Med-Surg II HESI Exam set One, Answered 100% Correct {All Answers Verified + Rationale}

Med-Surg II HESI Exam set One, Answered 100% Correct {All Answers Verified + Rationale} A client is admitted with a 6.5-cm thoracic aneurysm. The nurse records findings from the initial assessment in the client's chart, as shown below. At 10:30 AM, the client has sharp mid-chest pain after having a bowel movement. What should the nurse do first? 1. Assess the client's vital signs. 2. Administer a bolus of lactated Ringer's solution. 3. Assess the client's neurologic status. 4. Contact the physician. {{Correct Ans:- 1. Assess the client's vital signs. Nursing assessment of a 54-year-old client in the emergency department reveals severe back pain, Grey Turner's sign, nausea, blood pressure of 90/40, heart rate 128 bpm, and respirations 28/min. The nurse should first: 1. Assess the urine output. 2. Place a large-bore IV 3. Position onto the left side. 4. Insert a nasogastric tube. {{Correct Ans:- 2. Place a large-bore IV The most effective measure the nurse can use to prevent wound infection when changing a client's dressing after coronary artery bypass surgery is to: 1. Observe careful handwashing procedures. 2. Clean the incisional area with an antiseptic. 3. Use pre-packaged sterile dressings to cover the incision. 4. Place soiled dressings in a waterproof bag before disposing of them. {{Correct Ans:- 1. Observe careful handwashing procedures. For a client who excretes excessive amounts of calcium during the postoperative period after open heart surgery, which of the following measures should the nurse institute to help prevent complications associated with excessive calcium excretion? 1. Ensure a liberal fluid intake. 2. Provide an alkaline-ash diet. 3. Prevent constipation. 4. Enrich the client's diet with dairy products. {{Correct Ans:- 1. Ensure a liberal fluid intake.