MED SURG 2 HESI TEST BANK REAL EXAM
100+ QUESTIONS AND CORRECT VERIFIED
ANSWERS WITH RATIONALES | A GRADE
1.A2AA2clientA2withA2Cushing'sA2syndromeA2isA2recoveringA2fromA2anA2electiveA2laparoscop
icA2procedure.A2WhichA2assessmentA2findingA2warrant'sA2immediateA2interventionA2byA2th
eA2nurse?
a.A2PurpleA2marksA2onA2skinA2ofA2theA2abdomen
b.A2IrregularA2apicalA2pulse
c.A2QuarterA2sizeA2bloodA2spotA2onA2dressing
d.A2PittingA2ankleA2edemaA2-A2Ans--b.A2IrregularA2apicalA2pulse
2.A2AA2clientA2withA2lungA2cancerA2whoA2wearsA2aA2subcutaneousA2morphineA2sulfateA2pat
chA2forA2painA2isA2shortA2ofA2breathA2andA2isA2difficultA2toA2arouse.A2WhenA2performingA2aA
2headA2toA2toeA2assessment,A2theA2nurseA2discoversA2fourA2analgesicA2patchesA2onA2theA
2clientsA2body.A2WhichA2interventionA2shouldA2theA2nurseA2implementA2first?
a.A2RemoveA2allA2ofA2theA2morphineA2patches
b.A2AdministerA2aA2narcoticA2antagonist
c.A2ApplyA2oxygenA2perA2faceA2mask
d.A2MeasureA2theA2client'sA2bloodA2pressureA2-A2Ans--
b.A2AdministerA2aA2narcoticA2antagonist
3.A2AA2clientA2receivesA2prescriptionsA2forA2aA2multidrugA2regimenA2forA2theA2treatmentA2of
A2tuberculosis.A2WhichA2informationA2shouldA2theA2nurseA2prioritize?
a.A2AdherenceA2toA2theA2regimenA2isA2imperative
b.A2MedicationsA2shouldA2beA2takenA2withA2food
c.A2SerumA2liverA2panelsA2areA2collectedA2regularly
d.A2EnhancedA2sunA2protectionA2measuresA2willA2beA2neededA2-A2Ans--
a.A2AdherenceA2toA2theA2regimenA2isA2imperative
4.A2TheA2nurseA2isA2preparingA2aA2clientA2forA2surgeryA2whoA2wasA2admittedA2toA2theA2eme
rgencyA2centerA2followingA2aA2motorA2vehicleA2collision.A2TheA2clientA2hasA2anA2openA2frac
tureA2ofA2theA2femurA2andA2isA2bleedingA2moderatelyA2fromA2theA2boneA2protrusionA2site.A2
DuringA2theA2prescriptiveA2assessment,A2theA2nurseA2determinesA2thatA2theA2clientA2curre
ntlyA2receivesA2heparinA2sodiumA25,000A2unitsA2subcutaneouslyA2daily.A2WhatA2isA2theA2pr
iorityA2nursingA2action?
a.A2NotifyA2theA2healthcareA2providerA2ofA2theA2client'sA2medicationA2history
b.A2ObserveA2theA2heparinA2injectionsA2sitesA2forA2signsA2ofA2bruising
c.A2HaveA2theA2clientA2signA2theA2surgicalA2andA2transfusionA2permits
,d.A2EnsureA2thatA2theA2potentialA2forA2bleedingA2isA2explainedA2toA2theA2clientA2-A2Ans--
a.A2NotifyA2theA2healthcareA2providerA2ofA2theA2client'sA2medicationA2history
5.A2AA2clientA2withA2orthopneaA2expressesA2concernA2aboutA2theA2abilityA2toA2"getA2enoug
hA2air"A2duringA2aA2scheduledA2thoracentesis.A2OnA2whichA2informationA2shouldA2theA2nur
se'sA2responseA2beA2based?
a.A2AA2thoracentesisA2isA2aA2briefA2processA2thatA2hasA2minimalA2discomfort
b.A2OrthopneaA2isA2frequentlyA2causedA2byA2aA2client'sA2uncontrolledA2anxiety
c.A2TheA2procedureA2isA2performedA2withA2theA2clientA2inA2anA2uprightA2position
d.A2ExtraA2pillowsA2canA2beA2usedA2ifA2neededA2toA2elevateA2theA2client'sA2headA2-A2Ans--
c.A2TheA2procedureA2isA2performedA2withA2theA2clientA2inA2anA2uprightA2position
6.A2WhatA2informationA2shouldA2theA2nurseA2includeA2inA2theA2teachingA2planA2ofA2aA2client
A2diagnosedA2withA2gastroesophagealA2refluxA2diseaseA2(GERD)?
a.A2SleepA2withoutA2pillowsA2atA2nightA2toA2maintainA2neckA2alignment
b.A2AdjustA2foodA2intakeA2toA2threeA2fullA2mealsA2perA2dayA2andA2noA2snacks
c.A2MinimizeA2symptomsA2byA2wearingA2loose,A2comfortableA2clothing
d.A2AvoidA2participationA2inA2anyA2aerobicA2exerciseA2programsA2-A2Ans--
c.A2MinimizeA2symptomsA2byA2wearingA2loose,A2comfortableA2clothing
7.A2TheA2nurseA2isA2providingA2teachingA2toA2aA2clientA2withA2TypeA22A2diabetesA2mellitusA
2andA2peripheralA2neuropathy.A2WhichA2informationA2shouldA2theA2nurseA2provide?
a.A2FamilyA2membersA2canA2helpA2withA2regularA2footA2exams
b.A2HeatingA2padsA2areA2usefulA2ifA2onA2theA2lowA2setting
c.A2AchingA2feetA2mayA2beA2soakedA2inA2lukewarmA2waterA2forA2oneA2hourA2orA2more
d.A2ShoesA2shouldA2beA2wornA2outsideA2theA2house,A2butA2itA2isA2fineA2toA2beA2barefootA2in
sideA2-A2Ans--a.A2FamilyA2membersA2canA2helpA2withA2regularA2footA2exams
8.A2AA2clientA2inA2theA2operatingA2roomA2receivedA2succinylcholine.A2TheA2clientA2isA2expe
riencingA2muscleA2rigidityA2andA2hasA2anA2extremelyA2highA2temperature.A2WhatA2actionA2
shouldA2theA2nurseA2implement?
a.A2HoldA2aA2prescriptionA2forA2dantroleneA2untilA2feverA2isA2reduced
b.A2PrepareA2iceA2packsA2forA2placementA2inA2theA2clientsA2axillaryA2area
c.A2CallA2theA2PACUA2nurseA2toA2prepareA2forA2prolongedA2ventilatorA2support
d.A2DetermineA2ifA2prescribedA2antibioticsA2wereA2administeredA2preoperativelyA2-A2Ans--
b.A2PrepareA2iceA2packsA2forA2placementA2inA2theA2clientsA2axillaryA2area
9.A2TheA2nurseA2isA2developingA2aA2planA2ofA2careA2forA2aA2clientA2whoA2reportsA2blurredA2
visionA2andA2whoA2isA2newlyA2diagnosedA2withA2cardiovascularA2disease.A2WhichA2outco
meA2shouldA2theA2nurseA2includeA2inA2theA2planA2ofA2careA2forA2thisA2client?
a.A2TheA2nurseA2willA2encourageA2theA2clientA2toA2walkA2thirtyA2minutesA2everyA2day
,b.A2TheA2clientsA2familyA2willA2stateA2signsA2andA2symptomsA2aboutA2theA2disease
c.A2TheA2clientsA2dailyA2bloodA2pressureA2willA2beA2lessA2thanA2140/80A2thisA2month
d.A2TheA2clientA2bloodA2pressureA2readingsA2willA2beA2lessA2thanA2160/90A2-A2Ans--
c.A2TheA2clientsA2dailyA2bloodA2pressureA2willA2beA2lessA2thanA2140/80A2thisA2month
10.A2TheA2familyA2suspectsA2thatA2acquiredA2immuneA2deficiencyA2syndromeA2(AIDS)A2de
mentiaA2isA2occuringA2inA2theirA2sonA2whoA2isA2humanA2immunodeficiencyA2virusA2(HIV)A2
positive.A2WhichA2symptomsA2confirmA2theirA2suspicions?
a.A2HeA2hasA2begunA2toA2sleepA218A2outA2ofA224A2hours
b.A2AA2changeA2hasA2recentlyA2occurredA2inA2hisA2handwriting
c.A2HeA2refusesA2toA2seeA2anyA2ofA2hisA2friendsA2orA2toA2returnA2theirA2phoneA2calls
d.A2HeA2exhibitsA2angryA2outburstA2whenA2theA2subjectA2ofA2dyingA2isA2approachedA2-
A2Ans--b.A2AA2changeA2hasA2recentlyA2occurredA2inA2hisA2handwriting
11.A2AA2hospitalizedA2clientA2withA2peripheralA2arterialA2diseaseA2(PAD)A2isA2instructedA2re
gardingA2legA2andA2footA2care.A2WhichA2statementA2byA2theA2clientA2indicatesA2toA2theA2nu
rseA2thatA2learningA2hasA2occurred?
a.A2"WheneverA2IA2amA2sittingA2inA2aA2chairA2IA2willA2keepA2myA2legsA2upA2toA2reduceA2swel
ling"
b.A2"IA2canA2useA2aA2mirrorA2toA2checkA2theA2bottomsA2ofA2myA2feetA2forA2anyA2signsA2ofA2b
reakdown"
c.A2"IA2willA2tryA2toA2keepA2movingA2ifA2legA2painA2occursA2toA2helpA2promoteA2goodA2circul
ation"
d.A2"IA2willA2useA2myA2swimmingA2poolA2earlyA2inA2theA2dayA2whileA2theA2waterA2isA2stillA2ve
ryA2cool"A2-A2Ans--
b.A2"IA2canA2useA2aA2mirrorA2toA2checkA2theA2bottomsA2ofA2myA2feetA2forA2anyA2signsA2ofA2b
reakdown"
12.A2WhileA2completingA2aA2healthA2assessmentA2forA2aA2clientA2withA2migraineA2headach
es,A2theA2nurseA2assessesA2bilateralA2weaknessA2inA2theA2client'sA2handA2grips.A2TheA2clie
ntA2reportsA2jointA2painA2andA2troubleA2twistingA2aA2doorA2knobA2dueA2toA2weakness.A2Whi
chA2actionA2shouldA2theA2nurseA2takeA2inA2responseA2toA2theseA2findings?
a.A2ExplainA2thatA2reliefA2ofA2theA2migraineA2painA2willA2reduceA2relatedA2symptoms
b.A2GatherA2additionalA2assessmentA2dataA2aboutA2theA2painA2andA2weakness
c.A2ImplementA2fallA2precautionsA2toA2reduceA2theA2client'sA2riskA2forA2injury
d.A2ConsultA2withA2theA2occupationalA2therapistA2forA2aA2functionalA2assessmentA2-A2Ans--
d.A2ConsultA2withA2theA2occupationalA2therapistA2forA2aA2functionalA2assessment
13.A2TheA2nurseA2isA2caringA2forA2aA2clientA2inA2theA2postA2anesthesiaA2careA2unitA2(PACU
)A2whoA2underwentA2aA2thoracotomyA2twoA2hoursA2ago.A2TheA2nurseA2observesA2theA2follo
wingA2vitalA2signs:A2heartA2rateA2140A2bpm,A2respirationsA226A2breaths/
minuteA2andA2bloodA2pressureA2140/90.A2WhichA2interventionA2isA2mostA2importantA2forA2t
heA2nurseA2toA2implement?
, a.A2MedicateA2forA2painA2andA2monitorA2vitalA2signsA2accordingA2toA2protocol
b.A2AdminstedA2intravenousA2fluidA2bolusA2asA2prescribedA2byA2theA2HCP
c.A2ApplyA2oxygenA2atA210A2LA2viaA2non-
rebreatherA2maskA2andA2monitorA2pulseA2oximeter.
d.A2EncourageA2theA2clientA2toA2splintA2theA2incisionA2withA2aA2pillowA2toA2coughA2andA2de
epA2breatheA2-A2Ans--a.A2MedicateA2forA2painA2andA2monitorA2vitalA2signs
14.A2AnA2adultA2isA2diagnosedA2withA2restlessA2legA2syndromeA2andA2isA2referredA2toA2theA
2sleepA2clinic.A2TheA2HCPA2prescribedA2ferrousA2sulfateA2325A2POA2daily.A2WhichA2laborat
oryA2valuesA2shouldA2theA2nurseA2monitorA2?
a.A2PlateletA2countA2andA2hematocrit
b.A2SerumA2electrolytes
c.A2SerumA2ironA2andA2ferritin
d.A2NeutrophilsA2andA2eosinophilsA2-A2Ans--c.A2SerumA2ironA2andA2ferritin
15.A2WhileA2caringA2forA2aA2clientA2withA2aA2fullA2thicknessA2burnA2coveringA240%A2ofA2theA
2body,A2theA2nurseA2observesA2purulentA2drainageA2atA2theA2wound.A2BeforeA2reportingA2t
hisA2findingA2toA2theA2HCPA2,A2theA2nurseA2shouldA2reviewA2whichA2ofA2theA2client'sA2labor
atoryA2values?
a.A2WhiteA2bloodA2cellA2count
b.A2PlateletA2count
c.A2BloodA2pHA2level
d.A2HematocritA2-A2Ans--a.A2WhiteA2bloodA2cellA2count
16.A2AA2clientA2withA2aA2historyA2ofA2typeA21A2diabetesA2mellitusA2(DM)A2andA2asthmaA2isA2
readmittedA2toA2theA2unitA2forA2theA2thirdA2timeA2inA2twoA2monthsA2withA2aA2currentA2fasting
A2bloodA2sugarA2ofA2325A2mg/
dl.A2TheA2clientA2describesA2toA2theA2nurseA2ofA2notA2understandingA2whyA2theA2bloodA2glu
coseA2levelA2continuesA2toA2beA2outA2ofA2control.A2WhichA2interventionsA2shouldA2theA2nur
seA2implement?A2SelectA2allA2thatA2apply.
a.A2HaveA2theA2clientA2describeA2aA2typicalA2dayA2atA2work,A2home,A2andA2socialA2activitie
s
b.A2DetermineA2ifA2theA2clientA2isA2usingA2aA2newA2insulinA2needleA2eachA2administration
c.A2EvaluateA2theA2clientsA2asthmaA2medicationsA2thatA2canA2elevateA2theA2bloodA2glucos
e
d.A2AskA2theA2clientA2ifA2theyA2wantA2aA2differentA2manufacturesA2glucoseA2monitoringA2de
vice
e.A2HaveA2theA2clientA2demonstrateA2techniquesA2usedA2toA2monitorA2bloodA2glucoseA2lev
elsA2-A2Ans--
a.A2HaveA2theA2clientA2describeA2aA2typicalA2dayA2atA2work,A2home,A2andA2socialA2activitie
s
100+ QUESTIONS AND CORRECT VERIFIED
ANSWERS WITH RATIONALES | A GRADE
1.A2AA2clientA2withA2Cushing'sA2syndromeA2isA2recoveringA2fromA2anA2electiveA2laparoscop
icA2procedure.A2WhichA2assessmentA2findingA2warrant'sA2immediateA2interventionA2byA2th
eA2nurse?
a.A2PurpleA2marksA2onA2skinA2ofA2theA2abdomen
b.A2IrregularA2apicalA2pulse
c.A2QuarterA2sizeA2bloodA2spotA2onA2dressing
d.A2PittingA2ankleA2edemaA2-A2Ans--b.A2IrregularA2apicalA2pulse
2.A2AA2clientA2withA2lungA2cancerA2whoA2wearsA2aA2subcutaneousA2morphineA2sulfateA2pat
chA2forA2painA2isA2shortA2ofA2breathA2andA2isA2difficultA2toA2arouse.A2WhenA2performingA2aA
2headA2toA2toeA2assessment,A2theA2nurseA2discoversA2fourA2analgesicA2patchesA2onA2theA
2clientsA2body.A2WhichA2interventionA2shouldA2theA2nurseA2implementA2first?
a.A2RemoveA2allA2ofA2theA2morphineA2patches
b.A2AdministerA2aA2narcoticA2antagonist
c.A2ApplyA2oxygenA2perA2faceA2mask
d.A2MeasureA2theA2client'sA2bloodA2pressureA2-A2Ans--
b.A2AdministerA2aA2narcoticA2antagonist
3.A2AA2clientA2receivesA2prescriptionsA2forA2aA2multidrugA2regimenA2forA2theA2treatmentA2of
A2tuberculosis.A2WhichA2informationA2shouldA2theA2nurseA2prioritize?
a.A2AdherenceA2toA2theA2regimenA2isA2imperative
b.A2MedicationsA2shouldA2beA2takenA2withA2food
c.A2SerumA2liverA2panelsA2areA2collectedA2regularly
d.A2EnhancedA2sunA2protectionA2measuresA2willA2beA2neededA2-A2Ans--
a.A2AdherenceA2toA2theA2regimenA2isA2imperative
4.A2TheA2nurseA2isA2preparingA2aA2clientA2forA2surgeryA2whoA2wasA2admittedA2toA2theA2eme
rgencyA2centerA2followingA2aA2motorA2vehicleA2collision.A2TheA2clientA2hasA2anA2openA2frac
tureA2ofA2theA2femurA2andA2isA2bleedingA2moderatelyA2fromA2theA2boneA2protrusionA2site.A2
DuringA2theA2prescriptiveA2assessment,A2theA2nurseA2determinesA2thatA2theA2clientA2curre
ntlyA2receivesA2heparinA2sodiumA25,000A2unitsA2subcutaneouslyA2daily.A2WhatA2isA2theA2pr
iorityA2nursingA2action?
a.A2NotifyA2theA2healthcareA2providerA2ofA2theA2client'sA2medicationA2history
b.A2ObserveA2theA2heparinA2injectionsA2sitesA2forA2signsA2ofA2bruising
c.A2HaveA2theA2clientA2signA2theA2surgicalA2andA2transfusionA2permits
,d.A2EnsureA2thatA2theA2potentialA2forA2bleedingA2isA2explainedA2toA2theA2clientA2-A2Ans--
a.A2NotifyA2theA2healthcareA2providerA2ofA2theA2client'sA2medicationA2history
5.A2AA2clientA2withA2orthopneaA2expressesA2concernA2aboutA2theA2abilityA2toA2"getA2enoug
hA2air"A2duringA2aA2scheduledA2thoracentesis.A2OnA2whichA2informationA2shouldA2theA2nur
se'sA2responseA2beA2based?
a.A2AA2thoracentesisA2isA2aA2briefA2processA2thatA2hasA2minimalA2discomfort
b.A2OrthopneaA2isA2frequentlyA2causedA2byA2aA2client'sA2uncontrolledA2anxiety
c.A2TheA2procedureA2isA2performedA2withA2theA2clientA2inA2anA2uprightA2position
d.A2ExtraA2pillowsA2canA2beA2usedA2ifA2neededA2toA2elevateA2theA2client'sA2headA2-A2Ans--
c.A2TheA2procedureA2isA2performedA2withA2theA2clientA2inA2anA2uprightA2position
6.A2WhatA2informationA2shouldA2theA2nurseA2includeA2inA2theA2teachingA2planA2ofA2aA2client
A2diagnosedA2withA2gastroesophagealA2refluxA2diseaseA2(GERD)?
a.A2SleepA2withoutA2pillowsA2atA2nightA2toA2maintainA2neckA2alignment
b.A2AdjustA2foodA2intakeA2toA2threeA2fullA2mealsA2perA2dayA2andA2noA2snacks
c.A2MinimizeA2symptomsA2byA2wearingA2loose,A2comfortableA2clothing
d.A2AvoidA2participationA2inA2anyA2aerobicA2exerciseA2programsA2-A2Ans--
c.A2MinimizeA2symptomsA2byA2wearingA2loose,A2comfortableA2clothing
7.A2TheA2nurseA2isA2providingA2teachingA2toA2aA2clientA2withA2TypeA22A2diabetesA2mellitusA
2andA2peripheralA2neuropathy.A2WhichA2informationA2shouldA2theA2nurseA2provide?
a.A2FamilyA2membersA2canA2helpA2withA2regularA2footA2exams
b.A2HeatingA2padsA2areA2usefulA2ifA2onA2theA2lowA2setting
c.A2AchingA2feetA2mayA2beA2soakedA2inA2lukewarmA2waterA2forA2oneA2hourA2orA2more
d.A2ShoesA2shouldA2beA2wornA2outsideA2theA2house,A2butA2itA2isA2fineA2toA2beA2barefootA2in
sideA2-A2Ans--a.A2FamilyA2membersA2canA2helpA2withA2regularA2footA2exams
8.A2AA2clientA2inA2theA2operatingA2roomA2receivedA2succinylcholine.A2TheA2clientA2isA2expe
riencingA2muscleA2rigidityA2andA2hasA2anA2extremelyA2highA2temperature.A2WhatA2actionA2
shouldA2theA2nurseA2implement?
a.A2HoldA2aA2prescriptionA2forA2dantroleneA2untilA2feverA2isA2reduced
b.A2PrepareA2iceA2packsA2forA2placementA2inA2theA2clientsA2axillaryA2area
c.A2CallA2theA2PACUA2nurseA2toA2prepareA2forA2prolongedA2ventilatorA2support
d.A2DetermineA2ifA2prescribedA2antibioticsA2wereA2administeredA2preoperativelyA2-A2Ans--
b.A2PrepareA2iceA2packsA2forA2placementA2inA2theA2clientsA2axillaryA2area
9.A2TheA2nurseA2isA2developingA2aA2planA2ofA2careA2forA2aA2clientA2whoA2reportsA2blurredA2
visionA2andA2whoA2isA2newlyA2diagnosedA2withA2cardiovascularA2disease.A2WhichA2outco
meA2shouldA2theA2nurseA2includeA2inA2theA2planA2ofA2careA2forA2thisA2client?
a.A2TheA2nurseA2willA2encourageA2theA2clientA2toA2walkA2thirtyA2minutesA2everyA2day
,b.A2TheA2clientsA2familyA2willA2stateA2signsA2andA2symptomsA2aboutA2theA2disease
c.A2TheA2clientsA2dailyA2bloodA2pressureA2willA2beA2lessA2thanA2140/80A2thisA2month
d.A2TheA2clientA2bloodA2pressureA2readingsA2willA2beA2lessA2thanA2160/90A2-A2Ans--
c.A2TheA2clientsA2dailyA2bloodA2pressureA2willA2beA2lessA2thanA2140/80A2thisA2month
10.A2TheA2familyA2suspectsA2thatA2acquiredA2immuneA2deficiencyA2syndromeA2(AIDS)A2de
mentiaA2isA2occuringA2inA2theirA2sonA2whoA2isA2humanA2immunodeficiencyA2virusA2(HIV)A2
positive.A2WhichA2symptomsA2confirmA2theirA2suspicions?
a.A2HeA2hasA2begunA2toA2sleepA218A2outA2ofA224A2hours
b.A2AA2changeA2hasA2recentlyA2occurredA2inA2hisA2handwriting
c.A2HeA2refusesA2toA2seeA2anyA2ofA2hisA2friendsA2orA2toA2returnA2theirA2phoneA2calls
d.A2HeA2exhibitsA2angryA2outburstA2whenA2theA2subjectA2ofA2dyingA2isA2approachedA2-
A2Ans--b.A2AA2changeA2hasA2recentlyA2occurredA2inA2hisA2handwriting
11.A2AA2hospitalizedA2clientA2withA2peripheralA2arterialA2diseaseA2(PAD)A2isA2instructedA2re
gardingA2legA2andA2footA2care.A2WhichA2statementA2byA2theA2clientA2indicatesA2toA2theA2nu
rseA2thatA2learningA2hasA2occurred?
a.A2"WheneverA2IA2amA2sittingA2inA2aA2chairA2IA2willA2keepA2myA2legsA2upA2toA2reduceA2swel
ling"
b.A2"IA2canA2useA2aA2mirrorA2toA2checkA2theA2bottomsA2ofA2myA2feetA2forA2anyA2signsA2ofA2b
reakdown"
c.A2"IA2willA2tryA2toA2keepA2movingA2ifA2legA2painA2occursA2toA2helpA2promoteA2goodA2circul
ation"
d.A2"IA2willA2useA2myA2swimmingA2poolA2earlyA2inA2theA2dayA2whileA2theA2waterA2isA2stillA2ve
ryA2cool"A2-A2Ans--
b.A2"IA2canA2useA2aA2mirrorA2toA2checkA2theA2bottomsA2ofA2myA2feetA2forA2anyA2signsA2ofA2b
reakdown"
12.A2WhileA2completingA2aA2healthA2assessmentA2forA2aA2clientA2withA2migraineA2headach
es,A2theA2nurseA2assessesA2bilateralA2weaknessA2inA2theA2client'sA2handA2grips.A2TheA2clie
ntA2reportsA2jointA2painA2andA2troubleA2twistingA2aA2doorA2knobA2dueA2toA2weakness.A2Whi
chA2actionA2shouldA2theA2nurseA2takeA2inA2responseA2toA2theseA2findings?
a.A2ExplainA2thatA2reliefA2ofA2theA2migraineA2painA2willA2reduceA2relatedA2symptoms
b.A2GatherA2additionalA2assessmentA2dataA2aboutA2theA2painA2andA2weakness
c.A2ImplementA2fallA2precautionsA2toA2reduceA2theA2client'sA2riskA2forA2injury
d.A2ConsultA2withA2theA2occupationalA2therapistA2forA2aA2functionalA2assessmentA2-A2Ans--
d.A2ConsultA2withA2theA2occupationalA2therapistA2forA2aA2functionalA2assessment
13.A2TheA2nurseA2isA2caringA2forA2aA2clientA2inA2theA2postA2anesthesiaA2careA2unitA2(PACU
)A2whoA2underwentA2aA2thoracotomyA2twoA2hoursA2ago.A2TheA2nurseA2observesA2theA2follo
wingA2vitalA2signs:A2heartA2rateA2140A2bpm,A2respirationsA226A2breaths/
minuteA2andA2bloodA2pressureA2140/90.A2WhichA2interventionA2isA2mostA2importantA2forA2t
heA2nurseA2toA2implement?
, a.A2MedicateA2forA2painA2andA2monitorA2vitalA2signsA2accordingA2toA2protocol
b.A2AdminstedA2intravenousA2fluidA2bolusA2asA2prescribedA2byA2theA2HCP
c.A2ApplyA2oxygenA2atA210A2LA2viaA2non-
rebreatherA2maskA2andA2monitorA2pulseA2oximeter.
d.A2EncourageA2theA2clientA2toA2splintA2theA2incisionA2withA2aA2pillowA2toA2coughA2andA2de
epA2breatheA2-A2Ans--a.A2MedicateA2forA2painA2andA2monitorA2vitalA2signs
14.A2AnA2adultA2isA2diagnosedA2withA2restlessA2legA2syndromeA2andA2isA2referredA2toA2theA
2sleepA2clinic.A2TheA2HCPA2prescribedA2ferrousA2sulfateA2325A2POA2daily.A2WhichA2laborat
oryA2valuesA2shouldA2theA2nurseA2monitorA2?
a.A2PlateletA2countA2andA2hematocrit
b.A2SerumA2electrolytes
c.A2SerumA2ironA2andA2ferritin
d.A2NeutrophilsA2andA2eosinophilsA2-A2Ans--c.A2SerumA2ironA2andA2ferritin
15.A2WhileA2caringA2forA2aA2clientA2withA2aA2fullA2thicknessA2burnA2coveringA240%A2ofA2theA
2body,A2theA2nurseA2observesA2purulentA2drainageA2atA2theA2wound.A2BeforeA2reportingA2t
hisA2findingA2toA2theA2HCPA2,A2theA2nurseA2shouldA2reviewA2whichA2ofA2theA2client'sA2labor
atoryA2values?
a.A2WhiteA2bloodA2cellA2count
b.A2PlateletA2count
c.A2BloodA2pHA2level
d.A2HematocritA2-A2Ans--a.A2WhiteA2bloodA2cellA2count
16.A2AA2clientA2withA2aA2historyA2ofA2typeA21A2diabetesA2mellitusA2(DM)A2andA2asthmaA2isA2
readmittedA2toA2theA2unitA2forA2theA2thirdA2timeA2inA2twoA2monthsA2withA2aA2currentA2fasting
A2bloodA2sugarA2ofA2325A2mg/
dl.A2TheA2clientA2describesA2toA2theA2nurseA2ofA2notA2understandingA2whyA2theA2bloodA2glu
coseA2levelA2continuesA2toA2beA2outA2ofA2control.A2WhichA2interventionsA2shouldA2theA2nur
seA2implement?A2SelectA2allA2thatA2apply.
a.A2HaveA2theA2clientA2describeA2aA2typicalA2dayA2atA2work,A2home,A2andA2socialA2activitie
s
b.A2DetermineA2ifA2theA2clientA2isA2usingA2aA2newA2insulinA2needleA2eachA2administration
c.A2EvaluateA2theA2clientsA2asthmaA2medicationsA2thatA2canA2elevateA2theA2bloodA2glucos
e
d.A2AskA2theA2clientA2ifA2theyA2wantA2aA2differentA2manufacturesA2glucoseA2monitoringA2de
vice
e.A2HaveA2theA2clientA2demonstrateA2techniquesA2usedA2toA2monitorA2bloodA2glucoseA2lev
elsA2-A2Ans--
a.A2HaveA2theA2clientA2describeA2aA2typicalA2dayA2atA2work,A2home,A2andA2socialA2activitie
s
