HESI RN MEd SURG practice test

HESI RN MEd SURG practice test A client who has a chronic cough with blood-tinged sputum returns to the unit after a bronchoscopy. What nursing interventions should be implemented in the immediate post-procedural period? Keep the client on bed rest for eight hours. Check vital signs every 15 minutes for two hours. Allow the client nothing by mouth until the gag reflex returns. Encourage fluid intake to promote elimination of the contrast media. - Allow the client nothing by mouth until the gag reflex returns. Rationale The nasal pharynx and oral pharynx are anesthetized with local anesthetic spray prior to bronchoscopy, and the bronchoscope is coated with lidocaine (Xylocaine) gel to inhibit the gag reflex and prevent laryngeal spasm during insertion. The client should be NPO until the client's gag reflex returns to prevent aspiration from any oral intake or secretions. A Korean-American client, who speaks very little English, is being discharged following surgery. Which nurse should the nurse manager assign to provide the discharge instructions for the client? A graduate registered nurse (RN) with three weeks of experience. The registered nurse (RN) case-manager for the unit with 1 year's experience. A "floating" registered nurse (RN) with five years of nursing experience. An Korean-American practical nurse (PN) with six years of nursing experience. - The registered nurse (RN) case-manager for the unit with 1 year's experience. Rationale The RN case-manager is the best qualified nurse to assess and provide discharge educational needs, obtain resources for the client, enhance coordination of care, and prevent fragmentation of care. The nurse assesses a long-term resident of a nursing home and finds the client has a fungal infection (candidiasis) beneath both breasts. To prevent nosocomial infection, which protocol should the nurse review with the rest of the staff? Follow contact isolation procedures. Wash hands after caring for the client. Wear gloves when providing personal care. Restrict pregnant staff or visitors into the room. - Wash hands after caring for the client. Rationale The organism Candida albicans, that causes this infection, is part of the normal flora on the skin of most adults. Good handwashing is all that is needed to prevent nosocomial spread. The nurse is caring for a client with a small bowel obstruction. The client is vomiting foul smelling fecal-like material. What action should the nurse implement? Administer antiemetics every 2 to 3 hours. Position on the left side with knees drawn up. Encourage ice chips sparingly. Give IV fluids with electrolytes. - Give IV fluids with electrolytes. Rationale When the bowel is obstructed, electrolytes and fluids are not absorbed, so parenteral fluids with sodium chloride, bicarbonate, and potassium should be administered to prevent electrolyte imbalance and dehydration. The nurse is giving discharge instructions to a client with chronic prostatitis. What instruction should the nurse provide the client to reduce the risk of spreading the infection to other areas of the client's urinary tract? Wear a condom when having sexual intercourse. Avoid consuming alcohol and caffeinated beverages. Empty the bladder completely with each voiding. Have intercourse or masturbate at least twice a week. Full thickness burns rather than partial thickness. Supinates extremity but unable to fully pronate the extremity. Slow capillary refill in the digits with absent distal pulse points. Inability to distinguish sharp versus dull sensations in the extremity. - Have intercourse or masturbate at least twice a week. Rationale The prostate is not easily penetrated by antibiotics and can serve as a reservoir for microorganisms, which can infect other areas of the genitourinary tract. Draining the prostate regularly through intercourse or masturbation decreases the number of microorganisms present and reduces the risk for further infection from stored contaminated seminal fluids. Which finding should the nurse report to the healthcare provider for a client with a circumferential extremity burn? Obtain a prescription for a laxative. Withhold all oral fluid and food. Assist the client to ambulate in the hall. Administer the prescribed morphine sulfate. - Slow capillary refill in the digits with absent distal pulse points. Rationale A circumferential burn can form an eschar that results from burn exudate fluid that dries and acts as a tourniquet as fluid shifts occur in the interstitial tissue. As edema increases tissue pressure, blood flow to the distal extremity is compromised, which is manifested by slow capillary refill and absent distal pulses, so the healthcare provider should be notified about any compromised circulation that requires escharotomy. CONTINUES...