Med Surg HESI
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Which statement made by a client with
chronic pancreatitis indicates that further
education is needed?
To prevent exacerbations of chronic pan-
creatitis, clients should be instructed to
I will cut back on smoking cigarettes dai-
avoid nicotine entirely. Additional teach-
ly. Correct
ing includes avoiding caffeinated bever-
I will avoid drinking caffeinated bever-
ages, resting frequently as needed, and
ages.
eating a bland diet low fat and high in
I will rest frequently and avoid vigorous
protein.
exercise. Incorrect
I will eat a bland, low-fat, high-protein
diet.
How should the nurse position the elec- In MCL I monitoring, the positive elec-
trodes for modified chest lead one (MCL trode is placed on the client's mid-chest
I) telemetry monitoring? to the right of the sternum, and the neg-
ative electrode is placed on the upper
Negative polarity left shoulder, positive left part of the chest. The ground may be
polarity right chest nipple line, ground left placed anywhere, but is usually placed
chest nipple line. Correct on the lower left portion of the chest.
In preparing to administer intravenous al-
bumin to a client following surgery, which
are the priority nursing interventions? Albumin should be infused within four
(Select all that apply.) hours because it does not contain any
Set the infusion pump to infuse the albu- preservatives. Any fluid remaining after
min within four hours. Correct four hours should be discarded. A large
Compare the client's blood type with the gauge catheter allows for fast infusion
label on the albumin. rate, which may be necessary. Hemod-
Assign a UAP to monitor blood pressure ilution may decrease hemoglobin (HgB)
q15 minutes. and hematocrit (HCT) levels, so the HgB
Administer through a large gauge and HCT levels should be monitored
catheter. Correct while monitoring for bleeding because of
Monitor hemoglobin and hematocrit lev- the increased blood volume and blood
els. Correct pressure.
Assess for increased bleeding after ad-
ministration. Correct
Hypokalemia (normal 3.5 to 5 mEq/L [3.5
A client who has heart failure is ad-
to 5 mmol/L]) causes changes in myocar-
mitted with a serum potassium level of
dial irritability and ECG waveform, so it
, Med Surg HESI
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2.9 mEq/L (2.9 mmol/L). Which action is is most important for the nurse to initiate
most important for the nurse to imple- continuous cardiac monitoring to identify
ment? ventricular ectopy or other life-threaten-
Give 20 mEq of potassium chloride. ing dysrhythmias. After cardiac monitor-
Initiate continuous cardiac monitoring. ing is initiated, then the potassium chlo-
Correct ride should be given so that the effects
Arrange a consultation with the dietician. of potassium replacement on the cardiac
Teach about the side effects of diuretics. rhythm can be monitored.
After checking the urinary drainage sys-
tem for kinks in the tubing, the nurse de-
termines that a client who has returned
from the post-anesthesia care has a
dark, concentrated urinary output of 54 After surgery, an adult who weighs 132
mL for the last 2 hours. Which priority pounds (60 kg) should produce about
nursing action should be implemented? 60 mL of urine hourly (1 mL/kg/hour).
Dark, concentrated, and low volume of
Report the findings to the surgeon. Cor- urine output should be reported to the
rect surgeon.
Irrigate the indwelling urinary catheter.
Apply manual pressure to the bladder.
Increase the IV flow rate for 15 minutes.
Incorrect
Two days postoperative, a male client
reports aching pain in his left leg. The
nurse assesses redness and warmth on
the lower left calf. Which intervention
would be most helpful to this client?
For a client exhibiting symptoms of deep
Apply sequential compression devices vein thrombosis (DVT), a complication
(SCDs) bilaterally. of immobility, the initial care includes
Assess for a positive Homan's sign in bedrest and elevation of the extremity.
each leg. Incorrect
Pad all bony prominences on the affect-
ed leg.
Advise the client to remain in bed with
the leg elevated. Correct
Which description of pain is consistent
with a diagnosis of rheumatoid arthritis?
, Med Surg HESI
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Joint pain is worse in the morning and
involves symmetric joints. Correct
Joint pain is better in the morning and Rheumatoid arthritis (RA) is an autoim-
worsens throughout the day. mune disease that causes joint pain and
Joint pain is consistent throughout the swelling. RA is characterized by pain that
day and is relieved by pain medication. is worse when arising and involves sym-
Incorrect metric joints.
Joint pain is worse during the day and
involves unilateral joints.
A client's susceptibility to ulcerative col-
itis is most likely due to which aspect in
the client's history?
Ulcerative colitis is 4 to 5 times more
Jewish European ancestry. Correct
common among individuals of Jewish
H. pylori bowel infection.
European or Ashkenazi ancestry.
Family history of irritable bowel syn-
drome.
Age between 25 and 55 years.
While working in the emergency room,
the nurse is exposed to a client with ac-
tive tuberculosis. When should the nurse A tuberculin skin test is effective 4 to 6
plan to obtain a tuberculin skin test? weeks after an exposure, so the individ-
Immediately after the exposure. ual with a known exposure should wait
Within one week of the exposure. 4 to 6 weeks before having a tuberculin
Four to six weeks after the exposure. skin test.
Correct
Three months after the exposure.
The nurse knows that lab values some-
times vary for the older client. Which
data would the nurse expect to find
when reviewing laboratory values of an As older adults age, the protein found
80-year-old male? in urine slightly rises as a result of kid-
ney changes, and the serum glucose in-
Increased WBC, decreased RBC. creases slightly, also due to changes in
Increased serum bilirubin, slightly in- the kidney.
creased liver enzymes.
Increased protein in the urine, slightly
increased serum glucose levels. Correct
, Med Surg HESI
Study online at https://quizlet.com/_95k64v
Decreased serum sodium, an increased
urine specific gravity.
The nurse is assessing a client's labo-
ratory values following administration of
chemotherapy. Which lab value leads the Tumor lysis symdrome (TLS) results
nurse to suspect that the client is experi- in hyperkalemia, hypocalcemia, hype-
encing tumor lysis syndrome (TLS)? ruricemia, and hyperphosphatemia. A
serum calcium level of 5, which is low,
Serum PTT of 10 seconds. is an indicator of possible tumor lysis
Serum calcium of 5 mg/dL. Correct syndrome.
Oxygen saturation of 90%.
Hemoglobin of 10 g/dL.
Which intervention should the nurse
plan to implement when caring for a
client who has just undergone a right
above-the-knee amputation?
A large tourniquet should be placed in
plain sight at the client's bedside, in the
Maintain the residual limb on three pil-
event severe bleeding occurs. The pur-
lows at all times. Incorrect
pose is to have the tourniquet available
Place a large tourniquet at the client's
to apply to the residual limb to control
bedside. Correct
bleeding if hemorrhaging was to occur.
Apply constant, direct pressure to the
residual limb.
Do not allow the client to lie in the prone
position.
More SPECIFIC THAN BUN.
Creatinine
An elevated creatinine strongly indicates
nephron loss, reducing filtration.
Which nail color alteration should the
nurse expect to observe in a client with
Fingernails and toenails can be affect-
chronic kidney disease?
ed by chronic kidney disease. This con-
dition may cause horizontal white lines
Horizontal white banding. Correct
or bands (leukonychia) to appear on the
Diffuse blue discoloration.
nails.
Diffuse brown discoloration.
Thin, dark red vertical lines.
Study online at https://quizlet.com/_95k64v
Which statement made by a client with
chronic pancreatitis indicates that further
education is needed?
To prevent exacerbations of chronic pan-
creatitis, clients should be instructed to
I will cut back on smoking cigarettes dai-
avoid nicotine entirely. Additional teach-
ly. Correct
ing includes avoiding caffeinated bever-
I will avoid drinking caffeinated bever-
ages, resting frequently as needed, and
ages.
eating a bland diet low fat and high in
I will rest frequently and avoid vigorous
protein.
exercise. Incorrect
I will eat a bland, low-fat, high-protein
diet.
How should the nurse position the elec- In MCL I monitoring, the positive elec-
trodes for modified chest lead one (MCL trode is placed on the client's mid-chest
I) telemetry monitoring? to the right of the sternum, and the neg-
ative electrode is placed on the upper
Negative polarity left shoulder, positive left part of the chest. The ground may be
polarity right chest nipple line, ground left placed anywhere, but is usually placed
chest nipple line. Correct on the lower left portion of the chest.
In preparing to administer intravenous al-
bumin to a client following surgery, which
are the priority nursing interventions? Albumin should be infused within four
(Select all that apply.) hours because it does not contain any
Set the infusion pump to infuse the albu- preservatives. Any fluid remaining after
min within four hours. Correct four hours should be discarded. A large
Compare the client's blood type with the gauge catheter allows for fast infusion
label on the albumin. rate, which may be necessary. Hemod-
Assign a UAP to monitor blood pressure ilution may decrease hemoglobin (HgB)
q15 minutes. and hematocrit (HCT) levels, so the HgB
Administer through a large gauge and HCT levels should be monitored
catheter. Correct while monitoring for bleeding because of
Monitor hemoglobin and hematocrit lev- the increased blood volume and blood
els. Correct pressure.
Assess for increased bleeding after ad-
ministration. Correct
Hypokalemia (normal 3.5 to 5 mEq/L [3.5
A client who has heart failure is ad-
to 5 mmol/L]) causes changes in myocar-
mitted with a serum potassium level of
dial irritability and ECG waveform, so it
, Med Surg HESI
Study online at https://quizlet.com/_95k64v
2.9 mEq/L (2.9 mmol/L). Which action is is most important for the nurse to initiate
most important for the nurse to imple- continuous cardiac monitoring to identify
ment? ventricular ectopy or other life-threaten-
Give 20 mEq of potassium chloride. ing dysrhythmias. After cardiac monitor-
Initiate continuous cardiac monitoring. ing is initiated, then the potassium chlo-
Correct ride should be given so that the effects
Arrange a consultation with the dietician. of potassium replacement on the cardiac
Teach about the side effects of diuretics. rhythm can be monitored.
After checking the urinary drainage sys-
tem for kinks in the tubing, the nurse de-
termines that a client who has returned
from the post-anesthesia care has a
dark, concentrated urinary output of 54 After surgery, an adult who weighs 132
mL for the last 2 hours. Which priority pounds (60 kg) should produce about
nursing action should be implemented? 60 mL of urine hourly (1 mL/kg/hour).
Dark, concentrated, and low volume of
Report the findings to the surgeon. Cor- urine output should be reported to the
rect surgeon.
Irrigate the indwelling urinary catheter.
Apply manual pressure to the bladder.
Increase the IV flow rate for 15 minutes.
Incorrect
Two days postoperative, a male client
reports aching pain in his left leg. The
nurse assesses redness and warmth on
the lower left calf. Which intervention
would be most helpful to this client?
For a client exhibiting symptoms of deep
Apply sequential compression devices vein thrombosis (DVT), a complication
(SCDs) bilaterally. of immobility, the initial care includes
Assess for a positive Homan's sign in bedrest and elevation of the extremity.
each leg. Incorrect
Pad all bony prominences on the affect-
ed leg.
Advise the client to remain in bed with
the leg elevated. Correct
Which description of pain is consistent
with a diagnosis of rheumatoid arthritis?
, Med Surg HESI
Study online at https://quizlet.com/_95k64v
Joint pain is worse in the morning and
involves symmetric joints. Correct
Joint pain is better in the morning and Rheumatoid arthritis (RA) is an autoim-
worsens throughout the day. mune disease that causes joint pain and
Joint pain is consistent throughout the swelling. RA is characterized by pain that
day and is relieved by pain medication. is worse when arising and involves sym-
Incorrect metric joints.
Joint pain is worse during the day and
involves unilateral joints.
A client's susceptibility to ulcerative col-
itis is most likely due to which aspect in
the client's history?
Ulcerative colitis is 4 to 5 times more
Jewish European ancestry. Correct
common among individuals of Jewish
H. pylori bowel infection.
European or Ashkenazi ancestry.
Family history of irritable bowel syn-
drome.
Age between 25 and 55 years.
While working in the emergency room,
the nurse is exposed to a client with ac-
tive tuberculosis. When should the nurse A tuberculin skin test is effective 4 to 6
plan to obtain a tuberculin skin test? weeks after an exposure, so the individ-
Immediately after the exposure. ual with a known exposure should wait
Within one week of the exposure. 4 to 6 weeks before having a tuberculin
Four to six weeks after the exposure. skin test.
Correct
Three months after the exposure.
The nurse knows that lab values some-
times vary for the older client. Which
data would the nurse expect to find
when reviewing laboratory values of an As older adults age, the protein found
80-year-old male? in urine slightly rises as a result of kid-
ney changes, and the serum glucose in-
Increased WBC, decreased RBC. creases slightly, also due to changes in
Increased serum bilirubin, slightly in- the kidney.
creased liver enzymes.
Increased protein in the urine, slightly
increased serum glucose levels. Correct
, Med Surg HESI
Study online at https://quizlet.com/_95k64v
Decreased serum sodium, an increased
urine specific gravity.
The nurse is assessing a client's labo-
ratory values following administration of
chemotherapy. Which lab value leads the Tumor lysis symdrome (TLS) results
nurse to suspect that the client is experi- in hyperkalemia, hypocalcemia, hype-
encing tumor lysis syndrome (TLS)? ruricemia, and hyperphosphatemia. A
serum calcium level of 5, which is low,
Serum PTT of 10 seconds. is an indicator of possible tumor lysis
Serum calcium of 5 mg/dL. Correct syndrome.
Oxygen saturation of 90%.
Hemoglobin of 10 g/dL.
Which intervention should the nurse
plan to implement when caring for a
client who has just undergone a right
above-the-knee amputation?
A large tourniquet should be placed in
plain sight at the client's bedside, in the
Maintain the residual limb on three pil-
event severe bleeding occurs. The pur-
lows at all times. Incorrect
pose is to have the tourniquet available
Place a large tourniquet at the client's
to apply to the residual limb to control
bedside. Correct
bleeding if hemorrhaging was to occur.
Apply constant, direct pressure to the
residual limb.
Do not allow the client to lie in the prone
position.
More SPECIFIC THAN BUN.
Creatinine
An elevated creatinine strongly indicates
nephron loss, reducing filtration.
Which nail color alteration should the
nurse expect to observe in a client with
Fingernails and toenails can be affect-
chronic kidney disease?
ed by chronic kidney disease. This con-
dition may cause horizontal white lines
Horizontal white banding. Correct
or bands (leukonychia) to appear on the
Diffuse blue discoloration.
nails.
Diffuse brown discoloration.
Thin, dark red vertical lines.
