Med-Surg HESI Exam 160 Questions & Answers Graded A

The nurse reviews the laboratory results of a client during an annual physical examination and identifies a positive guar test of stool. Which additional serum laboratory test result should the nurse review? A. Glucose B. Platelet count C. White blood cell count D. Amylase - B A client who had a bliliopancreatic diversion procedure (BDP) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse? A. Strong would smelling flatus B. Gastrooccult positive emesis C. Complaint of poor night vision D. Loose bowel movements - B Patient had atrial fibrillation and then AED was used. One minute later, patient sudden goes into ventricular tachycardia. What should the nurse do? - Administer Adenosine over 1-2 seconds IV An older adult with heart failure is hospitalized during an acute exacerbation. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care? A. Assist with ambulation in the hallway B. Encourage active range of motion exercises C. Provide a bedside commode for toileting D. Teach to sleep in side lying position - C External fixation device-what should the nurse do first? - Assess for peripheral pulse at the foot An older adult man recently diagnosed with chronic obstructive pulmonary disease (COPD) is admitted with shortness fo breath. The nurse observes the client sitting upright and leaning over the bedside table, using accessory muscles to assist in breathing. What action should the nurse take? A. Assist the client to a high Fowler's position in bed B. Observe the client for the presence of a barrel chest C. Prepare to transfer the client to a critical care unit D. Instruct the client in pursed cup breathing techniques - D Cleint with CVA (stroke) has only eaten half of their food. Family is concern about nutrition. What should the nurse tell the family? - Demonstrate the use of visual scanning A male client with asthma has bronchoconstriction and mucous production due to exercising. What should the nurse do? - Determine if the client is using an inhaler before exercising A client with liver abscess and drainage of assess. Which lab value? - White blood cell count Suprapubic prostatectomy. Three way catheter, which assessment? - Urine leaking meatus A client with ulcerative colitis is admitted to the medical unit during an acute exacerbation. The nurse should instruct the unlicensed personnel (UAP) to report which finding related to the client's bowel movements? A. Hard pellets of stool B. Clay-colored stool C. Stool with fatty streaks D. Blood in the stool - C An adult client is admitted with flank pain and is diagnosed with acute pylenophritis. What is the priority nursing action? A. Auscultate for presence of bowel sounds B. Monitor hemoglobin and hematocrit C. Encourage turning and deep breathing D. Administer IV antibiotics as prescribed - D An older male client with long-standing lung diseases is admitted tot he medical unit for treatment of a pulmonary infection. In assessing for signs of increasing hypoxia, which actions should the nurse include? A. Monitor dryness of mucous membranes B. Check for changes in mentation C. Observe color of skin and nail beds D. Note appearance of jugular veins E. Assess breathing patterns - B, C, E Traction applied, but client is frustrated because client keeps calling the nurse for help with repositioning? - Use a trapeze bar Multiple sclerosis and urinary retention - Self catheterization Client works as a data desk job with Raynaud's syndrome. What to do to prevent wrist injury? - Space heater CKD lab to report - Potassium 6.5 Client with Gullian Barre is not blinking - Administer lubricant Taking prednisone PO 5 mg. What symtpom - Rapid weight gain Succinylcholin. High temperature - Ice pack axillary The nurse drops a sterile package of supplies on the floor in the operating room (OR) suite. The impervious wrapper. Which action should the nurse implement? - Open content to sterile field of package intact Client with acute glomerulonephritis - Restrict sodium Client ask about biopsy results form cancer cells well differentiated. What response? - Ask healthcare provider to gather more information Right cataract and lens implants. Which intervention should the nurse take first? - Provide an eye shield to be worn while sleeping The UAP reports to the nurse that a client who was admitted with abdominal pain has just had a large black tarry stool. What intervention should the nurse implement? - Test the stool for occult blood Which action is most important for the nurse to implement to reduce the risk for deep vein thrombosis in a postoperative client? - Advise the client to perform leg exercises regularly The nurse is preparing a client for a bronchoposcopy . While obtaining consent, the client complains of thirst and admits to drinking a small amount fo orange juice two hours ago. What action should the nurse take? - Delay procedures for 6 hours A client uses triamcinolone (kenalog), a corticosteroid ointment, to manage pruritus caused by a chronic skin rash. The client calls the clinic nurse to report increased erythema with purulent exudate at the site. What action should the nurse implement? - Schedule an appointment for the client to the healthcare provider The nurse learns in change of shift report that the x-ray report for a newly admit client indicates consolidation in the left lower lung. What action should the nurse take? - Administer a PRN dose of a bronchodilator The nurse is monitoring the glucose q4h of an adult woman admitted with DKA. Two hours after receiving 10 units of regular insulin of glucose of 2555, the client is perspiring and complaining of shakiness. What intervention should the nurse implement? - Check capillary glucose level The check x-ray for a client who is admitted for pneumonia shows plural effusion with decreased air flow int eh entire left upper lobe. What. breath sounds that verify x-ray findings should the nurse document after auscultation of the left upper lobe? - Diminished breath sounds Which food is most important for the nurse to encourage a male patient with osteomalacia to include in his daily diet? - Fortified milk and cereals An older adult women is seen in the clinic 3 months following her diagnosis of type 2 diabetes mellitus (DM). She tells the nurse that she has had a difficult time keeping her blood sugar in control. The nurse reviews the client's current finger-stick and daily log of blood glucose levels. Which intervention is most important for the nurse to implement? - Review the clients glycosylated hemoglobin (A1C) level The nurse is taking a client's blood pressure and observes carpal spasm after the sphygmomanometer cuff is inflated. What action should the nurse implement next? - Assess the clients recent serum calcium level A male client is recovering from an episode of urinary tract calculi. During discharge teaching, the client also asks about the dietary restriction he should following. In discussing fluid intake, the nurse should include which type of fluid limitation? A. Low sodium soups B. Over-all fluid intake C. Tea and hot chocolate D. Citrus fruit juices - C During the preoperative teaching for a male client scheduled for repair of an inguinal hernia, the client tells the nurse that he has had several surgeries and understands the need to perform coughing and deep breathing exercises after surgery. How should the nurse respond? A. Ask for demonstration of these exercises B. Exlplain that coughing should be avoided C. Review the client's previous surgical history D. Document the client's understanding of teaching - A A patient suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted tot he burn unit. Which intervention is most important for the nurse to include in the patient's plan of care? - Continuous cardiac monitoring After 3 days of persistent epigastric pain, a female patient presents to the clinic. She has been taking oral antacids without relief. Her vital signs are 122 beats/min, respirations 16 breaths/min, O2 96% and BP 116/70. The nurse obtains a 12-lead ECG. Which assessment finding is most critical? - ST elevation in three leads A male client with external fixation device for a fractured left femur is complaining of left foot pain. Which intervention should the nurse implement first? - Administer PRN pain medications Two days following abdominal surgery a client begins to complain of cramming abdominal pain, and the nurse's inspection of the abdomen indicates slight distention. Which action should the nurse implement first? - Auscultate abdomen quadrants A fair-skinned female client who is an avid runner is diagnosed with malignant melanoma, which is located on the lateral surface of the lower leg. After wide margin resection, the nurse provides discharge teaching. It is most important for the nurse to emphasize the need to observe for changes in which characteristic? - Appearance of any moles What instruction should the nurse include in the discharge teaching plan of a client who had a cataract extraction today? - Light housekeeping is permitted, but avoid heavy lifting When a nurse is caring for a client with acute hypothyroidism, which serum laboratory value requires immediate intervention? - Serum sodium 122 mEq/L A potential donor of corneal tissue for the eye bank has just died. The nurse enters the room prescribed antibiotic eye drops. What action should the nurse take next? - Secure eye shields over the closed eyes after instilling the eyedrops 3 months following her diagnosis of type 2 diabetes had a difficult time keeping her blood sugar centered. The nurse reviews that.....blood glucose levels.Which interventions is most important for the nurse to implement? - Review the clients glycosylated hemoglobin (A1c) level Retinal tear. What to do to avoid risk of retina damage? - 2 year old boy is having a health assessment. Which further assessment by nurse? - "He refuses to feed, but I make him eat meats" Parkinson's disease: - Teach the client to make an intentional swallow Cushing's syndrome: - Irregular apical pulse due to hypokalemia Addison's disease: - Monitor glucose levels (hypoglycemia) Congestive heart failure: - Daily weights Sputum culture: - Observe for color. quantity, and consistency SIADH: - Difficulty swallowing Nephrotic syndrome: - Monitor for weight A patient with diabetes complains that he is unable to sleep at night because of cold feet. What should the nurse advise? - Apply warm blankets to the feet Carpal tunnel syndromeL - Compression of the median nerve LAD, CAD another artery that supply the heart have a blockage of 95%, 99%, 99%. How should the nurse explain to the client: - 1-5% of blood gets to your heart (explain in layman/simple terms to the patient) Emphysema client teaching: - Deep breathing and pursed lips NG Tube: - Fowlers position, 30-90 degrees sitting position Paracentesis procedure - Sitting upright during procedure Finger stick glucose check with milking: - Check radial pulse Eczema: Dog allergy - Grandson and the dog visited the client A patient with ventricular tachycardia was given lidocaine. How does the nurse measure the treatment is effective? - Decreases episodes of ventricular tachycardia A patient who had intercourse 4 days ago comes to the clinic with burning/pain sensation on urination: - Obtain discharge in a swab for culture Open angle glaucoma - Decrease in periphery vision Obstruction of the common bile duct: - yellow sclera A patient is having a seizure is assisted to the floor. Which is priority? - Monitor for : apnea A male client has urinary dripping at night: - Palpate bladder above the pubic symphysis Patient is unable to wear his shoes: - Ask about weight Sodium level is 117 client may be in acute renal failure. With excessive water retention the sodium levels appear decreased (dilution). Nursing diagnostic? - Excess fluid volume Decreased peripheral pulses: - Doppler sound CVA occurs in: - Carotid arteries In teaching a client newly diagnosed with multiple sclerosis (MS), which approach should the nurse emphasize as most likely to prevent an exacerbation of symptoms? - Develop preplanned mechanisms to avoid or minimize the effects of triggers While assessing a client in a supine position, the nurse observes jugular vein distention. The client's vital signs are: heart rate 110 beats/minute, respirations 28 breaths/minute, and blood pressure 160/88. What action should the nurse take? - Raise the head of the bed 45 degrees A client is recovering from a transurethral prostectomy. Which activity should be limited until after the first postoperative visit with his healthcare provider? - Driving a car A client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse? - Further decline in level of consciousness After a computer tomography (CT) scan with intravenous medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement? - Prepare a dose of epinephrine (adrenalin) A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond? - Describe the use of an elimination diet to find trigger foods A female college student comes to the school's health clinic complaining of urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first? - Measure her temperature and pulse rate When preparing a teaching plan for a client newly diagnosed with diabetes mellitus, the nurse should describe which situation as requiring the most immediate action by the client or family? - Hypoglycemic shock Client is about to go to physical therapy but before that she is having a wound debridement (whirlpool therapy)? What should the nurse do? - Give analgesic An adult female client is diagnosed with restless leg syndrome and referred to the sleep clinic. The Healthcare provider prescribes ferrous sulfate (Feosol) 325 mg PO daily. Which lab values should the nurse monitor? A. Serum electrolytes B. Neutrophils and eosinophils C. Serum iron and ferritin D. Platelet count and hematocrit - Check serum iron and ferritin