1. A.: A nurse is reinforcing teaching with a client who has HIV and is being dischar
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ged to home. Which of the following instructions should the nurse includein the teac
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hing?
A. Take temperature once a day. s s s s
B. Wash the armpits and genitals with a gentle cleanser daily.
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C. Change the litter boxes while wearing gloves. s s s s s s
D. Wash dishes in warm water. s s s s
2. A.: A nurse is caring for a client who is postoperative following a tracheostomy,and
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has copious and tenacious secretions.Which of the following is an acceptablemetho
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d for the nurse to use to thin this client's secretions?
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A. Provide humidified oxygen. s s
B. Perform chest physiotherapy prior to suctioning. s s s s s
C. Prelubricate the suction catheter tip with sterile saline when suctioning theair s s s s s s s s s s s
way.
D. Hyperventilate the client with 100% oxygen before suctioning the airway.. s s s s s s s s s
3. B.: Following admission, a client with a vascular occlusion of the right lower extre
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mity calls the nurse and reports difficulty sleeping because of cold feet.Whichof the fol
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lowing nursing actions should the nurse take to promote the client's comfort?
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A. Rub the client's feet briskly for several minutes.
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B. Obtain a pair of slipper socks for the client.
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C. Increase the client's oral fluid intake. s s s s s
D. Place a moist heating pad under the client's feet.
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,MED-SURG II HESI TEST BANK EXAM SOLUTIONS S S S S S S
4. C.: A nurse is caring for a client is who is 4 hr postoperative following a transurethr
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al resection of the prostate (TURP).Which of the following is the priorityfinding for the
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nurse report to the provider?
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A. Emesis of 100 mL s s s
B. Oral temperature of 37.5° C (99.5° F)
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C. Thick, red-colored urine s s
D. Pain level of 4 on a 0 to 10 rating scale
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5. A.: A nurse is caring for a client who has a temperature of 39.7° C (103.5° F)and
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has a prescription for a hypothermia blanket. The nurse should monitor theclient fo
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r which of the following adverse effects of the hypothermia blanket?
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A. Shivering
B. Infection
C. Burns
D. Hypervolemia
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, MED-SURG II HESI TEST BANK EXAM SOLUTIONS S S S S S S
6. D.: A nurse is reinforcing teaching about exercise with a client who has type1 di
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abetes mellitus. Which of the following statements by the client indicates anunder
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standing of the teaching? s s s
A. "I will carry a complex carbohydrate snack with me when I exercise."
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B. "I should exercise first thing in the morning before eating breakfast."
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C. "I should avoid injecting insulin into my thigh if I am going to go running."
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D. "I will not exercise if my urine is positive for ketones."
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7. A.: A nurse notes a small section of bowel protruding from the abdominalinc
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ision of a client who
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is postoperative. After calling for assistance, which of the following actions shouldthe
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nurse take first?
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A. Cover the client's wound with a moist, sterile dressing.
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B. Have the client lie supine with knees flexed.
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C. Check the client's vital signs. s s s s
D. Inform the client about the need to return to surgery.
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8. B.: A nurse is collecting data from a client who has alcohol use disorder and isexp
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eriencing metabolic acidosis. Which of the following manifestations should thenurse
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expect?
A. Cool, clammy skin. s s
B. Hyperventilation
C. Increased blood pressure s s
D. Bradycardia
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, MED-SURG II HESI TEST BANK EXAM SOLUTIONS S S S S S S
9. A.: A nurse is reinforcing discharge teaching with a client following a cataractext
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raction. Which of the following should the nurse include in the teaching?
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A. Avoid bending at the waist. s s s s
B. Remove the eye shield at bedtime. s s s s s
C. Limit the use of laxatives if constipated.
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D. Seeing flashes of light is an expected finding following extraction.
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10. C: A nurse is caring for a client who has heart failure and has been taking digoxi
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n 0.25 mg daily. The client refuses breakfast and reports nausea. Which ofthe follow
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ing actions should the nurse take first?
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1) Suggest that the client rests before eating the meal.
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2) Request a dietary consult. s s s
3) Check the client's vital signs. s s s s
4) Request an order for an antiemetic. s s s s s
11. D.: A nurse is caring for a client who is 3 days postoperative following a cholecy
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stectomy. The nurse suspects the client's wound is infected because thedrainage f
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rom the dressing is yellow and thick. Which of the following findings
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