MED SURG HESI V2 - 2024/2025 EXAM QUESTIONS AND VERIFIED ANSWERS GUARANTEED SUCCESS

MED SURG HESI V2 - 2024/2025 EXAM QUESTIONS AND VERIFIED ANSWERS GUARANTEED SUCCESS “What information should the nurse include in the teaching plan of a client diagnosed with GERD? A. Sleep without pillows B. Adjust food intake to three full meals per day with no snacks C. Minimize symptoms by wearing loose comfortable clothing D. Avoid participation in any aerobic exercise program - CORRECT ANSWER Minimize symptoms by wearing loose comfortable clothing" "The nurse is teaching a client with glomerulonephritis about self care. Which dietary recommendations should the nurse encourage the client to follow. A. increase intake of high-fiber foods, such as bran cereal. B. Restrict protein intake by limiting meals and other high-protein foods C. limit oral fluid intake of 500/ml/day D. Increase intake of potassium rich foods such as bananas and cantaloupe - CORRECT ANSWER Restrict protein intake by limiting meals and other high-protein foods" "An overweight young adult male who was recently diagnosed with type 2 DM is admitted for a hernia repair. he tells the nurse that he is feeling very weak and jittery. Which actions should the nurse implement? Select all that apply. A.Check his fingerstick glucose B. Assess his skin temperature and moisture C. Measure his pulse and BP D. Document anxiety on the surgical checklist E. Administer a PRN dose of regular insulin - CORRECT ANSWER Check his fingerstick glucose, assess his skin temperature and moisture, measure his pulse and BP" "A client with Cushing Syndrome is recovering from an elective laparoscopic procedure. which assessment finding warrants immediate intervention by the nurse? A. Irregular apical pulse B. Purple marks on skin of the abdomen C. Quarter sized blood spot on the dressing D. Pitting ankle edema - CORRECT ANSWER Irregular apical pulse" "An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red and the client reports a burning sensation. What action should the nurse take? A. Apply a cool compress to the affected fingers for 20 minutes B. Secure a pulse oximeter to monitor the client's oxygen saturation C. Report the finding to the healthcare provider as soon as possible D. Continue to monitor the fingers until color returns to normal - CORRECT ANSWER Continue to monitor the fingers until color returns to normal" "A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. lung are coarse with diminished bibasilar breath sounds. Vital signs are T: 101 degrees, HR: 128, RR: 28, B/P: 122/82. Which interventions is most important for the nurse to implement first? A. Obtain oxygen saturation level. B. Encourage incentivize spirometry C. Assess lower extremity circulation D. Administer oral PRN antipyretic - CORRECT ANSWER Administer oral PRN antipyretic" "A client with cancer is receiving chemotherapy with a known vesicant. the clients IV has been in place for 72hrs. The nurse determines that a new IV site cannot be obtained and leaves present IV in place. What is greatest clinical risk? A. impaired skin integrity B. fluid volume excess C. Acute pain and anxiety D. Peripheral neuron vascular dysfunction - CORRECT ANSWER Impaired skin integrity" "A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the post-anesthesia unit. Before selecting which medication to administer, which action should the nurse implement? A. Document client report of pain in EMR B. Determine which prescription will have quickest onset action C. Compare the clients pain scale rating w/prescribed dosing D. Ask the client to choose which medication is needed for pain - CORRECT ANSWER Compare the clients pain scale rating w/prescribed dosing" "While assisting a female client to the toilet, the client begins to have a seizure and the nurse eases her to the floor. The nurse calls for help and monitors the client until the seizing stops. Which interventions should the nurse implement first? A. Document details of the seizure activity B. Observe for lacerations to the tongue C. Observe for prolonged periods of apnea D. Evaluate the evidence of incontinence - CORRECT ANSWER Document details of the seizure activity" "While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the clients finger that are reddened. The client reports the nodes are painful. Which action should nurse take? A. Review the clients dietary intake of high protein foods B. Notify the HCP of the finding immediately C. Discuss approaches to chronic pain control with the client D. Assess the clients radial pulses and capillary refill time - CORRECT ANSWER Discuss approaches to chronic pain control with the client" "A client who took a camping vacation 2 weeks ago in a country with tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. which finding is most important for the nurse to report to the HCP. A. Weakness and fatigue B. Intestinal cramping C. Weight loss D. Jaundiced sclera - CORRECT ANSWER Jaundiced sclera" "Ten hours following thrombolysis for an ST elevation myocardial infarction (STEMI) a client is receiving a lidocaine infusion for isolated runs of ventricular tachycardia. Which findings should the nurse document in the EMR as therapeutic response to the lidocaine? A. Stabilization of BP ranges B. Cessation of chest pain C. Reduce heart rate D. Decreased frequency of episodes of VT - CORRECT ANSWER Decreased frequency of episodes of VT" "After a CT scan with intravenous contrast medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement? A. Call respiratory therapy to give a breathing treatment. B. Send another nurse for emergency tracheostomy set C. Prepare a dose of epinephrine D. Review the clients complete list of allergies - CORRECT ANSWER Prepare a dose of epinephrine" "The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding A. Unchallenged rigidity B. Carotid bruit C. Jugular vein distention D. Palpable cervical lymph node - CORRECT ANSWER Carotid bruit" "The nurse is obtaining a clients fingerstick glucose level. After gently milking the clients finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take? A. Collect the blood sample B. Assess radial pulse volume C. Apply pressure to the site D. Select another finger - CORRECT ANSWER Collect the blood sample" "A client being admitted to a surgical unit is being evaluated for an intestinal obstruction. The HCP prescribes a NG tube to be inserted and placed to intermittent low wall suction. which intervention should the nurse implement to facilitate proper tube placement. A. Soak NG tube in warm water B. Insert tube with clients head tilted back C. Apply suction while inserting tube D. Elevate head of bed to 60 to 90 degrees - CORRECT ANSWER Elevate head of bed to 60 to 90 degrees" "A young female client with 7 children is having frequent morning headaches, dizziness, and blurred vision. Her b/p is 168/104. The client reports that her husband recently lost his job and she is not sleeping well. After administering a STAT dose of an antihypertensive IV med, which intervention is important? A. Measure urine output hourly to assess for renal perfusion B. Request a prescription for pain medication C. Use an automated BP machine to monitor for hypotension D. Provide privacy - CORRECT ANSWER Use an automated BP machine to monitor for hypotension" "expressive aphasia - CORRECT ANSWER slurred speech or inability to speak; they're unable to get out what they want to say" "No heavy lifting or bending over at the waste (nothing that will increase IOP ) Wear bandage or shield to protect the eye Eyes will feel like scratchy sand-like feeling in their eyes Need to have someone to drive for them 1st 24 hrs after surgery, they just need to relax (they can watch TV & read; nothing that will cause pressure) Don't want patient rubbing or pressing on their eye Shouldn't drink alcohol for at least 24 hours - CORRECT ANSWER Cataract extraction surgery education" "-Report if they are coughing up blood -Recognize if there is a rupture, there will be bleeding & immediate action needs to be taken -No spicy foods!! -To prevent pressure, you have to control their high blood pressure Majority of people who come in w/ esophogeal varices are alcoholics - CORRECT ANSWER Teaching for esophageal varices" "esophagel varices - CORRECT ANSWER enlarged, swollen, varicose veins at the lower end of the esophagus" "people that like to drink (alcohol) - CORRECT ANSWER Esphogeal varices are very common in __" "Decreased course crackles - CORRECT ANSWER Which assessment finding would you expect to see in a patient who had recently been suctioned via endotracheal tube? A. Increased course crackles B. Decreased course crackles C. Decreased fine crackles D. Increased fine crackles" "The patient's sclera is yellow (inflammation b/c of gallstones, the stones can get lodged in the bile duct, which backs up & causes damage in the liver) - CORRECT ANSWER Which assessment information will be most important for the nurse to report to the health care provider about a patient with cholelithiasis? A. The patient's urine is bright yellow B. The patient's sclera is yellow C. The patient has increased pain after eating D. The patient complains of chronic heartburn" "cholelithiasis - CORRECT ANSWER gallstones in the gallbladder" "Place the client in high Fowler's position. (They are in respiratory acidosis) Primary assessment: respiratory (listen to lungs, rate & depth) - CORRECT ANSWER A client with pneumonia presents with the following arterial blood gases of pH 7.28, PaCO2 of 74, HCO3 of 28 meq/L, and PO2 of 45. Which of the following is the most appropriate nursing intervention? A. Administer a sedative B. Place client in left lateral position C. Place client in high-fowlers position D. Assist the client to breathe into a paper bag What would be your primary assessment for this patient?" "Decreased cardiac ouput - CORRECT ANSWER A patient arrives to the ER with the diagnosis of sinus bradycardia. What is the primary nursing diagnosis for this patient? A. Risk for infection B. Decreased cardiac output C. Ineffective health maintenance D. Risk for injury" "Sinus Bradycardia - CORRECT ANSWER 60 bpm" "A. Establish IV access - CORRECT ANSWER A drug abuse client is being admitted to your unit with the diagnosis of cellulitis from a needle stick injury. What is the nurse's primary action for this client? A. Establish IV access B. Monitor urine output C. Administer the first dose of pain medication D. Consult case management for rehab placement" "Cellulitis - CORRECT ANSWER Infection of skin cells" "-Going to back up into the lungs (respiratory system) -SOB -dyspnea -wheezing -pulmonary edema -crackles -coughing (coughing up pink tinged secretions) -fatigued/weak - CORRECT ANSWER Left ventricular diastolic function S/S:" "Melena - CORRECT ANSWER The client with a duodenal ulcer may exhibit which of the following findings on assessment? A. Hematemsis B. Malnourishment C. Melena D. Pain with eating" "melena - CORRECT ANSWER Black tarry stool" "hematemesis - CORRECT ANSWER vomiting blood" "- No heavy lifting (no excess pressure) -Will always have to use eyedrops for the rest of their lives -S/S of open angle glaucoma: will have decreased peripheral vision, also it happens very slowly, you use lose vision before you ever even know there is a problem (Chronic) - CORRECT ANSWER Teaching plan for the client with open angle glaucoma" "F,H are incorrect - CORRECT ANSWER A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is about to have a seizure. Which of the following actions by the nurse are incorrect? (Select all that apply) A. Monitor for prolonged apnea B. Ease the client to the floor if standing C. Move furniture away from the cient D. Loosen the clients clothing E. Protect the clients head with padding F. Restrain the client G. Turn on side H. Place tongue blade in clients mouth I. Record the time & document details of seizure J. Document details of the seizure" "Looking for a bowel movement (they are going to have massive liquid diarrhea b/c Kayexalate causes potassium to exchange from sodium in the intestines & potassium goes out via BM) - CORRECT ANSWER A renal failure client with a potassium level of 5.5 mEq/L is to receive sodium polystryene sulfonate (kayexalate) orally. What do you want to monitor for immediately after this medication is given?" "D, C, A,B Once you confirm that it's in place, you would listen to bowel sounds - CORRECT ANSWER Sequence the procedure for verifying feeding tube placement: A. Measure the pH of aspirate, compare the color of the strip with the color on the chart provided by the manufactor B. Discard used supplies, remove gloves and discard, and perform hand hygiene C. Draw back on syringe & obtain 5 to 10 mL of gastric aspirate observe appearance of aspirate D. Perform hand hygiene. Apply clean gloves, draw up 30 mL of air into syringe, then attach to end of feeding tube, flush tube with 30 mL of air" "- check for increased HR, respirations, & temp - BP will drop - May have hemolytic rash & be itching - May see flushing - Chest or flank pain - Blood has to run off on a pump TIME FRAME FOR GIVING BLOOD HAS TO BE LESS THAN 4 HOURS; IF STILL BLOOD IN AFTER 4 HOURS, YOU HAVE TO TAKE IT DOWN - CORRECT ANSWER S/S of blood transfusion reaction?" "first thing to do is to stop the infusion & start flushing - CORRECT ANSWER What is nursing priority when a transfusion reaction is suspected? A. vital signs B. call the MD C. administer benadryl D. stop the infusion" "Assess immediately and hourly thereafter (something has changed; this is different from their norm) - CORRECT ANSWER An older adult client who is predominantly argumentative and combative becomes calm & sleeps through the night. What is the nurse's priority intervention? A. Assess immediately and hourly thereafter B. Call the MD C. Document the client is resting D. Allow the patient to rest and document a round every 4 hours" "A. Diet & exercise regimen (least invasive) (metformin would be the next; first drug of choice) - CORRECT ANSWER A 36 year old male is newly diagnosed with type 2 diabetes. Which of the following treatments do you expect the patient to be started on initially? A. Diet and exercise regimen B. Metformin BID by mouth C. Regular insulin subcutaneous D. None, monitoring at this time is sufficient enough" "Review their dietary log (check what they have been eating & keep up with what foods are causing the adjustments) - CORRECT ANSWER For patients with blood sugar ranges fluctuating high and low, what should be the nursing intervention? A. Increase the patients short acting insulin B. Decrease the patients long acting insulin C. Draw a serum glucose D. Review their dietary log" "Metformin (oral diabetes medicine that helps control blood sugar levels) - CORRECT ANSWER medication used for type 2 diabetes" "Administer nausea medication - CORRECT ANSWER What is the primary nursing action for a patient with chemo induced nausea? A. Take a blood pressure B. Apply a cold cloth to forehead C. Document amount of emesis D. Administer nausea medication" "30 minutes before (give it time to kick in; once someone gets nauseated with chemo, it's hard to catch it) - CORRECT ANSWER How many minutes prior to chemotherapy do you give antiemetic drugs? A. 15 B. 30 C. 45 D. 60" "TLS (tumor lysis syndrome) -Can put them into acute renal injury -They'll have hyperurecemia, hyperphosphatemia, hyperkalemia, hypocalcemia - CORRECT ANSWER Describe TLS and rationales for going into TLS" "atelectasis (parital full collapse of lung/alveoli; one of the most common breathing complications after surgery) this is why we're doing turn cough deep breathe, incentive spirometer - CORRECT ANSWER A surgical protocol states that all post operative patients must participate in early ambulation to prevent: A. Bed sores B. Atelectasis C. Contractures D. Dehiscence and eviscertion" "- Prep the room & make sure you've got all the equipment - They help with transfering & positioning the patient for surgery - Anybody needs anything, they go and get it - *They are responsible for calling the surgical TIME-OUT* (primary role) - CORRECT ANSWER Goal of the surgery circulating nurse:" "Bowel sounds in all 4 quadrants complication that can occur after abdominal surgery: - they can get an ileus (a painful obstruction of the ileum or other part of the intestine) - blocked bowel after surgery (important to get them up & giving stool softeners; dont feed until you hear bowel sounds) - CORRECT ANSWER A patient who received an emergency appendectomy 2 days ago is now experiencing abdominal pain on the med-surg unit. What shoud the RN consider to be the primary assessment? A. Pedal pulses B. Jugular vein distention C. Bowel sounds in all 4 quadrants D. Urinary output of 30 cc per hour" "- Expect to see no BP or sticks in that arm - Cannot use right away b/c it has to have time to heal - Auscultate to bruit - Palpate for thrill - CORRECT ANSWER Care of a newly inserted AV fistula" "- Check feet everyday; make sure you dry your feet - Wear proper shoes - Don't want them walking around bearfoot - Make sure bath water isn't too hot - CORRECT ANSWER Education needed regarding foot care on diabetic patients." "Sit the patient in high fowler's Priority nursing assessment: respiratory (listening to what their lungs sound like) - CORRECT ANSWER A patient diagnosed CHF present to the ER with SOB, dyspnea, rhonchi, dry cough, and tachycardia. What is the RN's first response? A. Complete chest percussions on bilateral lungs B. Push 1 amp o fmetoprolol C. Place the patient in trendelenburg D. Sit the patient in high fowler's What is the priority nursing assessment?" "Assess potassium level (when you're giving insulin & dextrose it pulls K+ out of cells too; it will drop) (check glucose BEFORE meals, not after) - CORRECT ANSWER An order is given to the RN to administer dextrose + insulin combined as a one time stat dose. What will be most important to include in this patient's plan of care? A. Assess range of motion B. Assess oxygen level C. Assess potassium level D. Assess glucose readings after each meal" "- Monitor glucose - Check amylase & lipase levels - May have to put an NG down & put it to suction - *one of the most common causes of pancreatitis is alcohol abuse, so talk about that* - * They will always be NPO* - Ultrasound - CORRECT ANSWER List all nursing interventions for a patient diagnosed with pancreatitis:" "popped, twisted, enlarged veins -legs ache, painful, feel heavy (S/S) - CORRECT ANSWER varicose veins" "RLS (restless leg syndrome) (unable to control the urge to move their legs) (typically happens at night/evenings; can occur whether you are sitting or lying down) - CORRECT ANSWER unpleasant sensations (itching, twitching, tingling, crawling) in the lower legs; irresistible urge to move the legs temporarily relieving the sensation but not disurbing sleep." "Risks: Diabetes, Smoking, Hypertension, Diet (fatty foods/high cholesterol), Family History Interventions: Diet and Exercise - CORRECT ANSWER Risk for developing Coronary Artery Disease: What interventions do you instruct the patient to slow progression of CAD?" "- Stool will be red (bloody diarrhea) (lower) - rectal bleeding - Blood count may show low H&H, may be anemic - CORRECT ANSWER S/S of ulcerative colitis" "apply oxygen by non-rebreather mask (too much carbon dioxide cause respiratory acidosis) - CORRECT ANSWER After reviewing ABG's the patient is in respiratory acidosis. What is the nurses's primary intervention? A. apply oxygen by non-rebreather mask B. sedate w/ ativan 1mg/kg C. Administer bicarb 1 amp D. Administer a bronchoocnstrictor" "Set patient up on a fixed pain med schedule q 4 hrs - CORRECT ANSWER A patient with stage IV bone cancer has no pain relief with the first dose of IV pain medication. What is the most appropriate nursing intervention for long term relief? A. Administer ibuprofen 400mg PO B. Set patient up on a fixed pain med schedule q 4 hrs C. Alternate rearranging pillows and cold cloth applications D. Support assisted suicide as the patient's advocate" "Bedside prep: Sterile saline, tape, gloves, dressing that has been order When changing the wound you are looking for signs of infection (redness, swelling), dehiscence (make sure that it is still together), also evisceration (make sure there is good tissue) - CORRECT ANSWER Bedside prep for a post op wound: Primary concerns:" "a. Age b. Alcohol - Limit to 1 a day for females and 2 a day for males c. Tobacco use (smoking) - Increases risk for cardiovascular disease d. Diabetes mellitus - Common in patients with HTN - Complications are more severe when these coexist e. Elevated serum lipids (Coronary artery disease) - Increased cholesterol and triglycerides are primary risk factors for atherosclerosis - Common in people with HTN f. Excessive dietary sodium - Sodium intake can contribute to HTN and decrease antihypertensive med g. Gender - Prevalent in men in young adulthood - After 64 - more prevalent in women h. Family history - First relatives increase risk i. Obesity - Weight gain is associated with increased frequency of HTN - BMI: 1. 18.5-25 - normal 2. 25-30 -OVERWEIGHT 3. 30 -OBESE j. Ethnicity - African Americans k. Sedentary lifestyle l. Socioeconomic (greater in lower socioeconomic areas) m. Stress - CORRECT ANSWER Risk factors for HTN" "a. Pursed lips b. Barrel chest (increase anteroposterior diameter) c. Tripod positioning d. Use of accessory muscles e. ALSO: chronic cough, sputum production, dyspnea, wheezing f. Medications: bronchodilators, incentive spirometer, CPT, O2 - CORRECT ANSWER COPD S/S" "a. Increase fluid intake to 3L/day if tolerated b. Intake can be IV or PO - CORRECT ANSWER What to do when a patient needs to expectorate thick lung secretions?" "a. Increase water intake to 3L / day b. DECREASE calcium, struvite (uric acid: gout), infections (bacterial: UTIs) c. Strain urine (shows composition of the stone) d. Increase ambulation *Foods to AVOID: calcium (milk, dairy, green leafy vegetables) & caffeine (coffee, tea, soda, chocolate); spinach nuts, wheats, brans, *Take thiazide diuretics to prevent calcium stones; allopurinol or colchicine to prevent uric acid stones; and antibiotics for bacteria (struvite) *S/S: male over ager 40, N/V, pain radiates to flank area, hematuria - CORRECT ANSWER Interventions for patient with renal calculi:" "a. Weak cough b. Speaking, swallowing, drooling - CORRECT ANSWER What calls for an immediate ALS (amyotropic lateral sclerosis) intervention? **RESPIRATORY** (MS lose cognitive function)" "a. Increased protein in the blood; decrease serum albumin b. Edema/swelling/abdominal edema c. Increase weight gain - CORRECT ANSWER Indicators of nephrotic syndrome" "Show pictures of charts to communicate - CORRECT ANSWER What to do when a patient is experiencing expressive aphasia?" "a. No lifting/straining/bending b. No driving for 2 days c. No contacts d. No alcohol for 24 hours e. No rubbing or pressing on eyes f. No bright lights - CORRECT ANSWER Cataract surgery education" "a. Manage airway!!! b. Decrease BP *MUST STAY LOW* à if ruptures, can bleed easily c. Coughing up blood (red or coffee grounds) d. Avoid acidic/spicy foods & aspirin, alcohol, NSAIDS e. Use beta blockers to keep BP low f. If bleeding occurs: Manage airway (suction) à stabilize the patient à IV therapy (octreotide [sandostatin] or vasopressin) - CORRECT ANSWER Esophageal varices: **COMMIN IN LIVER CIRRHOSIS** - medical emergency" "a. Yellow sclera, jaundice (because backing into the liver) b. Avoid fatty/spicy foods and alcohol c. S/S: - RUQ pain - Tachycardia/ diaphoresis - Pain 3-6 hours after a high fat meal or when laying down d. Management: - NPO with NG tube - IV fluids - Low fat diet iv. Fat soluble vitamins - CORRECT ANSWER What do you report to the HCP with cholelithiasis?" "a. Place patient in high fowlers (allows better oxygen) b. Check RR, respiratory depth, and O2 sat c. Use nonrebreather to keep O2 and release CO2 d. pH decreased; PaCO2 INCREASED; HCO3- normal or increased (compensation) e. NORMALS: *pH:7.35-7.45 PaCO2:35-45 HCO3:22-26* - CORRECT ANSWER Respiratory acidosis (CO2 excess)" "a. Check cultures (blood, sputum, urine) before starting antibiotics b. Give antibiotics if culture answer is NOT an option c. Establish IV access - CORRECT ANSWER Cellulitis from needle stick (worried about infection)" "Crackles, dyspnea, orthopnea, paroxysmal nocturnal dyspnea - CORRECT ANSWER Left ventricular diastolic failure signs and symptoms:" "Safety risk factors: - Changes to be made in the home include: colored step strips (yellow), tub and toilet grab bars, stairway hand rails, unclutter floor space, increase lighting and use of night lights Quality of life: - Depression can occur due to diagnoses, loss of self-esteem, life situations (retirement, loss of spouse, etc.); pain, insomnia, lethargy, agitation, weight loss, and dementia are associated with depression - Encourage older adults with depression to seek treatment - CORRECT ANSWER Older Adults" "a. Ambulation (first) b. SCDs (2nd) c. Low-molecular weight heparin (Lovenox) / anti-thrombolytics, coumadin PO - CORRECT ANSWER Decrease clotting formation" "a. Check IV site every hour b. Vesicant drugs: vancomycin, Levaquin, chemo agents (doxorubicin/adriamycin = red devil) c. IF INFILTRATED: stop infusion, apply ice, Call MD - CORRECT ANSWER Vesicants - watching for extravasation (swelling, redness, pain)" "a. Anticoagulants for lifetime b. Antibiotics for dental work c. Soft bristle toothbrushes d. 2g Na diet, low fat/cholesterol e. If on coumadin à LIMIT vitamin K (green leafy vegetables) - CORRECT ANSWER Mechanical valve replacement teaching:" "a. NEVER remove 1st dressings à HCP must remove because it may pull off the clot/skin b. Mark if oozing; if it spreads, reinforce - CORRECT ANSWER Post-op dressings" "a. Aspirin b. Spicy/fatty/acidic foods c. Alcohol d. DAIRY à exacerbates symptoms e. Coffee **Wait 2-3 hours after eating before laying down** **Common finding with duodenal ulcers: melena** - CORRECT ANSWER What to avoid w/ duodenal ulcers" "Food INCREASES symptoms - EXACERBATES Burning or gaseous - CORRECT ANSWER Gastric ulcers" "Food DECREASES symptoms - HELPS Mid-epigastric pain beneath xiphoid Bloating, nausea, vomiting & fullness - CORRECT ANSWER Duodenal ulcers" "a. Black dome vision "Tunnel vision" -LOSE PERIPHERAL VISION - 1ST symptom!!!! b. Pressure eyedrops - lifetime medication c. Check surroundings - CORRECT ANSWER Teaching for open angle glaucoma:" "-Sudden excruciating pain in or around the eye with N/V -Colored halos, blurred vision, & ocular redness - CORRECT ANSWER Teaching for closed-angle glaucoma" "- treatment of High K+ levels a. Watch for DIARRHEA (pulls out potassium and excretes through the bowels) b. If question asks what to look for INITIALLY à Diarrhea c. If diarrhea has already passed, look for POTASSIUM levels or EKG changes - CORRECT ANSWER Kayexalate" "Hand hygiene/gloves - Draw 20-30 mL air -attach tube - push air - listen for bubbles - aspirate pH - observe aspirate -measure pH (should be 5) - discard supplies - CORRECT ANSWER Verify tube placement" "1. *Blood should not transfuse more than 4 hours* ALWAYS ON A PUMP a. Itching b. Flank/chest pain c. Swelling d. Decrease BP; INCREASE RR, HR, & temp - CORRECT ANSWER Blood transfusion reaction" "a. Metabolic EMERGENCY b. Rapid release of components due to chemo & radiation into system à renal failure, hyperkalemia, hyperuricemia, hyperphosphatemia, HYPOcalcemia *hypocalcemia means that the body tries to pull calcium out of the bones, which leads to brittle bone syndrome - CORRECT ANSWER Tumor lysis syndrome" "1. *Do not want patient to sit there and let fluid buildup* a. Prevent pneumonia/atelectasis b. If patient refuses to ambulate - SCDs (sequential compression devices) - CORRECT ANSWER Early ambulation for patients" "a. Check POTASSIUM b. *Rationale: insulin pulls K+ out with glucose c. *Add D5 or D10 when BS reaches a level of 250 mg/dL DKA: pH decrease, acidosis (fruity breath) TYPE 1 HHS: no acidosis, BS 600 TYPE 2 - CORRECT ANSWER Dextrose + insulin combined" "a. NPO!!!! b. NG suction c. Abdominal ultrasound d. Amylase/lipase levels e. AVOID alcohol - CORRECT ANSWER Pancreatitis interventions" "(UC is lower GI) a. Abdominal pain b. Bloody diarrhea / rectal bleeding à main s/s!!! c. Low H & H à anemia - CORRECT ANSWER Ulcerative colitis S/S" "After hospitalization for SIADH, a client develops pontine myelinolysis. Which intervention should the nurse implement first? A. Reorient client to room B. Place a patch on one eye C. Evaluate clients ability to swallow D. Perform range of motion exercises - CORRECT ANSWER Reorient client to room" "A male client with heart failure calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain? A. What time did he take his medication? B. Has his weight changed in the last several days? C. Is he still able to tighten his belt buckle? D. How many hours did he sleep last night? - CORRECT ANSWER Has his weight changed in the last several days?" "An older adult woman with a long history of COPD is admitted with progressive shortness of breath and a persistent cough, is anxious, and is complaining of dry mouth. which intervention should the nurse implement? A. Administer a prescribed sedative B. Encourage client to drink water C. Apply a high flow Venturi mask D. Assist her to an upright position - CORRECT ANSWER Assist her to an upright position" "A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickening mucous and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self care? A. Increase the daily intake of oral fluids to liquify secretions B. Avoid crowded enclosed areas to reduce pathogens exposure C. Call the clinic if undesirable side effects or medications - CORRECT ANSWER Increase the daily intake of oral fluids to liquify secretions" "A cardiac catherization of a client with heart disease indicates the following blockages: 95% proximal left anterior descending (LAD), 99% proximal circumflex, and 95% proximal right coronary artery (RCA) the client later asks the nurse "What does all of that mean for me?" What information should the nurse provide. B. Three main arteries have major blockages, with only 1-5% of the blood flow getting through to the heart muscles - CORRECT ANSWER Three main arteries have major blockages, with only 1-5% of the blood flow getting through to the heart muscles" "The nurse is caring for a client with a lower left lobe pulmonary abscess. what position should the nurse instruct the client to maintain? A. Left lateral B. Supine, knees flexed. C. Dorsal recumbent D. Knee-chest - CORRECT ANSWER Left lateral" "A client with Cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseous and vomiting. Which finding should the nurse report to the healthcare provider? A. Belching B. Amber urine C. Yellow sclera D. Flatulence - CORRECT ANSWER Yellow sclera" "While caring for a client with Amyotrophic lateral sclerosis (ALS) a nurse performs a neurological assessment every 4 hours. Which assessment finding warrants immediate intervention by the nurse? A. Inappropriate laughter B. Increasing anxiety C. Weakened cough effort D. Asymmetrical weakness - CORRECT ANSWER Asymmetrical weakness" "The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft to promote burn healing. Which information should the provider this client? A. Grafting increase the risk for bacterial infections B. The xenograft is taken from a non-human source. C. Grafts are later removed by a debriding procedure D. As the burns heals, the graft permanently - CORRECT ANSWER The xenograft is taken from a non-human source" "A male client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning him, the wound dehiscences and ulcerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next. A. Bring additional sterile dressing supplies to the room. B. Prepare the client to return to the OR C. Obtain a sample of the drainage to send to the lab D. ausculate the abdomen for bowel sounds - CORRECT ANSWER Bring additional sterile dressing supplies to the room" "A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117/meq. Which nursing problem should the nurse include in the clients plan of care. A. Altered urinary elimination B. Impaired gas exchange C. Fluid volume excess D. Decreased cardiac output - CORRECT ANSWER Fluid volume excess" "A female client enters the clinic and insists on being seen. She is weak, nervous and reports a racing heart beat and recent weight loss of 15 pounds. After ruling out substance withdrawal, the MD suspects hyperthyroidisms and admits her for testing. which action should the nurse do? A. Begin preparing the client for thyroidectomy procedure B. Space the clients care to provide periods of rest C. Assess the client for hyperactive bowel sounds D. Provide warm blanket to prevent heat loss - CORRECT ANSWER Assess the client for hyperactive bowel sounds" "The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomy under general anesthesia. which finding warrants notification of the HCP prior to proceeding with the scheduled procedure? A. light yellow coloring of the clients skin and eyes. B. The clients blood pressure reading 184/88mm C. The client vomits 20 mL of clear yellowish fluid D. the IV insertion site is red, swollen, and leaking IV fluid - CORRECT ANSWER The clients blood pressure reading 184/88" "A client who has a history of hyperthyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse? A. Facial puffiness and periorbital edema B. Hematocrit of 30% C. cold and dry skin D. Further decline in LOC - CORRECT ANSWER Further decline in LOC" "Following surgical repair of the bladder, a female client is being discharged from the hospital to home with an indwelling urinary catheter. Which instruction is most important for the nurse to provide to this client? A. Avoid coiling the tubing and keep if free of kinks B. Cleanse the perineal area with soap and water twice daily C. Keep the drainage bag lower than the level of the bladder D. Drink 1,000 ml of fluids daily to irrigate catheter - CORRECT ANSWER Keep the drainage back lower than the level of the bladder" "Which client has the highest risk for developing skin cancer? A. A 16 year old dark skinned female who tans in tanning bed once a week. B. A 65 year old fair skinned male who is a construction worker C. A 25 year old dark skinned male who mother had skin cancer. D. A 70 year old fair skinned female who works as a secretary - CORRECT ANSWER A 65 year old fair skinned male who is a construction worker" "When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain? A. Daily weight B. Vital signs C. Level of consciousness D. Bowel sounds - CORRECT ANSWER Daily weight" "A female client client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in prep for an open reduction internal fixation (ORIF) the nurse determines that her distal pulse are diminished in the left foot. Which interventions should the nurse implement? (SATA) B. Verify pedal pulses using a Doppler C. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure D. Evaluate the splint to the left leg - CORRECT ANSWER Verify pedal pulses using a Doppler, monitor left leg for pain, pallor, paresthesia, paralysis, pressure, evaluate the splint to the left leg" "A male client with heroes zoster (shingles) on his thorax tells the nurse that he is having difficulty sleeping. what is the etiology of this problem? A. pain B. Nocturia C. Dyspnea D. Frequent cough - CORRECT ANSWER Pain" "When planning care for a client newly diagnosed with open angle glaucoma, the nurse identifies a priority nursing diagnoises of "visual sensory/perceptual alterations." This diagnosis is based on which etiology? A. limited eye movement B. Decreased peripheral vision C. Blurred distance, vision D. Photosensitivity - CORRECT ANSWER Decreased peripheral vision" "A client who is newly diagnosed with emphysema is being prepared for discharge. Which instruction is best for the nurse to provide the client to assist them with dyspnea self-management? A. Allow additional time to complete physical activities to reduce oxygen demand B. Practice inhaling through the nose and exhaling slowly through pursed lips C. Use a humidifier to increase air quality between 30-50% D. Strengthen abdominal muscles by alternating leg raises during exhalation - CORRECT ANSWER Practice inhaling through the nose and exhaling slowly through pursed lips" "A male client with diabetes mellitus transferred from the hospital to a rehabilitation facility following treatment for a stroke resulting in right hemiplegia. He tells the nurse that his feet are always uncomfortably cool at night, preventing him from falling asleep. which action should the nurse implement? A. Provide a warming pad to feet B. Medicate the client with a prescribed sedative C. Use a bed cradle to hold the covers off feet D. Place warm blanket next to the clients feed - CORRECT ANSWER Place warm blanket next to clients feet" "During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms? A. An old friend with eczema came for a visit B. Recently received an influenza immunization C. A grandson and his new dog recently visited D. Corticosteroid cream was applied to eczema - CORRECT ANSWER A grandson and his new dog recently visited" "While planning care for a client with carpal tunnel syndrome, the nurse identifies a collaborative problem of pain. What is the etiology of this problem? A. Irritation of nerve endings B. Diminished blood flow C. ischemic tissue changes D. Compression of a nerve - CORRECT ANSWER Compression of a nerve" "The nurse assesses a client being treated for Herpes Zoster (Shingles) which assessment should the nurse include when evaluating the effectiveness of treatment (SATA) A. Skin integrity B. Functional ability C. Heart sounds D. Pain scale E. Bowel sounds - CORRECT ANSWER Skin integrity, Functional ability, Pain scale" "A male client tells the nurse that he is experiencing burning on urination, and assessment reveals that he had sexual inter course four days w/a women he casually met. Which action should the nurse implement? A. Observe the perineal area for a chancroid-like lesion B. Obtain a specimen of urethral drainage for culture C. Assess for perineal itching, erythema, and excoriation D. Identify all sexual partners in the last four days - CORRECT ANSWER Obtain a specimen of urethral drainage for culture" "A client with Addison's disease taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor which serum lab value? A. Osmolarity B. glucose C. Albumin D. Platelets - CORRECT ANSWER glucose" "A client with AIDS has impaired gas exchange from a respiratory infection. Which assessment finding warrants immediate intervention by the nurse? A. Elevated temperature B. Generalized weakness C. Diminished lung sounds D. Pain when swallowing - CORRECT ANSWER Pain when swallowing" "An older male client tells the nurse he is losing sleep because he has to get up several times at night to go bathroom, that he has trouble starting his urinary stream and he doesn't feel like his bladder is empty. Which interventions? A. collect a urine specimen for culture analysis B. Review the clients fluid intake prior to bedtime C. Palpate the bladder above the symphysis pubis D. obtain a fingerstick glucose level - CORRECT ANSWER Palpate the bladder above the symphysis pubis" "Fluids are restricted to 1500 ml/day for a male client with AKI. He is frustrated and complaining of constant thirst, and the nurse discovers that the family is providing the client with additional fluids. What intervention should the nurse implement? A. Remove all sources of liquids from the clients room B. Allow family to give the client a measured amount of ice chips C. Restrict family visiting until the clients condition is stable D. Provide the client with oral swabs to moisten his mouth. - CORRECT ANSWER Provide the client with oral swabs to moisten his mouth." "During a paracentesis, 2L of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed and 50mL of straw colored fluid drains within 1st hr. What action to take? A. Palpate for abdominal distention B. Send fluid to the lab for analysis C. Continue to monitor the fluid output D. Clamp drainage tube for 5 mins - CORRECT ANSWER Continue to monitor the fluid output" "The wife of a client with Parkinson's disease expresses concern because her husband has lost so much weight. Which teaching is best for the nurse to provide? A. Invite friends over regularly to share meal times B. Encourage the client to drink clear liquids between meals C. Coach the client to make an intentional effort to swallow D. Talk to the HCP about prescribing an appetite stimulant. - CORRECT ANSWER Invite friends over regularly to share meal times." "A client who was discharged 8 months ago with cirrhosis and ascites is admitted with anorexia and recent hemoptysis. The client is drowsy but responds to verbal stimuli. The nurse programs a blood pressure monitor to take readings every 15 minutes. Which assessment should implement first? A. Evaluate distal capillary refill for relayed perfusion B. Check the extremities for bruising and petechiae C. Examine the pertibial regions for pitting edema D. Palpate the abdomen for tenderness/rigid - CORRECT ANSWER Palpate the abdomen for tenderness/rigid" "A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions? A. Report when hematuria becomes pink tinged B. Use incentive spirometer C. Restrict physical activities D. Monitor urinary stream for decrease in output - CORRECT ANSWER Monitor urinary stream for decrease in output" Alternate IV & IM medications - CORRECT ANSWER A 73 year old patient with end stage cancer is in the hospital for pain control and rates pain at a "12" on the numeric rating scale of 0 to 10. What is the appropriate method of pain control for this patient? A. Alternate acetaminophen & ibuprofen B. Only give PO medications on a scheduled basis C. Alternate IV & IM medications D. Wait for patient to request medication each time" "Dyspnea Barrel chest Tripod position Pursed-lip breathing - CORRECT ANSWER What physical assessment findings would a nurse expect to find in a client with COPD?" "Increase fluid intake to 3L/day if tolerated - CORRECT ANSWER What is the priority nursing intervention in helping a patient expectorate thick lung secretions? A. Humidify the oxygen as able B. Administer cough suppressant Q24HR C. Teach patient to splint the affected area D. Increase fluid intake to 3L/Day if tolerated" "*Obesity* *Smoking* *Diabetes* *Cholesterol* Stress - CORRECT ANSWER Risk factors for hypertension" "Decrease calcium (milk, cheese, tofood) Want them to get up and ambulate to get those stones down Increase water/fluid intake Strain urine - CORRECT ANSWER What interventions do you plan to include w/ a pt who has renal calculi?" "Increase water/fluid intake Decrease calcium Limit coffee, tea, & cola - CORRECT ANSWER What are dietary considerations for renal calculi?" "C. Weak cough - CORRECT ANSWER A patient is admitted to the ER with amyotrophic lateral sclerosis. Which nursing assessment warrants immediate intervention? A. Muscle spasms B. Severe constipation C. Weak cough D. Slow urine stream" "massive protein in urine hypoalbunemia (low protein in the blood) hyperlipidemia edema (anasarca; in ankles in feet) Weight gain make sure to do daily weights monitor edema in lower legs and in abdomen (ascites occurs commonly w/ nephrotic syndrome) - CORRECT ANSWER Indicators of nephrotic syndrome" "C. Use picture charts to communicate (they can point out what they are trying to say) - CORRECT ANSWER A patient is admitted to the ER with expressive aphasia. To further assess the patient, the nurse should include which of the following techniques: A. Speak slower to communicate B. Speak louder to communicate C. Use picture charts to communicate D. Type on computer screen to communicate" "amyotrophic lateral sclerosis (ALS) - CORRECT ANSWER condition of progressive deterioration of motor nerve cells resulting in total loss of voluntary muscle control; symptoms advance from muscle weakness in the arms and legs, to the muscles of speech, swallowing, and breathing, to total paralysis and death; also known as Lou Gehrig disease" "Let's discuss your risk factors for continued living. - CORRECT ANSWER An older adult client comes to the clinic for his annual physical. His primary concern is increased fatigue. Which response by the nurse would be the most appropriate? A. Have you looked into a nursing home placement? B. Decrease your level of activity throughout the day. C. Increase your level of activity throughout the day. D. Let's discuss your risk factors for continued living." "-ambulation -compression hose (leg stockings) -give Heparin, Lovenox (but least invasive first) - CORRECT ANSWER Nursing action to decrease clot formation" "Extravasation - CORRECT ANSWER leakage of intravenously (IV) infused, and potentially damaging, medications into the extravascular tissue around the site of infusion" "extravasation ( a vesicant irritates the vein) - CORRECT ANSWER A client on the oncology unit is receiving a vesicant chemotherapy agent. What is your priority nursing concern? A. Extravasation B. Dehisence C. Evisceration D. Fistula E. Hemorrhage" "Evisceration - CORRECT ANSWER The displacement of organs outside of the body." "-W/ a mechanical valve, they will always have to take blood thinners (Coumadin/any anticoagulant the doctor prescribes) for the rest of their lives -Using soft tooth brushes -Being careful not to cause any bleeding -They will always hear a clicking w/ mechanical valves - CORRECT ANSWER What are your priority teaching points for a patient being discharged with having a mechanical valve replacement?" "-Immediately post-op you don't take off the first one until the doctor does (never take off the first one) - Look at drainage & reinforce the dressing - CORRECT ANSWER Nursing duties for post-op surgical dressing changes" "-RBC count: 4.2-6.1 (Anemia) -Urinalysis: UTI (checking for WBC, blood, RBCs) for Diabetics we may be checking for ketones or protein -Na level: 135-145 (Conjestive Heart Failure; checking for electrolyte imbalance; Also check BNP for HF) -WBC count: 5,000-10,000 (infection, wound, or sepsis) BUN: 10-20 (Kidney/Renal Failure) - CORRECT ANSWER Normal lab values & primary diagnosis: A. RBC count B. Urinalysis C. Na Level D. WBC count E. BUN" "- Smoking - Spicy foods - Alcohol - *Milk/Milk products* - Caffiene, Coffee, Tea, Chocolate - CORRECT ANSWER Things to avoid with duodenal ulcers"