Potential |for |injury |related |to |impaired |lung |expansion
D. Social |isolation |related |to |inability |to |communicate
|A
Rationale:To |increase |the |client's |tolerance |of |endotracheal |intubation |and/or |mechanical |ventilation, |a
|skeletal |muscle |relaxant |such |as |vecuronium |is |usually |prescribed. |Option |A |is |a |serious |outcome |because
|the |client |cannot |communicate |his |or |her |needs. |Although |this |client |might |also |experience |option |D, |it |is |not |a
|priority |when |compared |with |option |A. |Infection |is |not |related |to |increased |intracranial |pressure. |The
|respirator |will |ensure |that |the |lungs |are |expanded, |so |option |C |is |incorrect.
, A |family |member |was |taught |to |suction |a |client's |tracheostomy |prior |to |the |client's |discharge |from |the |hospital.
|Which |observation |by |the |nurse |indicates |that |the |family |member |is |capable |of |correctly |performing |the
|suctioning |technique?
A. Turns |on |the |continuous |wall |suction |to |190 |mm |Hg.
B. Inserts |the |catheter |until |resistance |or |coughing |occurs.
C. Withdraws |the |catheter |while |maintaining |suctioning.
D. Reclears |the |tracheostomy |after |suctioning |the |mouth.
|B
Rationale:Option |B |indicates |correct |technique |for |performing |suctioning. |Suction |pressure |should |be |between
|80 |and |120 |mm |Hg, |not |190 |mm |Hg. |The |catheter |should |be |withdrawn |1 |to |2 |cm |at |a |time |with |intermittent, |not
|continuous, |suction. |Option |D |introduces |pathogens |unnecessarily |into |the |tracheobronchial |tree.
A |client |is |diagnosed |with |an |acute |small |bowel |obstruction. |W hich |assessment |finding |requires |the |most
|immediate |intervention |by |the |nurse?
A. Fever |of |102° |F
B. Blood |pressure |of |150/90 |mm |Hg
C. Abdominal |cramping
D. Dry |mucous |membranes
|A
Rationale:A |sudden |increase |in |temperature |is |an |indicator |of |peritonitis. |The |nurse |should |notify |the |health
|care |provider |immediately. |Options |B, |C, |and |D |are |also |findings |that |require |intervention |by |the |nurse |but | are
|of |less |priority |than |option |A. |Option |B |may |indicate |a |hypertensive |condition |but |is |not |as |acute |a |condition |as
|peritonitis. |Option |C |is |an |expected |finding |in |clients |with |small |bowel |obstruction |and |may |require |medication.
|Option |D |indicates |probable |fluid |volume |deficit, |which |requires |fluid |volume |replacement. |In |assessing |a |client
|diagnosed |with |primary |aldosteronism, |the |nurse |expects |the |laboratory |test |results |to |indicate |a |decreased
|serum |level |of |which |substance?
A. Sodium
B. Phosphate
C. Potassium
D. Glucose
|C
Rationale: |Clients |with |primary |aldosteronism |exhibit |a |profound |decline |in |serum |levels |of |potassium;
|hypokalemia; |hypertension |is |the |most |prominent |and |universal |sign. |The |serum |sodium |level |is |normal |or
|elevated, |depending |on |the |amount |of |water |resorbed |with |the |sodium. |Option |B |is |influenced |by |parathyroid
|hormone |(PTH). |Option |D |is |not |affected |by |primary |aldosteronism.
We |have |an |expert-written |solution |to |this |problem!
During |assessment |of |a |client |in |the |intensive |care |unit, |the |nurse |notes |that |the |client's |breath |sounds |are
|clear |on |auscultation, |but |jugular |vein |distention |and |muffled |heart |sounds |are |present. |Which |intervention
|should |the |nurse |implement?
A. Prepare |the |client |for |a |pericardial |tap.
B. Administer |intravenous |furosemide |(Lasix).
C. Assist |the |client |to |cough |and |breathe |deeply.
D. Instruct |the |client |to |restrict |oral |fluid |intake.
|A
Rationale: |The |client |is |exhibiting |symptoms |of |cardiac |tamponade, |a |collection |of |fluid |in |the |pericardial |sac
|that |results |in |a |reduction |in |cardiac |output, |which |is |a |potentially |fatal |complication |of |pericarditis. |Treatment
|for |tamponade |is |a |pericardial |tap. |Lasix |IV |is |not |indicated |for |treatment |of |pericarditis. |Because |the |client's
|breath |sounds |are |clear, |option |C |is |not |a |priority. |Fluids |are |frequently |increased |in |the |initial |treatment |of
|tamponade |to |compensate |for |the |decrease |in |cardiac |output, |but |this |is |not |the |same |priority |as |option |A.
EXAM QUESTIONS AND CORRECT ANSWERS WITH WELL-
ELABORATED RATIONALES EVOLVE HESI MEDICAL SURGICAL
LATEST EXAM 2024-2025
Which |data |would |the |nurse |expect |to |find |when |reviewing |laboratory |values |of |an |80-year-old |man |who |is |in
|good |health |overall?
A. Complete |blood |count |reveals |increased |white |blood |cell |(WBC) |and |decreased |red |blood |cell |(RBC)
|counts.
B. Chemistries |reveal |an |increased |serum |bilirubin |level |with |slightly |increased |liver |enzyme |levels.
C. Urinalysis |reveals |slight |protein |in |the |urine |and |bacteriuria, |with |pyuria.
D. Serum |electrolytes |reveal |a |decreased |sodium |level |and |increased |potassium |level.
|C
Rationale: |In |older |adults, |the |protein |found |in |urine |slightly |rises, |probably |as |a |result |of |kidney |changes |or
|subclinical |urinary |tract |infections, |and |clients |frequently |experience |asymptomatic |bacteriuria |and |pyuria |as |a
|result |of |incomplete |bladder |emptying. |Laboratory |findings |in |options |A, |B, |and |D |are |not |considered |to |be
|normal |findings |in |an |older |adult.
The |nurse |witnesses |a |baseball |player |receive |a |blunt |trauma |to |the |back |of |the |head |with |a |softball. |What
|assessment |data |should |the |nurse |collect |immediately?
A. Reactivity |of |deep |tendon |reflexes, |comparing |upper |with |lower |extremities
B. Vital |sign |readings, |excluding |blood |pressure |if |needed |equipment |is |unavailable
C. Memory |of |events |that |occurred |before |and |after |the |blow |to |the |head
D. Ability |to |open |the |eyes |spontaneously |before |any |tactile |stimuli |are |given |D
Rationale: |The |level |of |consciousness |(LOC) |should |be |established |immediately |when |a |head |injury |has
|occurred. |Spontaneous |eye |opening |is |a |simple |measure |of |alertness |that |indicates |that |arousal |mechanisms
|are |intact. |Option |A |is |not |the |best |indicator |of |LOC. |Although |option |B |is |important, |vital |signs |are |not |the |best
|indicators |of |LOC |and |can |be |evaluated |after |the |client's |LOC |has |been |determined. |Option |C |can |be |assessed
|after |LOC |has |been |established |by |assessing |eye |opening.
A |client |diagnosed |with |angina |pectoris |complains |of |chest |pain |while |ambulating |in |the |hallway. |Which |action
|should |the |nurse |implement |first?
A. Support |the |client |to |a |sitting |position.
B. Ask |the |client |to |walk |slowly |back |to |the |room.
C. Administer |a |sublingual |nitroglycerin |tablet.
D. Provide |oxygen |via |nasal |cannula.
|A
Rationale: |The |nurse |should |safely |assist |the |client |to |a |resting |position |and |then |perform |options |C |and |D.
|The |client |must |cease |all |activity |immediately, |which |will |decrease |the |oxygen |requirement |of |the |myocardial
|muscle. |After |these |interventions |are |implemented, |the |client |can |be |escorted |back |to |the |room |via |wheelchair
|or |stretcher.
We |have |an |expert-written |solution |to |this |problem!
In |assessing |a |client |with |an |arteriovenous |(AV) |shunt |who |is |scheduled |for |dialysis |today, |the |nurse |notes |the
|absence |of |a |thrill |or |bruit |at |the |shunt |site. |What |action |should |the |nurse |take?
A. Advise |the |client |that |the |shunt |is |intact |and |ready |for |dialysis |as |scheduled.
B. Encourage |the |client |to |keep |the |shunt |site |elevated |above |the |level |of |the |heart.
,C. Notify |the |health |care |provider |of |the |findings |immediately.
D. Flush |the |site |at |least |once |with |a |heparinized |saline |solution. |C
Rationale: |Absence |of |a |thrill |or |bruit |indicates |that |the |shunt |may |be |obstructed. |The |nurse |should |notify |the
|health |care |provider |so |that |intervention |can |be |initiated |to |restore |function |of |the |shunt. |Option |A |is |incorrect.
|Option |B |will |not |resolve |the |obstruction. |An |AV |shunt |is |internal |and |cannot |be |flushed |without |access |using
|special |needles.
We |have |an |expert-written |solution |to |this |problem!
The |nurse |initiates |neurologic |checks |for |a |client |who |is |at |risk |for |neurologic |compromise. |Which |manifestation
|typically |provides |the |first |indication |of |altered |neurologic |function?
A. Change |in |level |of |consciousness
B. Increasing |muscular |weakness
C. Changes |in |pupil |size |bilaterally
D. Progressive |nuchal |rigidity
|A
Rationale: |A |decrease |or |change |in |the |level |of |consciousness |is |usually |the |first |indication |of |neurologic
|deterioration. |Options |B |and |C |may |also |occur |but |are |much |less |likely |to |be |the |first |sign |of |neurologic
|compromise. |Option |D |is |often |a |sign |of |meningitis.
What |is |the |most |important |nursing |priority |for |a |client |who |has |been |admitted |for |a |possible |kidney |stone?
A. Reducing |dairy |products |in |the |diet
B. Straining |all |urine
C. Measuring |intake |and |output
D. Increasing |fluid |intake
|B
Rationale: |Straining |all |urine |is |the |most |important |nursing |action |to |take |in |this |case. |Encouraging |fluid |intake
|is |important |for |any |client |who |may |have |a |kidney |stone, |but |it |is |even |more |important |to |strain |all |urine.
|Straining |urine |will |enable |the |nurse |to |determine |when |the |kidney |stone |has |been |passed |and |may |prevent
|the |need |for |surgery. |Option |C |is |not |the |highest |priority |action. |Option |A |is |usually |not |recommended |until |the
|stone |is |obtained |and |the |content |of |the |stone |is |determined. |Even |then, |dietary |restrictions |are |controversial.
We |have |an |expert-written |solution |to |this |problem!
During |the |shift |report, |the |charge |nurse |informs |a |nurse |that |she |has |been |assigned |to |another |unit |for |the
|day. |The |nurse |begins |to |sigh |deeply |and |tosses |about |her |belongings |as |she |prepares |to |leave, |making |it
|known |that |she |is |very |unhappy |about |being |floated |to |the |other |unit. |What |is |the |best |immediate |action |for
|the |charge |nurse |to |take?
A. Continue |with |the |shift |report |and |talk |to |the |nurse |about |the |incident |at |a |later | time.
B. Ask |the |nurse |to |call |the |house |supervisor |to |see |if |she |must |be |reassigned.
C. Stop |the |shift |report |and |remind |the |nurse |that |all |staff |are |floated |equally.
D. Inform |the |nurse |that |her |behavior |is |disruptive |to |the |rest |of |the |staff. |A
Rationale: |Continuing |with |the |shift |report |is |the |best |immediate |action |because |it |allows |the |nurse |who |was
|floated |some |cooling |off |time. |At |a |later |time |(after |the |nurse |has |cooled |off) |the |charge |nurse |should |discuss |the
|conduct |of |the |nurse |in |private. |Option |B |encourages |the |nurse |to |shirk |the |float |assignment. |Option |C |is
|disruptive. |Reprimanding |the |nurse |in |front |of |the |staff |would |increase |the |nurse's |hostility, |so |the |nurse |should
|be |counseled |in |private.
When |educating |a |client |after |a |total |laryngectomy, |which |instruction |would |be |most |important |for |the |nurse |to
|include |in |the |discharge |teaching?
,A. Recommend |that |the |client |carry |suction |equipment |at |all |times.
B. Instruct |the |client |to |have |writing |materials |with |him |at |all |times.
C. Tell |the |client |to |carry |a |medical |alert |card |that |explains |his |condition.
D. Caution |the |client |not |to |travel |outside |the |United |States |alone.
|C
Rationale: |Neck |breathers |carry |a |medical |alert |card |that |notifies |health |care |personnel |of |the |need |to |use
|mouth |to |stoma |breathing |in |the |event |of |a |cardiac |arrest |in |this |client. |Mouth |to |mouth |resuscitation |will |not
|establish |a |patent |airway. |Options |A |and |D |are |not |necessary. |There |are |many |alternative |means |of
|communication |for |clients |who |have |had |a |laryngectomy; |dependence |on |writing |messages |is |probably |the
|least |effective.
The |nurse |receives |the |client's |next |scheduled |bag |of |TPN |labeled |with |the |additive |NPH |insulin. |Which |action
|should |the |nurse |implement?
A. Hang |the |solution |at |the |current |rate.
B. Refrigerate |the |solution |until |needed.
C. Prepare |the |solution |with |new |tubing.
D. Return |the |solution |to |the |pharmacy.
|D
Rationale: |Only |regular |insulin |is |administered |by |the |IV |route, |so |the |TPN |solution |containing |NPH |insulin
|should |be |returned |to |the |pharmacy. |Options |A, |B, |and |C |are |not |indicated |because |the |solution |should |not
|be |administered.
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A |postoperative |client |receives |a |Schedule |II |opioid |analgesic |for |pain. |Which |assessment |finding |requires |the
|most |immediate |intervention |by |the |nurse?
A. Hypoactive |bowel |sounds |with |abdominal |distention
B. Client |reports |continued |pain |of |8 |on |a |10-point |scale
C. Respiratory |rate |of |12 |breaths/min, |with |O2 |saturation |of |85%
D. Client |reports |nausea |after |receiving |the |medication
|C
Rationale: |Administration |of |a |Schedule |II |opioid |analgesic |can |result |in |respiratory |depression, |which |requires
|immediate |intervention |by |the |nurse |to |prevent |respiratory |arrest. |Options |A, |B, |and |D |require |action |by |the
|nurse |but |are |of |less |priority |than |option |C.
A |client |is |placed |on |a |mechanical |ventilator |following |a |cerebral |hemorrhage, |and |vecuronium |bromide, |0.04
|mg/kg |every |12 |hours |IV, |is |prescribed. |What |is |the |priority |nursing |diagnosis |for |this |client?
A. Impaired |communication |related |to |paralysis |of |skeletal |muscles
B. High |risk |for |infection |related |to |increased |intracranial |pressure
C. Potential |for |injury |related |to |impaired |lung |expansion
D. Social |isolation |related |to |inability |to |communicate
|A
Rationale:To |increase |the |client's |tolerance |of |endotracheal |intubation |and/or |mechanical |ventilation, |a
|skeletal |muscle |relaxant |such |as |vecuronium |is |usually |prescribed. |Option |A |is |a |serious |outcome |because
|the |client |cannot |communicate |his |or |her |needs. |Although |this |client |might |also |experience |option |D, |it |is |not |a
|priority |when |compared |with |option |A. |Infection |is |not |related |to |increased |intracranial |pressure. |The
|respirator |will |ensure |that |the |lungs |are |expanded, |so |option |C |is |incorrect.
, A |family |member |was |taught |to |suction |a |client's |tracheostomy |prior |to |the |client's |discharge |from |the |hospital.
|Which |observation |by |the |nurse |indicates |that |the |family |member |is |capable |of |correctly |performing |the
|suctioning |technique?
A. Turns |on |the |continuous |wall |suction |to |190 |mm |Hg.
B. Inserts |the |catheter |until |resistance |or |coughing |occurs.
C. Withdraws |the |catheter |while |maintaining |suctioning.
D. Reclears |the |tracheostomy |after |suctioning |the |mouth.
|B
Rationale:Option |B |indicates |correct |technique |for |performing |suctioning. |Suction |pressure |should |be |between
|80 |and |120 |mm |Hg, |not |190 |mm |Hg. |The |catheter |should |be |withdrawn |1 |to |2 |cm |at |a |time |with |intermittent, |not
|continuous, |suction. |Option |D |introduces |pathogens |unnecessarily |into |the |tracheobronchial |tree.
A |client |is |diagnosed |with |an |acute |small |bowel |obstruction. |W hich |assessment |finding |requires |the |most
|immediate |intervention |by |the |nurse?
A. Fever |of |102° |F
B. Blood |pressure |of |150/90 |mm |Hg
C. Abdominal |cramping
D. Dry |mucous |membranes
|A
Rationale:A |sudden |increase |in |temperature |is |an |indicator |of |peritonitis. |The |nurse |should |notify |the |health
|care |provider |immediately. |Options |B, |C, |and |D |are |also |findings |that |require |intervention |by |the |nurse |but | are
|of |less |priority |than |option |A. |Option |B |may |indicate |a |hypertensive |condition |but |is |not |as |acute |a |condition |as
|peritonitis. |Option |C |is |an |expected |finding |in |clients |with |small |bowel |obstruction |and |may |require |medication.
|Option |D |indicates |probable |fluid |volume |deficit, |which |requires |fluid |volume |replacement. |In |assessing |a |client
|diagnosed |with |primary |aldosteronism, |the |nurse |expects |the |laboratory |test |results |to |indicate |a |decreased
|serum |level |of |which |substance?
A. Sodium
B. Phosphate
C. Potassium
D. Glucose
|C
Rationale: |Clients |with |primary |aldosteronism |exhibit |a |profound |decline |in |serum |levels |of |potassium;
|hypokalemia; |hypertension |is |the |most |prominent |and |universal |sign. |The |serum |sodium |level |is |normal |or
|elevated, |depending |on |the |amount |of |water |resorbed |with |the |sodium. |Option |B |is |influenced |by |parathyroid
|hormone |(PTH). |Option |D |is |not |affected |by |primary |aldosteronism.
We |have |an |expert-written |solution |to |this |problem!
During |assessment |of |a |client |in |the |intensive |care |unit, |the |nurse |notes |that |the |client's |breath |sounds |are
|clear |on |auscultation, |but |jugular |vein |distention |and |muffled |heart |sounds |are |present. |Which |intervention
|should |the |nurse |implement?
A. Prepare |the |client |for |a |pericardial |tap.
B. Administer |intravenous |furosemide |(Lasix).
C. Assist |the |client |to |cough |and |breathe |deeply.
D. Instruct |the |client |to |restrict |oral |fluid |intake.
|A
Rationale: |The |client |is |exhibiting |symptoms |of |cardiac |tamponade, |a |collection |of |fluid |in |the |pericardial |sac
|that |results |in |a |reduction |in |cardiac |output, |which |is |a |potentially |fatal |complication |of |pericarditis. |Treatment
|for |tamponade |is |a |pericardial |tap. |Lasix |IV |is |not |indicated |for |treatment |of |pericarditis. |Because |the |client's
|breath |sounds |are |clear, |option |C |is |not |a |priority. |Fluids |are |frequently |increased |in |the |initial |treatment |of
|tamponade |to |compensate |for |the |decrease |in |cardiac |output, |but |this |is |not |the |same |priority |as |option |A.
