2022 HESI Med-Surg v2

2022 HESI Med-Surg v2 16. an older adult male is admitted three days after a fall because his wife called 911 this morning when he became confused. the client has a history of chronic kidney disease and diabetes and has vital signs on admission heart rate 120 beats respirations 12 breaths and blood pressure 180/96. which assessment finding warrants immediate intervention by the nurse? 6. A client who is receiving external beam radiation therapy to the spine for cancer palliation develops a reddened area on the back and reports of it itching. Which intervention should the nurse implement to ease the itching? Parkland formula question: 4L for the whole 8 hours. You will need to divide by 8 to get the total mLs per hour (round to nearest whole number). 4L = 4,000 mL / 8 hours = 500 mL per hour S - The Marketplace to Buy and Sell your Study Material Distribution of this document is illegal #47 rest of question: On admission to the intensive care unit for sepsis caused by a ruptured appendix, the clients temperature is 103.6 F and blood pressure is and white blood cell count of which classification of prescribed medication should the nurse evaluate for client 1. Which problem, reported to the nurse by a 70-year-old male client, requires the most immediate intervention by the nurse? A. Urinary hesitancy B. Slow urinary stream C. Frequent nocturia D. Painless hematuria Downloaded by: CHRISJAY | S - The Marketplace to Buy and Sell your Study Material Downloaded by: CHRISJAY | Distribution of this document is illegal 2. when conducting assessments at an assisted living community, the nurse finds that an older adult client for the nurse to implement? a) obtain a clean voided urine sample using a urinal hat b) evaluate the client’s response to bladder training efforts c) place a protective undergarment on the client d) encourage increased fluid for 24 hours 3. A is receiving procarpme hydrochlonde ophthalmic drops for glaucoma. The client calls the clinic nurse and reports difficulty seeing at night explanation should the nurse provide? a) The medication causes pupils to dilate, which reduces night vision b) The drops increase the in the eyes and cloud the visual field c) The eye drops slow pupil response to accommodate for darkness d) The drug can cause the lens to become more opaque 4. A patient who is receiving external beam radiation therapy to the spine for cancer palliation develops a reddened area on the back and 5. A client is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires immediate intervention? 6. The nurse observes a newly admitted older adult client take short steps and walk very slowly while pushing a walker. Which action 7. When reviewing an older client’s daily laboratory findings, the nurse notes the blood urea nitrogen (BUN) level is 23mg / d * L; (8.2 mmoll) should the nurse take first 8. An older female who is complaining of pain in her arm and back is brought to the Emergency Department last year for a variety of superficial injuries. Which nursing action has the highest priority? Ask if she has considered living in an assisted living facility 9. On the postoperative day the nurse an older client and the bed The first S - The Marketplace to Buy and Sell your Study Material Downloaded by: CHRISJAY | Distribution of this document is illegal 10.The nurse is caring for a client with the sexually transmitted infection (STI) chlamydia. The client reports having sex with multiple partners which response the nurse provide 11.A 55-yearold client reports a sudden onset of seeing flashing lights and floating spots Which is the best nursing action? common physiological change that occurs with aging is likely to influence an older adult's nutritional status? 13.An older client being admitted to a using acute care hospital following a cerebrovascular accident (CVA) When reviewing the client's prescribed implement first? 14.An older adult male is admitted three days a because his wife called 911 this morning when he became confused The has a history of kidney disease a 120 beats 12 breaths minute, and blood pressure 180/96. assessment finding warrants immediate Intervention by the nurse 15.A. female client returns to the clinic after being treated for chlamydia with azithromycin IM and reports that she still has symptoms. The client reports maintaining a monogamous relationship when the laboratory results are positive for the sexually transmitted infection Ask the client if the complete course of antibiotics was taken 16.A A client has a prescription for a fentanyl transdermal patch to be applied every 72 hours’ implement? a) А Leave the patch in place and administer a prescribed PRN b) B Advise the client that it is too soon to apply a new transdermal c) Remove the patch and notify the healthcare provider d) Replace the transdermal patch with a new patch. S - The Marketplace to Buy and Sell your Study Material Downloaded by: CHRISJAY | Distribution of this document is illegal 17.An older client with no cognitive impairment had a left hip arthroplasty 72 hours ago and now confused and lethargic. Which action 18.AA 148-pound adult female is admitted to the emergency center with burns to 30 percent of her body. Using burn) the client should receive one half of the 24-hour volume within the first 8 hours. The nurse should s is required round to the nearest whole number) • 30 of 55 A center percent of her the Parkland formula for requirement for the 24 after the (home pump to (is the wole) 19. The nurse is visiting an older client who is homebound which finding about the client's nutritional status requires additional follow-up? 1,200 calorie diet Patient dying of cancer and receives RT radiation therapy. Why? – Palliative measure Question about fluid ounces 4 ounces 6 ounces 1 cup - 8 ounces How many mLs total Math question 250 mL was in the problem - A client with deep vein thrombosis (DVT) is receiving a continues infusion of heparin sodium 25,000 unit in 5% dextrose injection 250ml. The prescription indicates the dosage should be increase 900 units/hr. The nurse should program the infusion pump to deliver how many ml/hr.? 9 mL/hour 1. Which problem reported to a nurse by a 70-year-old client requires the most immediate intervention by a nurse? A = painless hematuria S - The Marketplace to Buy and Sell your Study Material Downloaded by: CHRISJAY | Distribution of this document is illegal 2. When conducting assessments at an assisted living community. The nurse finds that an older adult client who is normally alert and oriented and continent is confused and incontinent of urine. Which intervention is most important for the nurse to implement? Obtain a clean voided urine sample using a urinal hat 3. The nurse is preparing a client for discharge following cataract extraction. Which instruction should the nurse include in the discharge teaching? Avoid straining to stool, stooping, or lifting heavy objects 4. An older male client who has been talking to his deceased mother has been referred to the psychiatric clinic for evaluation. Which assessment is most important for the nurse to complete first? Determine cognitive status (I think) 5. A male client is receiving pilocarpine hydrochloride (Isopto Carpine) ophthalmic drops for glaucoma. He calls the clinic and ask the nurse why he has difficulty seeing at night. What explanation should the nurse provide? a. The eye drops slow pupil response to accommodate for darkness b. The drops increase the fluid in the eyes and cloud the visual field (possible answer) c. The drug can cause lens to become more opaque d. The medication causes pupils to dilate which reduces night vision 6. When treating a patient with a hospital acquired infection with Vancomycin, what would you do? a) report the HAI to Medicare b) assess patient's response c) obtain WBC count d) ensure to obtain a peak and trough 7. The healthcare provider adds the anticonvulsant topiramate to the medication regimen of a client who has been taking phenytoin the first week after the client has started topiramate? a) Alter the client's meal times to facilitate administration of both of the medications OB b) Draw a complete blood) assess for the expected abnormal findings c) Collect blood for a serum phenytoin level to assess for elevated drug concentration d) No specific nursing intervention is needed after the client has started topiramate S - The Marketplace to Buy and Sell your Study Material Downloaded by: CHRISJAY | Distribution of this document is illegal 8. an older client is being admitted to a skilled nursing facility from an acute care hospital following a CVA. When reviewing the clients prescribed medications, which intervention should the nurse implement first? a) determine which medications may be given generic form rather than brand name only b) compare admission prescriptions with the list of medications previously taken by the client c) provide client teaching regarding the desired effects of the client’s admission prescriptions d) Reconcile prescribed medication dosages with the published recommended dosage ranges 9. During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. What intervention is most important for the RN to implement during the admission process? Assist the client in developing alternative coping skills. 10. An elderly woman comes to the clinic because of vaginal bleeding. The healthcare provider finds a vaginal tear, which the client reports is likely to have occurred during unprotected sexual intercourse. Which content is most important for the nurse to include in the client's teaching plan? The importance of using vaginal lubricants. 11. The nurse observes a newly admitted older adult female take short steps and walk very slowly while pushing a walker in front of her. What action should the nurse take in response to these observations? Complete a full fall risk assessment of the client. 12. A 60-year-old female client with a positive family hx for ovarian cancer has developed an abdominal mass is being evaluated for passible ovarian cancer. Her PAP smear results are negative. What information should the nurse include in the client's teaching plan? Further evaluation involving surgery may be needed B. A pelvic exam is also needed before cancer is ruled out C. Pap smear evaluation should be continued every six months D. One additional negative pap smear is six months is needed Further evaluation involving surgery may be needed 13. A client is admitted to the hospital with symptoms consistent with right hemisphere stroke. Which neurovascular assessment requires immediate intervention by the nurse? Unequal bilateral hand grip strengths S - The Marketplace to Buy and Sell your Study Material Downloaded by: CHRISJAY | Distribution of this document is illegal 14. A client has been taking oral corticosteroids for the past five days because of seasonal allergies. Which assessment finding is of most concern to the nurse? A) White blood count of 10,000 mm3. B) Serum glucose of 115 mg/dl. C) Purulent sputum. D) Excessive hunger. 15. The wife of a client diagnosed with Parkinson's disease calls the clinic and tells the nurse her husband is having involuntary jerky movements of the legs and arms and is confused. Which action should the clinic nurse implement first? Ask the clients wife to list all medications her husband is currently taking 16.AA 48-yearold female client who has been treated for metastasized breast cancer the past year is told by her healthcare provider the and asks the nurse, "Who will care my children?" Which response is best for the nurse to provide? a) "What would you like to see happen with your children?" b) "Try to think about getting well Someone will care for your children c) "Your husband will have to be there for your children." d) "Have you talked to your family about who will be responsible for your children?" 17.A client with a respiratory has been receiving an antibiotic and an antipyretic for five days. Which current result is the best indication that the antibiotic is effective? A client with a respiratory infection has been receiving an antibiotic and an antipyretic for five days. What current datum is the best indication that the antibiotic is effective? The sputum specimen culture report shows no growth 18.A male client comes to the clinic with a complaint dysfunction (ED) Which information is most important for the nurse to obtain? Current Medication Regimen 19.The nurse is preparing to teach a class on breast self-examination. In describing an "at risk" individual, the nurse should describe which woman as having the highest risk of developing breast cancer? A 32-year-old woman whose mother had breast cancer S - The Marketplace to Buy and Sell your Study Material Downloaded by: CHRISJAY | Distribution of this document is illegal 20.At bedtime client with dementia becomes increasingly confused and agitated because she believes someone is standing in her room. Which action is best for the nurse to implement? a. Put a night light on in the room b. Provide soft music at bedtime c. Reassure her that she is alone d. Give an anxiolytic at bedtime 21.Question about a provider discussing end of life options with a family who agrees to end of life measures for their family member who was in an accident. The question asked which intervention should the nurse implement and the choices were: ▪ turn off the ventilator and write down time of death ▪ ask the family if they would like to be there during this process (maria said this one?!) ▪ request a living will be put in the client’s record ▪ discuss the withdrawal process and offer support to the family. 22. Question about a patient starting to take topiramate after already taking been taking phenytoin for 20 years. (The pt. would now be taking both). The question was asking what should the nurse do the first week after the patient starts taking this medication? - telling the patient to take the meds after mealtime - drawing a CBC to look for expected abnormal results - collect blood for serum phenytoin to check levels (maria said this one too) - no interventions needed 23. A female client is admitted to the hospital with a diagnosis of right lower quadrant (RLQ) abdominal pain and a possible ectopic pregnancy. She tells the nurse that the pain is gone but she is now experiencing generalized abdominal aching Her blood pressure has decreased and her pulse has increased over the past two hours. while waiting for the healthcare provider to arrive, which intravenous solution is best for the nurse to initiate? Lactated Ringers 150 mL/hour 24. The nurse-manager observes that the stair nurse has used wrist restraints to help secure an elderly female in her wheelchair. The client is that the client needs to be restrained in the wheelchair so that the nurse can change her bed linens. What is the priority action by the nurse? Advise the staff nurse to remove the restraints from the client’s wrists S - The Marketplace to Buy and Sell your Study Material Distribution of this document is illegal 25. On the first postoperative day. The nurse finds an older male client disoriented and trying to climb over the bed railing. Previously he was oriented to person place and time on admission. Which intervention should the nurse implement first? Assess the client for pain. 26. A female client returns to the clinic after being treated for chlamydia with Azithromycin IM and reports that she still has symptoms. The HCP obtains a swab of the discharge from the cervix for testing for chlamydia. The client reports maintaining a monogamous relationship when the laboratory result are positive for the sexually transmitted infection. Which information should the nurse obtain to evaluate the ineffective results of treatment? Ask the client if the complete course of antibiotics was taken. 27. Which common physiological change that occurs with aging is likely to influence and older adult’s nutritional status? Diminished sense of smell 28. A young adult who suffered a severe brain injury in an automobile collision has been mechanically ventilated for the past three days and has no spontaneous respiratory effort. After serial electroencephalograms reveal no brain activity, the healthcare provider discusses end of life options with the family who agrees to discontinue life support. Which intervention should the nurse implement? Discuss the withdrawal procedure with the family and offer support 29. The nurse is visiting an older client who is homebound. Which finding about the client’s nutritional status requires additional followup? Ate approximately 1,200 calories daily for the past two weeks 30. An older female who is complaining of pain in her arm and back is brought to the emergency department by her son who states she fell out of her chair. The nurse notes that the client has been in the ED five times in the last for a variety of superficial injuries. Which nursing action has the highest priority? Take mom to pDr oiwvnalot aeder doboy:mCHRaISnJdAYa|smkarr i jof ns18o2m@s hurting her S - The Marketplace to Buy and Sell your Study Material Downloaded by: CHRISJAY | Distribution of this document is illegal 31. When conducting assessments at an assisted living community, the nurse finds that an older adult client who is normally alert, oriented, and continent, is confused and incontinent of urine. Which intervention is MOST important for the nurse to implement? Obtain a clean, voided urine sample using a urinal hat 32. A client has a prescription for a fentanyl transdermal patch to be applied every 72 hours. The patch was applied 48 hours ago and the client now reports experiencing breakthrough pain. What action should the nurse implement? a. Replace the transdermal patch with a new patch b. Remove the patch and notify the HCP c. Advise the client that is too soon to apply a new transdermal patch Leave the patch in place and administer a prescribed PRN analgesic 33. During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. What intervention is most important for the RN to implement during the admission process? Assist the client in developing alternative coping skills 34. total mL question = 4 ounces + 6 ounces + 8 ounces = 540 total mL 35. Burn total percentage formula question - Parkland formula question: 4L for the whole 8 hours. You will need to divide by 8 to get the total mLs per hour (round to nearest whole number). 4L = 4,000 mL / 8 hours = 500 mL per hour 36. An older client with no cognitive impairment had a left hip arthroplasty 72 hours ago and is now confused and lethargic. Which action should the nurse implement? Observe the surgical incision 37. When reviewing an older client’s daily laboratory findings, the nurse notes that the blood urea nitrogen (BUN) level is 23 mg/dk (8.2mmol/L). Which action should the nurse take first? Review prior BUN findings in the client’s record. S - The Marketplace to Buy and Sell your Study Material Downloaded by: CHRISJAY | Distribution of this document is illegal 38. An older adult is admitted to an acute medical unit from a long-term care facility. When reviewing the client’s prescribed medications, which intervention should the nurse implement first? Compare admission prescriptions with the list of medications previously taken by the client 39. On admission to the ICU for sepsis the client’s temperature is 104 and blood pressure is 68/42. Other hemodynamic findings are cardiac output of 10.7L/min, systemic vascular resistance of 480 dynes/sec/cm, and white blood cell count 28,000. Which classification of prescribed medication should the nurse evaluate for client stabilization? Vasoconstrictor 40. A client who is receiving NS at 75 mL/h has dry, sticky mucous membranes and inelastic skin turgor. Which action should the nurse implement? Continue the NS at 75 mL/h and encourage oral fluids intake (wasn’t this a Q?) I think it was 41. On the first postoperative day. The nurse finds an older male client disoriented and trying to climb over the bed railing. Previously he was oriented to person place and time on admission. Which intervention should the nurse implement first? Assess the client for pain