HESI RN MEDSURG

HESI RN MEDSURG 2021/2022 EXAM PACK ACTUAL EXAMBEST FOR 2022 EXAM REVIEW HESI RN MED SURG/ACTUAL EXAM THIS FILE WAS TESTED APRIL 2022 Answers included 1. An adult client is diagnosed with restlessleg syndrome and isreferred to the sleep clinic. The healthcare provider prescribes ferrous sulfate 325 mg pO daily. Which laboratory values should the nurse monitor? a. Serum iron and ferritin b. Platelet count and hematocrit c. Neutrophils and eosinophils d. Serum electrolytes 2. The nurse is caring for a client who is newly diagnosed with adrenocortical insufficiency. The client is experiencing chronic fatigue and weakness. Which intervention should the nurse implement? a. Begin education about fluid restriction and waysto incorporate into ongoing therapy b. Explain that the hormone therapy will be needed for a time until adrenal glands are stimulated c. Provide encouragement that symptoms will rapidly improve as hormone therapy is initiated d. Advise the client to schedule energy intensive activitiesfor later in the day 3. the nurse is caring for an immobile client after spinal surgery. Which action is most important for the nurse to take to prevent postoperative complications? a. Maintain intervascular infusion rate b. Progress diet slowly from ice chipsto clear liquid c. Apply intermittent pneumatic compression devices d. Obtain frequent pain level assessments 4. An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action? a. Encourage turning and deep breathing b. Auscultate for presence of bowel sounds c. Administer IV antibiotics as prescribed d. Monitor hemoglobin and hematocrit 5. The nurse is obtaining a health history from a new client who has a history of kidney stones. Which statement by the client indicates an increased risk for renal calculi? a. Eats a vegetarian diet with cheese 2 to 3 times a day b. Experiences additional stresssince adopting a child c. Jogs more frequently than usual daily routine d. Drinksseveral bottles of carbonated water daily 6. A client with orthopnea expresses concern about the ability to “get enough air” during a scheduled thoracentesis. On which information should the nurse’s response be based on? a. Extra pillows can be used if needed to elevate the client’s head b. Orthopnea is frequently caused by a clients uncontrolled anxiety c. The procedure is performed with the client in an upright position d. A thoracentesis is a brief procedure that has minimal discomfort 7. The nurse is performing the postoperative assessment of a client with an abdominal aortic aneurysm. Which finding is most important for the nurse to provide in the preoperative report? a. Respirations 20 breaths/minute b. Diminished peripheral pulses c. Hypoactive bowelsounds d. S3 hearsound on auscultation 8. The nurse is providing teaching to a client with type 2 diabetes mellitus about managing care at home. Which information stated by the client indicates understanding? a. Avoid seasoning foods with salt and salt-containing spices b. Keep any wounds covered with an antibiotic ointment c. Check blood sugar levels every four to six hours every day d. Soak feet daily in hot water no longer than 10 minutes 9. The home health nurse providesteaching about insulin self-injecting to a client who was recently diagnosed with diabetes mellitus. When the client begins to perform a return demonstration of an insulin injection into the abdomen as seen in the video, which instruction should the nurse provide? a. Lie down flat for betterskin exposure b. Select a different injection site c. Keep the skin flat rather than bunched d. Continue with the insulin injection 10. The nurse is collecting information from a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain? a. Color and consistency of feces b. Eating patterns and dietary intake c. Level and amount of physical activity d. Presence and activity of bowel sounds 11. A client with herpeszoster (shingles) on the thorax tellsthe nurse of having difficulty sleeping. Which is the probable etiology of this problem? a. Noctuia b. Dyspnea c. Frequent cough d. Pain 12. The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this medical diagnosis? a. Marked loss of weight and appetite over the last 3 or 4 months b. Upper mid-abdominal pain described as gnawing and burning c. Frequent use of chewable and liquid antacidsfor indigestion d. Severe abdominal cramps and diarrhea after eating spicy foods 13. An obese client with emphysema who smokes at least a pack of cigarettes daily is admitted after experiencing a sudden increase in dyspnea and activity intolerance. Oxygen therapy isinitiated and is determined that the client will be discharged with oxygen. Which information is most important for the nurse to emphasize in the discharge teaching plan? a. Methodsfor weight gain b. Guidelinesfor oxygen used c. Strategiesfor smoking cessation d. Approachesto conserve energy 14. A hospitalized client with peripheral arterial disease (PAD) isinstructed regarding leg and foot care. Which statement by the client indicates to the nurse that learning has occurred? a. “whenever I am sitting in a chair I will keep my legs up to reduce swelling” b. “I can use a mirror to check the bottoms of my feet for any signs of breakdown” c. “I will try to keep moving if leg pain occursto help promote good circulation” d. “I will use my swimming pool early in the day while the water isstill very cool. 15. To reduce the risk for pulmonary complication for a client with amyotrophic lateral sclerosis (ALS), which interventions should the nurse implement? SATA a. Perform chest physiotherapy b. Initiate passive range of motion exercise e. Establish a regular bladder routine 16. An adult who was recently diagnosed with glaucoma tells the nurse, “It feels like I am driving through a tunnel”. The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client? a. Wear prescription glasses b. Maintain prescribed eye drop regimen c. Avoid frequent eye pressure measurements d. Eat a diet high in carotene (vit C) 17. The nurse observes an increase number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a trans-urethral resection of the prostate (TURP). What is the best initial nursing action? a. Provide additional oral fluid intake b. Administer a PRN dose of an antispasmodic agent c. Measure the clientsintake and output d. Increase the flow of bladder irrigation 18. The healthcare provider prescribes diagnostic test for a client whose chest xray indicates pneumonia. Which diagnostic test should the nurse review for implementation in the most therapeutic treatment of the pneumonia? a. Arterial blood gases (ABG) b. Sputum culture and sensitivity c. Computerized tomography (CT) of the chest d. Blood cultures 19. The family suspects that acquired immune deficiency syndrome (AIDS) dementia is occurring in their son who is human immunodeficiency virus (HIV) positive. Which symptom confirms theirsuspicions? a. He refusesto see any of his friends or to return their phone calls b. He has begun to sleep 19 out of 24 hours c. He exhibits angry outburst when the subject of dying is approached c. Encourage use of incentive spirometer d. Teach the client breathing exercises d. A change hasrecently occurred in his handwriting 20. The nurse is providing discharge instructions to a client who is receiving prednisone 5 mg PO daily for a rash due to contact with poison ivy. Which symptom should the nurse tell the client to report to the health care provider? a. Moon facies b. Gastric irritation c. Abdominal striae d. Rapid weight gain 21. The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observesthe following vitalsigns: heart rate 140 breaths/minute, respirations 26 breaths/minute, and blood pressure 140/90 mmHG. Which intervention is most important for the nurse to implement? a. Medicate for pain and monitor vitalsigns according to protocol b. Administer intravenousfluid bolus as prescribed by the healthcare provider c. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter d. Encourage the client to splint the incision with a pillow to cough and deep breathe. 22. A client with lung cancer who wears a subcutaneous morphine sulfate patch for pain is short of breath and is difficult to arouse. When performing a head to toe assessment, the nurse discovers four analgesic patches on the client’s body. Which intervention should the nurse implement first? a. Remove all of the morphine patches b. Administer a narcotic antagonist c. Measure the clients blood pressure d. Apply oxygen per face mask 23. The nurse assess a client who is newly diagnosed with hyperthyroidism and observes that the clients eyeballs are protuberant, causing a wide-eyed appearance and eye discomfort. Based on thisfinding, which action should the nurse include in the clients plan of care? a. Assessfor signs of increased ICP b. Prepared to administerintravenouslevothyroxine c. Obtain a prescription for artificial tear drops d. Review the clientsserum electrolyte value 24. A client with Cushing’ssyndrome isrecovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse? a. Purple marks on skin of the abdomen b. Pitting ankle edema c. Quartersize blood spot on dressing d. Irregular apical pulse 25. Four daysfollowing an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities and pedal pulses are not palpable. Which action should the nurse implement first? a. Wrap the feet with warmed blankets b. Elevate extremities on pillows c. Assess pulses with a vascular doppler d. Evaluate edema for pitting 26. A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened,tenacious mucous, and the inability to walk up a flight ofstairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care? a. Call the clinic if undesirable side effects of medication occur b. Increase the daily intake of oral fluidsto liquefy secretions c. Teach anxiety reduction methodsforfeelings ofsuffocation d. Avoid crowded enclosed areasto reduce pathogen exposure 27. A client tellsthe clinic nurse about experiencing burning on urination, and assessment reveals that the client had sexual intercourse four days ago with a person who was casually met. Which action should the nurse implement? a. Observe the perineal area for chancroid like lesion b. Obtain a specimen of urethral drainage for culture c. Assessfor perineal itching, erythema, and excoriation d. Identify allsexual partners in the last 4 days 28. A client is hospitalized with heart failure (HF). Which intervention should the nurse implement to improve ventilation and reduce venous return? a. Place the client in high fowler position b. Perform passive range of motion exercises c. Increase the clients activity level d. Administer oxygen per nasal cannula 29. During spring break, a young adult presents to the urgent care clinic and reports a stiff neck, a fever for the past 6 hours and a headache. Which intervention is most important for the nurse to implement first? a. Draw blood cultures b. Administer an antipyretic c. Prepare for a lumbar puncture d. Initiate isolation precautions 30. The nurse is providing teaching to a client with type 2 diabetes mellitus and peripheral neuropathy. Which information should the nurse provide? a. Aching feet may be soaked in lukewarm water for one hour or more b. Family members can help with regular foot exams c. Heat pads are useful if on the lowestsetting d. Shoesshould be worn outside the house, but it isfine to be barefoot inside 31. The nurse is planning care for an older adult client who experienced a cerebrovascular accident several weeks ago. The client has expressive aphasia and often becomes frustrated with the nursing staff. Which intervention should the nurse implement? a. Encourage clients use of picture charts b. Ask the client simple questions c. Speak slowly to the client d. Teach the client use of basic sign language 32. Which client hasthe highest risk for developing skin cancer? a. a 25 year old dark skinned client whose mother had skin cancer b. a 70 year old fair skinned client who works as a secretary c. a 65 year old fair skinned client who is a construction worker d. a 16 year old dark skinned client who tansin tanning beds once a week 33. The nurse is preparing a client for surgery who was admitted to the emergency center following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that client currently receives heparin sodium 5,000 units subcutaneously daily. What isthe priority nursing action? a. Notify the health care provider of the clients medication history b. Have the client sign the surgical and transfusion permits c. Observe the heparin injection sitesforsigns of bruising d. Ensure that the potential for bleeding is explain to the client. 34. What food is most important for the nurse to encourage a client with osteomalacia to include in a daily diet? a. Citrusfruits and juices b. Green leafy vegetables c. Fortified milk and cereals d. Red meats and eggs 35. While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting thisfinding to the healthcare provider, the nurse should review which of the client’s laboratory values? a. White blood cell (WBC) count b. Blood pH level c. Platelet count d. Hematocrit 36. A client with gout arthritisreports tenderness and swelling of the right ankle and great toe. The nurse observes the area of inflammation above the ankle area. The client receives prescription for colchicine and indomethacin. Which instruction should the nurse include in the discharge teaching? a. Encourage active range of motion to limitstiffness b. Drink at least 8 cups (1920 mL) of water per day c. Use electric heating pad when pain is at its worse d. Eat high protein foodsto achieve ideal body weight 37. A client with acute renal injury (AKI) weights 50 kg and has potassium level of 6.7 mEq/L is admitted to the hospital. Which prescribed medication should the nurse administer first? a. Sodium polystyrene sulfonate 15 grams by mouth b. Sevelamer one table by mouth c. Calcium acetate one tablet by mouth d. Epoetin alfa,recombinant 2,500 unit subcutaneously 38. While completing a health assessment for a client with migraine headaches, the nurse assesses bilateral weakness in the client’s hand grips. The client reports join pain and trouble twisting a doorknob due to weakness. Which action should the nurse take in response to these findings? a. Explain the relief of the migraine pain will reduce related symptoms b. Consult with the occupational therapist for a functional assessment c. Implement fall precautionsto reduce the client’srisk for injury d. Gather additional assessment data about the pain and weakness 39. The nurse assesses a client with petechiae and ecchymosisscattered across the arms and legs. Which laboratory result should the nurse review? a. Platelet count b. Red blood cell count c. White blood cell count d. Hemoglobin levels 40. An older client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment. Which assessments would the nurse complete to determine if a patient with type 2 diabetes mellitus (DM) is experiencing long term complications? SATA a. Signs of respiratory tractinfection b. Serum creatine and blood urea nitrogen (BUN) c. Skin condition of lower extremities d. Sensation in feet and legs e. Visual acuity 41. A client in the operating room received succinylcholine. The client is experiencing muscle rigidity and has an extremely high temperature. Which action should the nurse implement? a. Call the PACU nurse to prepare for prolonged ventilatory support b. Hold a prescription for dantrolene until fever isreduced c. Prepare ice packs for placement in the client’s axillary area d. Determine if prescribed antibiotics were administered preoperatively 42. A client with chronic kidney disease is started on hemodialysis. During the first dialysis treatment, the clients blood pressure dropsfrom 150/90 mmHG to 80/30 mmHG. Which action should the nurse take first? a. Administer 5% albumin IV b. Monitor blood pressure q45 minutes c. Stop the dialysis treatment d. Lower the head of the chair and elevate feet 43. After three days of persistent epigastric pain, a female presents to the clinic, she has been taking oral antacids without relief. Her vitalsigns are heart rate 122 beats/minute, respirations 16 breaths/minute, oxygen saturation 96% and blood pressure 116/70 mmHG. The nurse obtains a 12-lead electrocardiogram (ECG). Which assessment finding is most critical? a. Complaint of radiating jaw pain b. Irregular pulse rate c. ST elevation in three leads d. Bile colored emesis 44. A nurse is caring for a client with diabetesinsipidus (DI). Which data warrants the most immediate intervention by the nurse? a. Serum sodium 185 mEq/L b. Apical rate of 110 beats per minute c. Dry skin with inelastic turgor d. Polyuria and excessive thirst 45. A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit? a. Profuse diaphoresis and severe, pounding headache b. Complaints of chest pain and shortness of breath c. Pain and a burning sensation upon urination and hematuria d. Hypotension and venous pooling in the extremities 46. The nurse observes pitting edema in both hands and all fingers of a client with diffuse systemic sclerosis (Scleroderma). Which action should the nurse include in the plan of care? a. Cover areasliberally with lubricant b. Examine skin for ulcerations c. Observe forscleral jaundice d. Apply cold packs as needed 47. When conducting discharge teaching for a client with diverticulosis, which diet instruction should the nurse include? a. Have small frequent meals and sit up for at least two hours after meals b. Eat a soft diet with increased intake of milk and milk products c. Eat a high-fiber diet and increase fluid intake d. Eat a bland diet and avoid spicy foods 48. An older client with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. The client is anxious and is complaining of a dry mouth. Which intervention should the nurse implement? a. Administer a prescribed sedative b. Assist client to an upright position c. Apply a high-flow venturi mask d. Encourage client to drink water 49. A client with cholelithiasisis admitted with jaundice due to obstruction of the common bile duct. Which finding is most important for the nurse to report to the healthcare provider? a. Clay colored stool b. Radiating sharp pain in right shoulder c. Distended, hard and ridged abdomen d. Bile-stained emesis 50. The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis a. Decreased renin-angiotensin response related to an increase in renal blood flow b. Decreased portacaval pressure with greater collateral circulation c. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules d. Hypoalbuminemia that results in decreased colloidal oncotic pressure 51. The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portalsite should the nurse provide? a. Apply moisture lotions daily to the radiation portalsite b. Protect the skin of the radiation portalsite from sunlight exposure c. Avoid washing the skin inside the radiation portalsite d. Remove the ink marks of the portal after each radiation treatment. 52. MATH 53. MATH HESI RN MED SURG/ACTUAL EXAM THIS FILE WAS TESTED LASTWEEK SCORED 1026 Answers included 1- A male client who reports feeling chronically fatigued has a hemoglobin of 11.0 grams/dl (110 mmol/L or SI), hematocrit of 34% and microcytic and hypochromic red blood cells. Based on the findings, which dinner selection should the nurse suggest for the patient? A. Beef steak with steam broccoli and orange slices B. Cheese pasta and a lettuce and tomato salad C. Broil white fish with a baked sweet potato D. Grill shrimp and seasoned rice with asparagus salad. 2- Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires the most immediate action by the nurse? A. Surgical consent form is not signed B. Preoperative serum potassium level is 2.8 mEq/L (2.8mmol/L) C.Preoperative chest x-ray report is not available D. Client's pulse oximeter reading is 96% 3- The nurse is assessing a client's arteriovenous (AV) fistula. Which finding provides evidence of its normal function? A. Ecchymotic area B. Enlarged vein C. Pulselessness D. Redness 4- Following a transurethral resection of the prostate (TURP), a client is discharged from the hospital with an indwelling urinary catheter. Which instruction is important for the nurse to include in the discharge teaching plan? A. Avoid driving a car for 2 weeks B. Drink 3 liters of water each day C. Eliminate all spicy foods from your diet D. Clamp the catheter when taking a shower 5- A client is receiving chemotherapy for treatment of metastatic carcinoma. When monitoring the client for systemic side effects, which assessment finding warrants intervention by the nurse? A. Leukopenia B. Polycythemia C. Ascites D. Nystagmus 6- A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse? A. Irregular apical pulse B. Pitting ankle edema C. Quarter size blood spot on dressing D. Purple marks on skin of the abdomen 7- ( Algo de esto, pero fue que el paciente tenia dolor y los dedos cianoticos )A client who fractured the right femur from a fall at home is placed in a skeletal traction while awaiting surgery. When the client tells the nurse the need to urinate, which intervention should the nurse implement? A. Insert an indwelling catheter preoperatively B.Release the traction so the client can use a bedpan C. Log roll the client and place adult disposable briefs beneath the client D. Maintain traction while the client uses a female urinal 8- The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition? A. Has everyone at home already had varicella? B. Have the anti fungal creams been effective? C. Do your family members share combs and brushes? D. Do you have any dry patches on your feet and hands? 9- Which instruction should the nurse include in the discharge teaching for a client who has gastroesophageal reflux? A. Encourage the client to lie down and rest after meals B. Remind the client to avoid high-fiber foods C. Teach the client to elevate the head of the bed on blocks D. Instruct the client to use antacids only as a last resort 10- The nurse prepares a teaching plan for an adult client with metabolic syndrome. Which findings should the nurse address to help the client reduce the risk for diabetes mellitus and vascular disease? (Select all that apply) A. Hypothyroidism B. Increased triglyceride levels C. Hyperglycemia D. Blood pressure of 150/96 E. Elevated high density lipoproteins F. Abdominal obesity 11- A client is admitted with a deep and productive cough, hemoptysis, and a low-grade fever. The client's Mantoux skin test has a 15mm induration. Which intervention should the nurse implement first? A. Administer the initial dose of rifampin and isoniazid B. Collect a sputum specimen for acid-fast bacillus C. Provide a mask for the client to wear in public areas D. Initiate airborne particulate isolation precautions 12- ? While caring for a client with a full-thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provide, the nurse should review which of the client's laboratory values? A. White blood cell count B. Blood pH level C. Platelet count D. Hematocrit 13- The home health nurse is evaluating a male client who manages his asthma and measures his peak expiratory flow rate (PEFR). Today he is experiencing an acute exacerbation and tells the nurse his PEFR is 60% of his personal-best reading. He is experiencing expiratory and inspiratory wheezes and has a RR of 24 breaths/minute, and oxygen saturation rate of 94% on room air. Which PRN medication should the nurse instruct the client to use? A. Albuterol 2.5 to 5 mg per nebulization B. Epinephrine auto-injector 0.15 mg C. Salmeterol 2 puffs per measured-dose inhaled D. Oxygen at 6 liter/minute by nasal cannula 14- Which food is most important for the nurse to encourage a client with osteomalacia to include in a daily diet? A. Fortified milk and cereals B. Citrus fruits and juices C. Red meats and eggs D. Green leafy vegetables 15- After several days of coughing and taking acetaminophen to treat temperature of 101 F, a client with diabetes mellitus (DM) is admitted to the hospital with an upper respiratory infection. Several hours after admission, the client reports having a severe headache and feeling dizzy. Which intervention should the nurse implement first? A. Reassess vital signs B. Administer an antipyretic C. Obtain a sputum for culture D. Obtain a fingerstick glucose 16- An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI) Prescriptions for intravenous antibiotics and insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse? A. blood ph of 7.30 B. glucose of 350 mg /dl C. white blood cell count of 15000mm D. potassium of 2.5 meq/l 17- ( La que salio fue si esta tomando warfarin que test se tiene que revisar)The nurse is caring for a patient prescribed warfarin (Coumadin) orally. The nurse reviews the patient’s prothrombin time (PT) level to evaluate the effectiveness of the medication. The nurse should also evaluate which of the following laboratory values? a) International normalized ratio (INR) b) Partial thromboplastic time (PTT) c) Sodium d) Complete blood count (CBC) a) International normalized ratio (INR) Explanation: The INR, reported with the PT, provides a standard method for reporting PT levels and eliminates the variation of PT results from different laboratories. The INR, rather than the PT alone, is used to monitor the effectiveness of warfarin. The therapeutic range for INR is 2 to 3.5, although specific ranges vary based on diagnosis. The other laboratory values are not used to evaluate the effectiveness of Coumadin. 18- The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a Thoracotomy two hours ago. The nurse observes the following vital signs: heart rate 140 beats/minute, respirations 26 breaths/minute, and blood pressure 140/90 mmHg. Which intervention is most important for the nurse to implement? A. Administer IV fluid bolus as prescribed by the healthcare provider B. Medicate for pain and monitor vital signs according to protocol C. Encourage the client to splint the incision with a pillow to cough and deep breathe??? D. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter 19- An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI) Prescriptions for intravenous antibiotics and insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse? A. blood ph of 7.30 B. glucose of 350 mg /dl C. white blood cell count of 15000mm D. potassium of 2.5 meq/l 20- An older female client with long term type 2 diabetes mellitus (DM) is seen in the client for a routine health assessment. To determine if the client is experiencing any long – term complications of DM, which assessments should the nurse obtain? (Select all that apply) a. Serum creatinine and blood urea nitrogen (BUN). b. Sensation in feet and legs. c. Skin condition of lower extremities. d. Signs of respiratory tract infection e. Visual acuity. 21- The nurse determines that an adult client who is admitted to the post anesthesia care unit (PACU) following abdominal surgery has a tympanic temperature of 94.6 F(34.8*C), a pulse rate of 88 beast/minute, a respiratory rate of 14 breaths/minute, and a blood pressure of 94/64 mmHg. Which action should the nurse implement? a. Take the client’s temperature using another method. b. Raise the head of the bed to 60 to 90 degrees. c. Ask the client to cough and deep breathe. d. Check the blood pressure every five minutes for one hour. 22- The nurse teaching a client how to collect a sputum specimen. Which steps should the nurse instruct the client to follow when collecting sputum? a. Restrict fluids before expectorating the sputum specimen. b. Obtain the specimen before bedtime. c. Avoid mouth care prior to collecting the sputum. d. Breathe deeply, followed by coughing up the sputum. 23- While caring for a client with Guillain-Barre syndrome, the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse? a. Lower leg weakness. b. Sensory loss at T-8. c. Leg pain worsening at night. d. Profuse diaphoresis. 24- 25- 26- Solo puse b y d 27- 28- Yo puse c 29- 30- 31- 32- 33- Cambio algo me parece que era cancer y no hernia 34- 35- After teaching a female client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Elimination of which food choices by the client indicates teaching is successful R/ Whole milk and daily ice cream servings 36- A client with a bariatric surgery 2 months ago, and a week ago, has vomiting, nausea anorexia, fever, put in NPO. What should the nurse do next? R/Insert nasogastric tube with low suction intermittent 37- A client with chronic kidney disease (CDK) arrives at the clinic reporting shortness of breath on exertion and extreme weakness. Vital signs are temperature 100.4 F (38 C), heart rate 110beats/minute, respirations 28 breaths/minute, and blood pressure 175/98 mmHg. The client usually receives dialysis three times a week but missed the last treatment. STAT blood specimens are sent to the laboratory for analysis. Which laboratory results should the nurse report to the healthcare provider immediately? Potassium 6.5 mEq/L (mmol/L) 38- A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care? Teach the client techniques for performing intermittent catheterization 39- A client with Parkinson Disease presenting mask like face. What other sign alert the nurse for rapid intervention? Swallowing inability 40- A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 1 to 10 scale. Which intervention should the nurse implement? Administer opioid and non-opioid medication simultaneously 41- A nurse assists a male client with Parkinson's disease (PD) to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. He tells the nurse that he is pretending to step over a crack on the floor. How should the nurse respond? Confirm that this is an effective technique to help with ambulation 42- A nurse is caring for a client with Diabetes Insipidus (DI). Which data warrants the most immediate intervention by the nurse? Serum sodium of 185 mEq/L 43- 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? Provide a bedside commode for toileting 44- An older client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement? Provide an eye shield to be worn while sleeping 45- An older female client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment. To determine if the client is experiencing any long-term complication of DM, which assessments should the nurse obtain? (selectall that apply) Serum creatinine and blood urea nitrogen (BUN) Sensation in feet and legs Skin condition of lower extremities Visual acuity 46- An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action? A. Encourage turning and deep breathing. B. Auscultate for presence of bowel sounds C. Monitor hemoglobin and hematocrit D.Administer IV antibiotics as prescribed 47- The nurse is caring for a client diagnosed with psoriasis vulgaris who receiving a psoralen and ultraviolet a light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment? A. Thick skin plaques topped by silvery white scales B. Requires sunglasses because sunlight hurts eyes C. Tenderness upon palpation and generalized erythema D. Brown, rough, greasy, wart-like papules on the face 48- The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a trans-urethral resection of the prostate (TURP) .What is the best initial nursing action? A. Administer a PRN dose of an antispasmodic agent B. Measure the client’s intake and output C. Provide additional oral fluid intake D. Increase the flow of the bladder irrigation 49- HESI RN NEW MED SURG EXAM 2022 -MULTIPLE QUESTIONS -QUESTIONS&ANSWERS -55 QUESTIONS -TESTED 2022 1.The client who experiences angina has been told to follow a low cholesterol diet. Which of the following meals would be best? 1. Hamburger, salad, and milkshake. 2. Baked liver, green beans, and coffee. 3. Spaghetti with tomato sauce, salad, and coffee. 4. Fried chicken, green beans, and skim milk. 2. The nurse should caution the client with diabetes mellitus who is taking a sulfonylurea (GLIPAZIDE, GLYBURIDE) that alcoholic beverages should be avoided while taking these drugs because they can cause which of the following? 1. Hypokalemia. 2. Hyperkalemia. 3. Hypocalcemia. 4. Disulfiram (Antabuse)–like symptoms. 3. Which of the following conditions is the most significant risk factor for the development of type 2 diabetes mellitus? 1. Cigarette smoking. 2. High-cholesterol diet. 3. Obesity. 4. Hypertension. 4. Which of the following indicates a potential complication of diabetes mellitus? 1. Inflamed, painful joints. 2. Blood pressure of 160/100 mm Hg. 3. Stooped appearance. 4. Hemoglobin of 9 g/dL (90 g/L). 5. The nurse is teaching the client about home blood glucose monitoring. Which of the following blood glucose measurements indicates hypoglycemia? 1. 59 mg/dL (3.3 mmol/L). 2. 75 mg/dL (4.2 mmol/L). 3. 108 mg/dL (6 mmol/L). 4. 119 mg/dL (6.6 mmol/L). 6. Assessment of the diabetic client for common complications should include examination of the: 1. Abdomen. 2. Lymph glands. 3. Pharynx. 4. Eyes.- Diabetic retinopathy, cataracts, and glaucoma are common complications. Feet should also be examined at each encounter. 7. The client with type 1 diabetes mellitus is taught to take isophane insulin suspension NPH (Humulin N) at 5 PM each day. The client should be instructed that the greatest risk of hypoglycemia will occur at about what time? 1. 11 AM, shortly before lunch. 2. 1 PM, shortly after lunch. 3. 6 PM, shortly after dinner. 4. 1 AM, while sleeping. – eat a bedtime snack to help prevent hypoglycemia while sleeping. 8. A nurse is teaching a client with type 1 diabetes mellitus who jogs daily about the preferred sites for insulin absorption. What is the most appropriate site for a client who jogs? 1. Arms. 2. Legs. 3. Abdomen. 4. Iliac crest. 9. A client with diabetes is taking insulin lispro (Humalog) injections. The nurse should advise the client to eat: 1. Within 10 to 15 minutes after the injection. 2. 1 hour after the injection. 3. At any time, because timing of meals with lispro injections is unnecessary. 4. 2 hours before the injection. 10. The best indicator that the client has learned how to give an insulin self-injection correctly is when the client can: 1. Perform the procedure safely and correctly. 2. Critique the nurse's performance of the procedure. 3. Explain allsteps of the procedure correctly. 4. Correctly answer a posttest about the procedure. 11. The nurse is instructing the client on insulin administration. The client is performing a return demonstration for preparing the insulin. The client's morning dose of insulin is 10 units of regular and 22 units of NPH. The nurse checks the dose accuracy with the client. The nurse determines that the client has prepared the correct dose when the syringe reads how many units? 32 units. 12. Angiotensin-converting enzyme (ACE) inhibitors may be prescribed for the client with diabetes mellitus to reduce vascular changes and possibly prevent or delay development of: 1. Chronic obstructive pulmonary disease (COPD). 2. Pancreatic cancer. 3. Renal failure. – ACEI increase renal blood flow and are effective in decreasing diabetic neuropathy. 4. Cerebrovascular accident. 13. Which nursing intervention is most important in preventing septic shock? 1. Administering IV fluid replacement therapy as prescribed. 2. Obtaining vital signs every 4 hours for all clients. 3. Monitoring red blood cell counts for elevation. 4. Maintaining asepsis of indwelling urinary catheters. 14. Which of the following is an indication of a complication of septic shock? 1. Anaphylaxis. 2. Acute respiratory distress syndrome (ARDS). 3. Chronic obstructive pulmonary disease (COPD). 4. Mitral valve prolapse. 15. A nurse hastwo middle-aged clients who have a prescription to receive a blood transfusion of packed red blood cells at the same time. The first client's blood pressure dropped from the preoperative value of 120/80 mm Hg to a postoperative value of 100/50. The second client is hospitalized because he developed dehydration and anemia following pneumonia. After checking the patency of their IV lines and vital signs, what should the nurse do next? 1. Call for both clients' blood transfusions at the same time. 2. Ask another nurse to verify the compatibility of both units at the same time. 3. Call for and hang the first client's blood transfusion. 4. Ask another nurse to call for and hang the blood for the second client. 16. The nurse identifies deficient knowledge when the client undergoing induction therapy for leukemia makes which of the following statements? 1. “I will pace my activities with rest periods.” 2. “I can't wait to get home to my cat!” 3. “I will use warm saline gargle instead of brushing my teeth.” 4. “I must report a temperature of 100°F (37.7°C).” 17. A client with acute myeloid leukemia (AML) reports overhearing one of the other clients say that AML had a very poor prognosis. The client has understood that the client's physician informed the client that his physician told him that he has a good prognosis. Which is the nurse's best response? 1. “You must have misunderstood. Who did you hear that from?” 2. “AML does have a very poor prognosis for poorly differentiated cells.” 3. “AML is the most common nonlymphocytic leukemia.” 4. “Your doctorstated your prognosis based on the differentiation of your cells.” 18. The goal of nursing care for a client with acute myeloid leukemia (AML) is to prevent: 1. Cardiac arrhythmias. 2. Liver failure. 3. Renal failure. 4. Hemorrhage. 19. The nurse is assessing a client with chronic myeloid leukemia (CML). The nurse should assess the client for: 1. Lymphadenopathy. 2. Hyperplasia of the gum. 3. Bone pain from expansion of marrow. 4. Shortness of breath. 20. Which of the following individuals is most at risk for acquiring acute lymphocytic leukemia (ALL)? The client who is: 1. 4 to 12 years. 2. 20 to 30 years. 3. 40 to 50 years. 4. 60 to 70 years. 21. The client with acute lymphocytic leukemia (ALL) is at risk for infection. The nurse should: 1. Place the client in a private room. 2. Have the client wear a mask. 3. Have staff wear gowns and gloves. 4. Restrict visitors. 22. In assessing a client in the early stage of chronic lymphocytic leukemia (CLL), the nurse should determine if the client has: 1. Enlarged, painless lymph nodes. 2. Headache. 3. Hyperplasia of the gums. 4. Unintentional weight loss. 23. The nurse is planning care with a client with acute leukemia who has mucositis. The nurse should advise the client that after every meal and every 4 hours while awake the client should use: 1. Lemon-glycerin swabs. 2. A commercial mouthwash. 3. A saline solution. 4. A commercial toothpaste and brush 24. The client with acute leukemia and the health care team establish mutual client outcomes of improved tidal volume and activity tolerance. Which measure would be least likely to promote outcome achievement? 1. Ambulating in the hallway. 2. Sitting up in a chair. 3. Lying in bed and taking deep breaths. 4. Using a stationary bicycle in the room. 25. 1) When assessing a patient'srespiratory status, which of the following nonrespiratory data are most important for the nurse to obtain? A. Height and weight B. Neck circumference C. Occupation and hobbies D. Usual daily fluid intake 26.If a nurse is assessing a patient whose recent blood gas determination indicated a pH of 7.32 and respirations are measured at 32 breaths/min, which of the following isthe most appropriate nursing assessment? A. The rapid breathing is causing the low pH. B. The nurse should sedate the patient to slow down respirations. C. The rapid breathing is an attempt to compensate for the low pH. D. The nurse should give the patient a paper bag to breathe into to correct the low pH. 27) If a patient with an uncuffed tracheostomy tube coughs violently during suctioning and dislodges the tracheostomy tube, a nurse should first A. call the physician. B. attempt to reinsert the tracheostomy tube. C. position the patient in a lateral position with the neck extended. D. cover the stoma with a sterile dressing and ventilate the patient with a manual bag-mask until the physician arrives. 28.) Upon entering the room of a patient who has just returned from surgery for total laryngectomy and radical neck dissection, a nurse should recognize a need for intervention when finding A. a gastrostomy tube that is clamped. B. the patient coughing blood-tinged secretionsfrom the tracheostomy. C. the patient positioned in a lateral position with the head of the bed flat. D. 200 ml ofserosanguineous drainage in the patient's portable drainage device. 29) When administering oxygen to a patient with COPD with the potential for carbon dioxide narcosis, the nurse should A. never administer oxygen at a rate of more than 2 L/min. B. monitor the patient's use of oxygen to detect oxygen dependency. C. monitorthe patient forsymptoms of oxygen toxicity,such as paresthesias. D. use ABGs as a guide to determine what FIO2 level meets the patient's needs. 30) To ensure the correct amount of oxygen delivery for a patient receiving 35% oxygen via a Venturi mask, it is most important that the nurse A. keep the air-entrainment ports clean and unobstructed. B. apply an adaptor to increase humidification of the oxygen. C. drain moisture condensation from the oxygen tubing every hour. D. keep the flow rate high enough to keep the bag from collapsing during inspiration. 31) While caring for a patient with respiratory disease, a nurse observes that the oxygen saturation dropsfrom 94% to 85% when the patient ambulates. The nurse should determine that A. supplemental oxygen should be used when the patient exercises. B. ABG determinationsshould be done to verify the oxygen saturation reading. C. this finding is a normal response to activity and that the patient should continue to be monitored. D. the oximetry probe should be moved from the finger to the earlobe for an accurate oxygen saturation measurement during activity. 32) A nurse establishesthe presence of a tension pneumothorax when assessment findings reveal a(n) A. absence of lung sounds on the affected side. B. inability to auscultate tracheal breath sounds. C. deviation of the trachea toward the side opposite the pneumothorax. D. shift of the point of maximal impulse (PMI) to the left, with bounding pulses. 33) Which of the following statements made by a nurse would indicate proper teaching principles regarding feeding and tracheostomies? A. "Follow each spoon of food consumed with a drink of fluid." B. "Thin your foodsto a liquid consistency whenever possible." C. "Tilt your chin forward toward the chest when swallowing your food." D. "Make sure your cuff is overinflated before eating if you have swallowing problems." 34) If a patientstates, "It's hard for me to breathe and I feelshort-winded all the time," what is the most appropriate terminology to be applied in documenting this assessment by a nurse? A. Apnea B. Dyspnea C. Tachypnea D. Respiratory fatigue 35)To prevent atelectasis in an 82-year-old patient with a hip fracture, a nurse should A. supply oxygen. B. suction the upper airway. C. ambulate the patient frequently. D. assist the patient with aggressive coughing and deep breathing. 36) Which of the following physical assessment findings in a patient with pneumonia best supportsthe nursing diagnosis of ineffective airway clearance? A. Oxygen saturation of 85% B. Respiratory rate of 28 C. Presence of greenish sputum D. Basilar crackles 37) Which of the following clinical manifestations would the nurse expect to find during assessment of a patient admitted with pneumococcal pneumonia? A. Hyperresonance on percussion B. Fine crackles in all lobes on auscultation C. Increased vocal fremitus on palpation D. Vesicular breath sounds in all lobes 38) Which of the following nursing interventions is of the highest priority in helping a patient expectorate thick secretions related to pneumonia? A. Humidify the oxygen as able B. Increase fluid intake to 3L/day if tolerated. C. Administer cough suppressant q4hr. D. Teach patient to splint the affected area. 39) During discharge teaching for a 65-year-old patient with emphysema and pneumonia, which of the following vaccines should the nurse recommend the patient receive? A. S. aureus B. H. influenzae C. Pneumococcal D. Bacille Calmette-Guérin (BCG) 40) The nurse evaluatesthat discharge teaching for a patient hospitalized with pneumonia has been most effective when the patient states which of the following measures to prevent a relapse? A. "I will increase my food intake to 2400 calories a day to keep my immune system well." B. "I must use home oxygen therapy for 3 months and then will have a chest x-ray to reevaluate." C. "I willseek immediate medical treatment for any upper respiratory infections." D. "Ishould continue to do deep-breathing and coughing exercises for at least 6 weeks." 41) After admitting a patient to the medical unit with a diagnosis of pneumonia, the nurse will verify that which of the following physician orders have been completed before administering a dose of cefotetan (Cefotan) to the patient? A. Serum laboratory studies ordered for AM B. Pulmonary function evaluation C. Orthostatic blood pressures D. Sputum culture and sensitivity 42) Which of the following nursing interventions is most appropriate to enhance oxygenation in a patient with unilateral malignant lung disease? A. Positioning patient on rightside. B. Maintaining adequate fluid intake C. Performing postural drainage every 4 hours D. Positioning patient with "good lung down" 43) A 71-year-old patient is admitted with acute respiratory distressrelated to cor pulmonale. Which of the following nursing interventions is most appropriate during admission of this patient? A. Delay any physical assessment of the patient and review with the family the patient's history of respiratory problems. B. Perform a comprehensive health history with the patient to review prior respiratory problems. C. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress. D. Complete a full physical examination to determine the effect of the respiratory distress on other body functions. 44) When planning appropriate nursing interventions for a patient with metastatic lung cancer and a 60-pack-year history of cigarette smoking, the nurse recognizes that the smoking has most likely decreased the patient's underlying respiratory defenses because of impairment of which of the following? A. Reflex bronchoconstriction B. Ability to filter particles from the air C. Cough reflex D. Mucociliary clearance 45) While ambulating a patient with metastatic lung cancer, the nurse observes a drop in oxygen saturation from 93% to 86%. Which of the following nursing interventions is most appropriate based upon these findings? A. Continue with ambulation as this is a normal response to activity. B. Move the oximetry probe from the finger to the earlobe for more accurate monitoring during activity. C. Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity. D. Obtain a physician's order for arterial blood gas determinations to verify the oxygen saturation. 46) The nurse is caring for a 73-year-old patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient complains of shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4o F, blood pressure 130/88, respirations 36, and oxygen saturation 91% on room air. Which of the following should the nurse first suspect as the etiology of this episode? A. Septic embolus from the knee joint B. Pulmonary embolus from deep vein thrombosis C. New onset of angina pectoris D. Pleural effusion related to positioning in the operating room 47. A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which of the following prescribed medications should the nurse instruct the client to withhold for 48 hr prior to cardioversion? Digoxin 48. A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurse’s priority? Apply firm pressure to the insertion site 49. A nurse is assessing a client who has graves’ disease. Which of the following images should indicate to the nurse that the client has exophthalmos? The nurse should identify an outward protrusion of the eyes as exophthalmos, a common finding of graves’ disease. An overproduction of the thyroid hormone causes edema of the extraocular muscle and increases fatty tissue behind the eye, which results in the eyes protruding outward. Exophthalmos can cause the client to experience problems with vision,including focusing on objects, as well as pressure on the optic nerve. 50. A nurse is caring for a client who has a stage 111 pressure injury. Which of the following findings contributes to delayed wound healing? Urine output 25 mL/hr 51. A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa.Which of the following client statements indicates an understanding of the teaching? “ I will monitor my blood pressure while taking this medication 52. A nurse is providing discharge instructions to a client following an upper gastrointestinal series with barium contrast. Which of the following information should the nurse provide? Increase fluid intake 53.A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse’s priority? Tachycardia 54. A nurse isteaching a client who has a family history of colorectal cancer. To help migrate this risk, which of the following dietary alterations should the nurse recommend? Add Cabbage to the diet 55. A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first? Instruct the client to allow the machine to breathe for them. HESI RN MED SURG 1. The nurse is assessing a 48-year-old client with a history of smoking during a routine clinic visit. The client, who exercises regularly, reports having pain in the calf during exercise that disappears at rest. Which of the following findings requires further evaluation? 1. Heart rate 57 bpm. 2. SpO2 of 94% on room air. 3. Blood pressure 134/82. 4. Ankle-brachial index of 0.65. An Ankle-Brachial Index of 0.65 suggests moderate arterial vascular disease in a client who is experiencing intermittent claudication. Normal ABI 1-1.4. A Doppler ultrasound is indicated for further evaluation. The bradycardic heart rate is acceptable in an athletic client with a normal blood pressure. The SpO2 is acceptable; the client has a smoking history. 2. A client with peripheral vascular disease has undergone a right femoral popliteal bypass graft. The blood pressure has decreased from 124/80 to 94/62. What should the nurse assess first? 1. IV fluid solution. 2. Pedal pulses. 3. Nasal cannula flow rate. 4. Capillary refill. With each set of vital signs, the nurse should assess the dorsalis pedis and posterior tibial pulses. The nurse needs to ensure adequate perfusion to the lower extremity with the drop in blood pressure. IV fluids, nasal cannula setting, and capillary refill are important to assess; however, priority is to determine the cause of drop in blood pressure and that adequate perfusion through the new graft is maintained. CN: Reduction of risk potential; CL: Analyze 3. An overweight client taking warfarin (Coumadin) has dry skin due to decreased arterial blood flow. What should the nurse instruct the client to do? Select all that apply. 1. Apply lanolin or petroleum jelly to intact skin. 2. Follow a reduced-calorie, reduced-fat diet.- promote circulation by reducing weight. 3. Inspect the involved areas daily for new ulcerations. 4. Instruct the client to limit activities of daily living (ADLs). 5. Use an electric razor to shave. 1, 2, 3, 5. Maintaining skin integrity is important in preventing chronic ulcers and infections. The client should be taught to inspect the skin on a daily basis. The client should reduce weight to promote circulation; a diet lower in calories and fat is appropriate. Because the client is receiving Coumadin, the client is at risk for bleeding from cuts. To decrease the risk of cuts, the nurse should suggest that the client use an electric razor. The client with decreased arterial blood flow should be encouraged to participate in ADLs. In fact, the client should be encouraged to consult an exercise physiologist for an exercise program that enhances the aerobic capacity of the body. CN: Health promotion and maintenance; CL: Synthesize 4. The nurse is caring for a client with peripheral artery disease who has recently been prescribed clopidogrel (Plavix). The nurse understands that more teaching is necessary when the client states which of the following: 1. “I should not be surprised if I bruise easier or if my gums bleed a little when brushing my teeth.” 2. “It doesn't really matter if I take this medicine with or without food, whatever works best for my stomach.” 3. “I should stop taking Plavix if it makes me feel weak and dizzy.” 4. “The doctor prescribed this medicine to make my platelets less likely to stick together and help prevent clots from forming.” Weakness, dizziness, and headache are common adverse effects of Plavix and the client should report these to the physician if they are problematic; in order to decrease risk of clot formation, Plavix must be taken regularly and should not be stopped or taken intermittently. The main adverse effect of Plavix is bleeding, which often occurs as increased bruising or bleeding when brushing teeth. Plavix is well absorbed, and while food may help decrease potential gastrointestinal upset, Plavix may be taken with or without food. Plavix is an antiplatelet agent used to prevent clot formation in clients who have experienced or are at risk for myocardial infarction, ischemic stroke, peripheral artery disease, or acute coronary syndrome. CN: Pharmacological and parenteral therapies; CL: Evaluate 5. A client is receiving Cilostazol (Pletal) for peripheral arterial disease causing intermittent claudication. The nurse determines this medication is effective when the client reports which of the following? 1. “I am having fewer aches and pains.” 2. “I do not have headaches anymore.” 3. “I am able to walk further without leg pain.” 4. “My toes are turning grayish black in color.” Cilostazol is indicated for management of intermittent claudication. Symptoms usually improve within 2 to 4 weeks of therapy. Intermittent claudication prevents clients from walking for long periods of time. Cilostazol inhibits platelet aggregation induced by various stimuli and improving blood flow to the muscles and allowing the client to walk long distances without pain. Peripheral arterial disease causes pain mainly of the leg muscles. “Aches and pains” does not specify exactly where the pain is occurring. Headaches may occur as a side effect of this drug, and the client should report this information to the health care provider. Peripheral arterial disease causes decreased blood supply to the peripheral tissues and may cause gangrene of the toes; the drug is effective when the toes are warm to the touch and the color of the toes is similar to the color of the body. CN: Pharmacological and parenteral therapies; CL: Evaluate 6. The client admitted with peripheral vascular disease (PVD) asks the nurse why her legs hurt when she walks. The nurse bases a response on the knowledge that the main characteristic of PVD is: 1. Decreased blood flow. 2. Increased blood flow. 3. Slow blood flow. 4. Thrombus formation. 7. The nurse is planning care for a client who is diagnosed with peripheral vascular disease (PVD) and has a history of heart failure. The nurse should develop a plan of care that is based on the fact that the client may have a low tolerance for exercise related to: 1. Decreased blood flow. 2. Increased blood flow. 3. Decreased pain. 4. Increased blood viscosity. 8. When assessing the lower extremities of a client with peripheral vascular disease (PVD), the nurse notes bilateral ankle edema. The edema is related to: 1. Competent venous valves. 2. Decreased blood volume. 3. Increase in muscular activity. 4. Increased venous pressure. 9. The nurse is obtaining the pulse of a client who has had a femoral-popliteal bypass surgery 6 hours ago. (See below) Which assessment provides the most accurate information about the client's postoperative status? NA 10. The nurse is teaching a client about risk factors associated with atherosclerosis and how to reduce the risk. Which of the following is a risk factor that the client is not able to modify? 1. Diabetes. 2. Age. 3. Exercise level. 4. Dietary preferences. 11. The nurse is assessing the lower extremities of the client with peripheral vascular disease (PVD). During the assessment, the nurse should expect to find which of the following clinical manifestations of PVD? Select all that apply. 1. Hairy legs. 2. Mottled skin. 3. Pink skin. 4. Coolness. 5. Moist skin. 12. The nurse is unable to palpate the client's left pedal pulses. Which of the following actions should the nurse take next? 1. Auscultate the pulses with a stethoscope. 2. Call the physician. 3. Use a Doppler ultrasound device. 4. Inspect the lower left extremity. 13. Which of the following lipid abnormalities is a risk factor for the development of atherosclerosis and peripheral vascular disease? 1. Low concentration of triglycerides. 2. High levels of high-density lipid (HDL) cholesterol. 3. High levels of low-density lipid (LDL) cholesterol. 4. Low levels of LDL cholesterol. 14. When assessing an individual with peripheral vascular disease, which clinical manifestation would indicate complete arterial obstruction in the lower left leg? 1. Aching pain in the left calf. 2. Burning pain in the left calf. 3. Numbness and tingling in the left leg. 4. Coldness of the left foot andankle. 15. A client with peripheral vascular disease returns to the surgical care unit after having femoral-popliteal bypass grafting. Indicate in which order the nurse should conduct assessment of this client. 1. Postoperative pain. 2. Peripheral pulses. 3. Urine output. 4. Incision site. 2,4,3,1 16. A client with heart failure has bilateral +4 edema of the right ankle that extends up to midcalf. The client is sitting in a chair with the legs in a dependent position. Which of the following goals is the priority? 1. Decrease venous congestion. 2. Maintain normal respirations. 3. Maintain body temperature. 4. Prevent injury to lower extremities. 17. The nurse is assessing an older Caucasian male who has a history of peripheral vascular disease. The nurse observes that the man's left great toe is black. The discoloration is probably a result of: 1. Atrophy. 2. Contraction. 3. Gangrene. 4. Rubor. 18. A client has peripheral vascular disease (PVD) of the lower extremities. The client tells the nurse, “I've really tried to manage my condition well.” Which of the following routines should the nurse evaluate as having been appropriate for this client? 1. Resting with the legs elevated above the level of the heart. 2. Walking slowly but steadily for 30 minutes twice a day. 3. Minimizing activity. 4. Wearing antiembolism stockings at all times when out of bed. 19. A client is scheduled for an arteriogram. The nurse should explain to the client that the arteriogram will confirm the diagnosis of occlusive arterial disease by: 1. Showing the location of the obstruction and the collateral circulation. 2. Scanning the affected extremity and identifying the areas of volume changes. 3. Using ultrasound to estimate the velocity changes in the blood vessels. 4. Determining how long the client can walk. 20. A client is scheduled to have an arteriogram. During the arteriogram, the client reports having nausea, tingling, and dyspnea. The nurse's immediate action should be to: 1. Administer epinephrine. 2. Inform the physician. 3. Administer oxygen. 4. Inform the client that the procedure is almost over. 21. Which of the following is an expected outcome when a client is receiving an IV administration of furosemide? 1. Increased blood pressure. 2. Increased urine output. 3. Decreased pain. 4. Decreased premature ventricular contractions. 22. The nurse is preparing to measure central venous pressure (CVP). Mark the spot on the torso indicating the location for leveling the transducer. NA 23. A client has had a pulmonary artery catheter inserted. In performing hemodynamic monitoring with the catheter, the nurse will wedge the catheter to gain information about which of