MEDSURG HESI EXAM REPORTED QUESTIONS WITH REVISED AND UPDATED ANSWERS

MEDSURG HESI EXAM REPORTED QUESTIONS WITH REVISED AND UPDATED ANSWERS Looking for a bowel movement (they are going to have massive liquid diarrhea b/c Kayexalate causes potassium to exchange from sodium in the intestines & potassium goes out via BM) -Answer-A renal failure client with a potassium level of 5.5 mEq/L is to receive sodium polystryene sulfonate (kayexalate) orally. What do you want to monitor for immediately after this medication is given? D, C, A,B Once you confirm that it's in place, you would listen to bowel sounds -Answer-Sequence the procedure for verifying feeding tube placement: A. Measure the pH of aspirate, compare the color of the strip with the color on the chart provided by the manufactor B. Discard used supplies, remove gloves and discard, and perform hand hygiene C. Draw back on syringe & obtain 5 to 10 mL of gastric aspirate observe appearance of aspirate D. Perform hand hygiene. Apply clean gloves, draw up 30 mL of air into syringe, then attach to end of feeding tube, flush tube with 30 mL of air - check for increased HR, respirations, & temp - BP will drop - May have hemolytic rash & be itching - May see flushing - Chest or flank pain - Blood has to run off on a pump TIME FRAME FOR GIVING BLOOD HAS TO BE LESS THAN 4 HOURS; IF STILL BLOOD IN AFTER 4 HOURS, YOU HAVE TO TAKE IT DOWN -Answer-S/S of blood transfusion reaction? first thing to do is to stop the infusion & start flushing -Answer-What is nursing priority when a transfusion reaction is suspected? A. vital signs B. call the MD C. administer benadryl D. stop the infusion Assess immediately and hourly thereafter (something has changed; this is different from their norm) -Answer-An older adult client who is predominantly argumentative and combative becomes calm & sleeps through the night. What is the nurse's priority intervention? A. Assess immediately and hourly thereafter B. Call the MD C. Document the client is resting D. Allow the patient to rest and document a round every 4 hours A. Diet & exercise regimen (least invasive) (metformin would be the next; first drug of choice) -Answer-A 36 year old male is newly diagnosed with type 2 diabetes. Which of the following treatments do you expect the patient to be started on initially? A. Diet and exercise regimen B. Metformin BID by mouth C. Regular insulin subcutaneous D. None, monitoring at this time is sufficient enough Review their dietary log (check what they have been eating & keep up with what foods are causing the adjustments) -Answer-For patients with blood sugar ranges fluctuating high and low, what should be the nursing intervention? A. Increase the patients short acting insulin B. Decrease the patients long acting insulin C. Draw a serum glucose D. Review their dietary log Metformin (oral diabetes medicine that helps control blood sugar levels) -Answer-medication used for type 2 diabetes Administer nausea medication -Answer-What is the primary nursing action for a patient with chemo induced nausea? A. Take a blood pressure B. Apply a cold cloth to forehead C. Document amount of emesis D. Administer nausea medication 30 minutes before (give it time to kick in; once someone gets nauseated with chemo, it's hard to catch it) -Answer-How many minutes prior to chemotherapy do you give antiemetic drugs? A. 15 B. 30 C. 45 D. 60 TLS (tumor lysis syndrome) -Can put them into acute renal injury -They'll have hyperurecemia, hyperphosphatemia, hyperkalemia, hypocalcemia -Answer-Describe TLS and rationales for going into TLS atelectasis (parital full collapse of lung/alveoli; one of the most common breathing complications after surgery) this is why we're doing turn cough deep breathe, incentive spirometer -Answer-A surgical protocol states that all post operative patients must participate in early ambulation to prevent: A. Bed sores B. Atelectasis C. Contractures D. Dehiscence and eviscertion - Prep the room & make sure you've got all the equipment - They help with transfering & positioning the patient for surgery - Anybody needs anything, they go and get it - *They are responsible for calling the surgical TIME-OUT* (primary role) -Answer-Goal of the surgery circulating nurse: Bowel sounds in all 4 quadrants complication that can occur after abdominal surgery: - they can get an ileus (a painful obstruction of the ileum or other part of the intestine) - blocked bowel after surgery (important to get them up & giving stool softeners; dont feed until you hear bowel sounds) -Answer-A patient who received an emergency appendectomy 2 days ago is now experiencing abdominal pain on the med-surg unit. What shoud the RN consider to be the primary assessment? A. Pedal pulses B. Jugular vein distention C. Bowel sounds in all 4 quadrants D. Urinary output of 30 cc per hour - Expect to see no BP or sticks in that arm - Cannot use right away b/c it has to have time to heal - Auscultate to bruit - Palpate for thrill -Answer-Care of a newly inserted AV fistula - Check feet everyday; make sure you dry your feet - Wear proper shoes - Don't want them walking around bearfoot - Make sure bath water isn't too hot -Answer-Education needed regarding foot care on diabetic patients. Sit the patient in high fowler's Priority nursing assessment: respiratory (listening to what their lungs sound like) -Answer-A patient diagnosed CHF present to the ER with SOB, dyspnea, rhonchi, dry cough, and tachycardia. What is the RN's first response? A. Complete chest percussions on bilateral lungs B. Push 1 amp o fmetoprolol C. Place the patient in trendelenburg D. Sit the patient in high fowler's What is the priority nursing assessment? Assess potassium level (when you're giving insulin & dextrose it pulls K+ out of cells too; it will drop) (check glucose BEFORE meals, not after) -Answer-An order is given to the RN to administer dextrose + insulin combined as a one time stat dose. What will be most important to include in this patient's plan of care? A. Assess range of motion B. Assess oxygen level C. Assess potassium level D. Assess glucose readings after each meal - Monitor glucose - Check amylase & lipase levels - May have to put an NG down & put it to suction - *one of the most common causes of pancreatitis is alcohol abuse, so talk about that* - * They will always be NPO* - Ultrasound -Answer-List all nursing interventions for a patient diagnosed with pancreatitis: popped, twisted, enlarged veins -legs ache, painful, feel heavy (S/S) -Answer-varicose veins RLS (restless leg syndrome) (unable to control the urge to move their legs) (typically happens at night/evenings; can occur whether you are sitting or lying down) -Answer-unpleasant sensations (itching, twitching, tingling, crawling) in the lower legs; irresistible urge to move the legs temporarily relieving the sensation but not disurbing sleep. Risks: Diabetes, Smoking, Hypertension, Diet (fatty foods/high cholesterol), Family History Interventions: Diet and Exercise -Answer-Risk for developing Coronary Artery Disease: What interventions do you instruct the patient to slow progression of CAD? - Stool will be red (bloody diarrhea) (lower) - rectal bleeding - Blood count may show low H&H, may be anemic -Answer-S/S of ulcerative colitis apply oxygen by non-rebreather mask (too much carbon dioxide cause respiratory acidosis) -Answer-After reviewing ABG's the patient is in respiratory acidosis. What is the nurses's primary intervention? A. apply oxygen by non-rebreather mask B. sedate w/ ativan 1mg/kg C. Administer bicarb 1 amp D. Administer a bronchoocnstrictor Set patient up on a fixed pain med schedule q 4 hrs -Answer-A patient with stage IV bone cancer has no pain relief with the first dose of IV pain medication. What is the most appropriate nursing intervention for long term relief? A. Administer ibuprofen 400mg PO B. Set patient up on a fixed pain med schedule q 4 hrs C. Alternate rearranging pillows and cold cloth applications D. Support assisted suicide as the patient's advocate