HESI RN MED SURG 2

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-