med surg hesi v1
Study online at https://quizlet.com/_f5784x
1. The nurse obtains a fingerstick glucose level utilizing C
bedside lancet/glucose meter equipment from a client
with prescribed sliding scale insulin protocol. The me-
ter 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.
2. To achieve maximum mobility and independence for a D
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
3. A client is admitted to the hospital with symptoms C
consistent with a right hemisphere stroke. Which neu-
rovascular assessment requires immediate interven-
tion by the nurse?
A. Pupillary changes to ipsilateral dilation
B. Orientation to person and place only
, med surg hesi v1
Study online at https://quizlet.com/_f5784x
C. Left- sided drooping and dysphagia
D. Unequal bilateral hand grip strengths
4. The nurse is teaching a client with glomerulonephri- B
tis 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 ba-
nanas and cantaloupe.
D. Increase intake of high fiber foods such as bran
cereal
5. The nurse is caring for a client with Herpes zoster B
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
6. A young adult who suffered a severe brain injury in C
an automobile collision has been mechanically venti-
lated 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
, med surg hesi v1
Study online at https://quizlet.com/_f5784x
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
7. Following a transurethral resection of the prostate B
(TURP), a client is discharged from the hospital with an
indwelling urinary catheter. which instruction is impor-
tant for the nurse to include in the discharge teaching
plan?
A. Eliminate all spicy foods from your diet
B. Drink 3 liters of water each day
C. Clamp the catheter when taking a shower
D. Avoid driving a car for 2 weeks
8. On the first postoperative day, the nurse finds an old- D
er male client disoriented and trying to climb over
the bed railing. Previously, he was oriented to per-
son, place, and time on admission. Which intervention
should the nurse implement first?
A. Apply wrist restraints
B. Determine the clients blood pressure
C. Administer a mild sedative
D. Assess the client for pain
Study online at https://quizlet.com/_f5784x
1. The nurse obtains a fingerstick glucose level utilizing C
bedside lancet/glucose meter equipment from a client
with prescribed sliding scale insulin protocol. The me-
ter 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.
2. To achieve maximum mobility and independence for a D
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
3. A client is admitted to the hospital with symptoms C
consistent with a right hemisphere stroke. Which neu-
rovascular assessment requires immediate interven-
tion by the nurse?
A. Pupillary changes to ipsilateral dilation
B. Orientation to person and place only
, med surg hesi v1
Study online at https://quizlet.com/_f5784x
C. Left- sided drooping and dysphagia
D. Unequal bilateral hand grip strengths
4. The nurse is teaching a client with glomerulonephri- B
tis 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 ba-
nanas and cantaloupe.
D. Increase intake of high fiber foods such as bran
cereal
5. The nurse is caring for a client with Herpes zoster B
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
6. A young adult who suffered a severe brain injury in C
an automobile collision has been mechanically venti-
lated 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
, med surg hesi v1
Study online at https://quizlet.com/_f5784x
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
7. Following a transurethral resection of the prostate B
(TURP), a client is discharged from the hospital with an
indwelling urinary catheter. which instruction is impor-
tant for the nurse to include in the discharge teaching
plan?
A. Eliminate all spicy foods from your diet
B. Drink 3 liters of water each day
C. Clamp the catheter when taking a shower
D. Avoid driving a car for 2 weeks
8. On the first postoperative day, the nurse finds an old- D
er male client disoriented and trying to climb over
the bed railing. Previously, he was oriented to per-
son, place, and time on admission. Which intervention
should the nurse implement first?
A. Apply wrist restraints
B. Determine the clients blood pressure
C. Administer a mild sedative
D. Assess the client for pain
