Med Surge HESI Real Exam 4 200 Questions
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The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which symptom of
hyperglycemia is an older adult most likely to exhibit?
A.
Polyuria
B.
Polydipsia
C.
Weight loss
D.
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Infection –
Correct Answer :D
ptoms of hyperglycemia in older adults may include fatigue, infection, and evidence of
neuropathy (e.g., sensory changes). The nurse needs to remember that classic signs and
symptoms of hyperglycemia, such as options A, B, and C and polyphagia, may be absent in
older adults.
A client with chronic asthma is admitted to the PACU complaining of pain at a level of 8 on a 1
to 10 scale, with a blood pressure of 124/78 mm Hg, pulse of 88 beats/min, and respirations of
20 breaths/min. The PACU recovery prescription is "Morphine, 2 to 4 mg IV push, while in
recovery for pain level over 5." Which action should the nurse take first?
A.
Give the medication as prescribed to decrease the client's pain.
B.
Call the anesthesia provider for a different medication for pain.
C.
Use nonpharmacologic techniques before giving the medication.
D.
Reassess the pain level in 30 minutes and medicate if it remains elevated. –
Correct Answer :B
Rationale:
The nurse should call the provider for a different medication because morphine is a histamine-
releasing opioid and should be avoided when the client has asthma. Option A is unsafe
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because it puts the client at risk for an asthma exacerbation. Even if the drug were safe for
the client, options C and D both disregard the prescription and the client's need for pain relief
in the immediate postoperative period.
The nurse is interviewing a client who is taking interferon-alfa-2a and ribavirin combination
therapy for hepatitis C. The client reports experiencing overwhelming feelings of depression.
Which action should the nurse take first?
A.
Recommend mental health counseling.
B.
Review the medication actions and interactions.
C.
Assess for the client's daily activity level.
D.
Provide information regarding a support group. –
Correct Answer :B
Rationale:
Interferon-alfa-2a and ribavirin combination therapy can cause severe depression; therefore, it
is most important for the nurse to review the medication effects and report these to the
health care provider. Options A, C, and D might be implemented after the physiologic aspects
of the situation have been assessed.
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The nurse in the emergency room assesses a client with a head trauma and notes a Glasgow
Coma Scale (GCS) score of 5. What actions will the nurse take to ensure the client's safety?
(Select all that apply.)
A.
Place the client in the supine position.
B.
Assess airway and suction secretions as needed.
C.
Change the client's position every 2 hours.
D.
Avoid mouth care, to avoid stimulating a seizure.
E.
Monitor for drainage from the ears. –
Correct Answer :B, C, E
Rationale:
The client should be at least sitting at a 45 degree angle to avoid aspiration and increased
intracranial pressure. Provide frequent mouth care as the client is unable to do so at this time.
The remaining actions are appropriate for the client with a GCS score of 5.
A client is placed on a mechanical ventilator following a cerebral hemorrhage. What are the
priority nursing actions for this client? (Select all that apply.)
A.
Assess lung sounds.
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