HESI RN Med Surg II

HESI RN Med Surg II A nurse is caring for a client who is learning how to take care of a newly created colostomy. When observing a return demonstration of the colostomy irrigation, the nurse evaluates that more teaching is required when the client: Hangs the irrigation bag on the door clothes hook during fluid insertion Following surgery, a client asks the nurse if he or she can help measure intake and output. What is the best nursing response? Assess the client's ability to measure the intake and output A client with cancer of the pancreas has a pancreaticoduodenectomy (Whipple procedure). The nurse expects that the client will have which tube after surgery? Nasogastric A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, the nurse expects the client to state: "I have trouble breathing when I walk rapidly." A client with a spontaneous pneumothorax asks, "Why did they put this tube into my chest?" The nurse explains that the purpose of the chest tube is to: Remove air from the pleural space Following surgery in the inguinal area, the client complains of pain on the right side of the chest, becomes dyspneic, and begins to cough violently. The nurse suspects that a pulmonary embolus has occurred. What is the priority nursing action? Elevate the head of the bed As an acute episode of rheumatoid arthritis subsides, active and passive range-of-motion exercises are taught to the client's spouse. The nurse should teach that direct pressure should not be applied to the client's joints because this may precipitate: Pain A client is admitted to the hospital with the diagnosis of cancer of the thyroid and a thyroidectomy is scheduled. What is important for the nurse to consider when caring for this client during the postoperative period? Hoarseness and airway obstruction may result from laryngeal nerve damage. A client is scheduled to have a cardiac catheterization via the femoral approach. The nurse teaches the client about post-procedure interventions that protect the catheter insertion site. The nurse instructs the client that the leg used for catheter insertion will be: Kept extended while on bed rest A female client who has recurrent urinary tract infections (UTIs) is inquiring about the prevention of future UTIs. What information should the nurse include when teaching the client? (Select all that apply.) -Drink 8 to 10 glasses of water each day -Urinate immediately after sexual intercourse A client is diagnosed with Cushing syndrome. Which clinical manifestation does the nurse expect to increase in a client with Cushing syndrome? Glucose level A client with hepatic cirrhosis begins to develop slurred speech, confusion, drowsiness, and a flapping tremor. With this evidence of impending hepatic coma, which diet can the nurse expect will be prescribed for this client? 20 g of protein, 2000 calories Upgrade to remove ads Only $3.99/month A nurse concludes that the anemia that accompanies chronic kidney disease should be treated because it contributes to: Chronic fatigue A client is scheduled to receive general anesthesia during an upcoming surgery. The nurse provides education about common side effects of general anesthesia. The nurse concludes that the teaching has been effective when the client states, "Immediately after surgery I may experience: A sore throat." A client has surgery for the creation of burr holes after sustaining head trauma. An early clinical manifestation of meningeal irritation for which the nurse assesses the client is: Kernig's sign What therapeutic effect should the nurse identify as the reason for administration of neomycin sulfate to a client before colon surgery? Destroy intestinal bacteria A client newly diagnosed with myasthenia gravis is concerned about fluctuations in physical condition and generalized weakness. When caring for this client it is most important for the nurse to plan to: Space activities throughout the day A client is diagnosed with myasthenia gravis, and the anticholinesterase medication pyridostigmine (Mestinon) is prescribed. When teaching the client about this medication, the nurse explains that the desired effect is to increase: Contraction of skeletal muscles A client with a history of a pulmonary embolus is to receive 3 mg of warfarin (Coumadin) daily. The client has blood drawn twice weekly to ascertain that the international normalized ratio (INR) stays within a therapeutic range. The nurse provides dietary teaching. Which food selected by the client indicates that further teaching is necessary? Spinach salad A client with advanced bone cancer is experiencing cachexia. The nurse discusses the nutritional aspect of palliative care with the family. Why is it important to explain these nutritional interventions to the family? Enhance the quality of the client's life When providing discharge teaching to a client who had a total hip replacement, the nurse should instruct the client to avoid: Sitting in a low chair A client comes to the clinic for a physical and asks to be tested for acquired immunodeficiency syndrome (AIDS). Which test should the nurse explain will be used for the initial screening for AIDS? Enzyme-linked immunosorbent assay (ELISA) Upgrade to remove ads Only $3.99/month A nurse is caring for a client who is receiving total parenteral nutrition. Which responses indicate that the client is experiencing hyperglycemia? (Select all that apply.) -Polyuria -Polydipsia Tuberculosis is confirmed and isoniazid (INH), rifampin (Rifadin), and pyridoxine (vitamin B6) are prescribed for a client. The client says, "I've never had to take so many medicines for an infection before." What is the nurse's best reply? "This type of organism is difficult to destroy." A nurse in a rehabilitation center teaches clients with quadriplegia to use an adaptive wheelchair. Why is it important that the nurse provide this instruction? It is unlikely that the client will regain the ability to walk. A male client has discharge from his penis. Gonorrhea is suspected. To obtain a specimen for a culture, the nurse should: Swab the drainage directly from the urethra to obtain a specimen A nurse teaches the signs of organ rejection to a client who had a kidney transplant. What should be included in the education? Elevated blood pressure Which relationship does the nurse consider reflective of the relationship of naloxone (Narcan) to morphine sulfate? Protamine sulfate to parenteral heparin On the first postoperative day following a thyroidectomy, a client tolerates a full-fluid diet. This is changed to a soft diet on the second postoperative day. The client reports having a sore throat when swallowing. What should the nurse do first? Administer analgesics as prescribed before meals When caring for an anxious patient, the nurse should monitor for which signs of hyperventilation? Respiratory alkalosis A nurse obtains daily stool specimens for a client with chronic bowel inflammation. The nurse concludes that these stool examinations were prescribed to determine: Occult blood. Which clinical indicator is the nurse most likely to identify when assessing a client with a ruptured cerebral aneurysm? Sudden severe headache Upgrade to remove ads Only $3.99/month A nurse is evaluating a client's response to fluid replacement therapy. Which clinical finding indicates adequate tissue perfusion to vital organs? Urinary output of 30 mL in an hour In response to a client's question, the nurse explains the difference between partial-thickness (seconddegree) burns and full-thickness (third-degree) burns. What information about partial-thickness burns should the nurse include in the discussion? They are painful, reddened, and have blisters A client with acute kidney failure is to receive peritoneal dialysis and asks why the procedure is necessary. The nurse's best response is, "It: Helps perform some of the work usually done by the kidneys." A client has a closed chest drainage system in place. To determine the amount of chest tube drainage, the nurse should: Refer to the date and time markings on the outside of the collection chamber A farmer seeks medical care for a large crusty patch of skin on the cheek. The client states that even after using different remedies, it still bleeds easily and has not gotten better. From the client's history, the nurse suspects skin cancer because the major precipitating factor associated with skin cancer is: Exposure to radiation A nurse determines that a client in the acute phase of burns has eaten only a small portion of each meal. Considering this finding, the nurse should assess the client for: Prolonged wound healing A client has had a total gastrectomy. What should the nurse include in the discharge teaching? Injections of vitamin B12 for life. A client with extensive bone and soft tissue injuries to the right leg is on bed rest. When positioning the client, the nurse should: Elevate the entire right leg with pillows, keeping the foot higher than the knee A nurse is caring for a client with a new colostomy. Which client outcome is most important for achievement of long-range goals associated with adjusting to a new colostomy? Readiness to accept an altered body function On the third postoperative day after a subtotal thyroidectomy for a tumor, a client complains of a "funny, jittery feeling." On the basis of this statement, the nurse's best action is to: est for Chvostek's and Trousseau's signs and notify the health care provider of the complaints Upgrade to remove ads Only $3.99/month After a transurethral vaporization of the prostate, the client returns to the unit with an indwelling urinary catheter and a continuous bladder irrigation. The client puts the call light on to report the need to urinate. What should the nurse do first? Assess that the tubing attached to the collection bag is patent A client who is receiving methotrexate for acute lymphocytic leukemia (ALL) develops a temperature of 101° F. The nurse notifies the health care provider. Aspirin 650 mg every four hours as needed for temperature equal to or greater than 101° F is prescribed. What should the nurse do regarding this prescription? Express concern about the type of antipyretic prescribed. A nurse is caring for a client who is scheduled to have an abdominal perineal resection for colorectal cancer. A type and cross match is done because of a concern about blood loss. The client has type Bnegative blood. The blood type that can be used for this client is: B negative The nurse is creating a dietary plan for a client with cholecystitis who has been placed on a modified diet. What would be appropriate to include in the dietary plan? Decreased fat intake to avoid stimulation of the cholecystokinin mechanism for bile release A client is admitted to the hospital with numbness of the hands and feet, which has progressed upward and now involves the arms, legs, and lower trunk. The client tells the nurse that approximately two weeks ago, the client experienced 48 hours of chills, fever, and upper respiratory congestion. A tentative diagnosis of Guillain-Barré syndrome is made. The nurse assesses for what major clinical manifestations of the syndrome? Paresthesias and paralysis Immediately after a liver biopsy, a client is placed onto the right side. The nurse explains that the rationale for this positioning is to: Compress blood vessels to prevent bleeding A client is cautioned to avoid vitamin D toxicity while increasing protein intake. Which nutrient selected by the client indicates to the nurse that the dietary teaching is understood? Tofu A client just has returned from the postanesthesia care unit after having a laparotomy. Which sign or symptom indicates to the nurse that peristalsis has begun to return? Borborygmi are auscultated A client who is scheduled for a bowel resection is to receive antibiotics preoperatively. The nurse teaches the client that the purpose of the antibiotics is to help: Eliminate bacteria from the gastrointestinal (GI) tract After sustaining multiple internal injuries when hit by a motor vehicle, a client has a sudden drop in blood pressure to 80/60 mm Hg. What does the nurse determine probably caused this response? Reduction in circulating blood volume. Upgrade to remove ads Only $3.99/month A nurse completes an admission assessment on a client who is diagnosed with myasthenia gravis. Which clinical finding is the nurse most likely to identify? Difficulty swallowing saliva A client has a permanent sigmoid colostomy as a result of cancer of the rectum. The primary health care provider prescribes daily colostomy irrigations. The nurse explains that the primary purpose of these irrigations is to: Establish a regular elimination schedule A client is experiencing diplopia, ptosis, and mild dysphagia. Myasthenia gravis is diagnosed and an anticholinergic medication is prescribed. The nurse is planning care with the client and spouse. What instruction is the priority? Take the medication according to a specific schedule The nurse is providing postoperative care eight hours after a client had a total cystectomy and the formation of an ileal conduit. What assessment finding should be reported immediately? Dusky-colored stoma A child with a congenital heart defect has a cardiac catheterization. What is an essential element of nursing care after this procedure? Monitoring the extremity distal to the insertion site A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who develops a pneumothorax and has a chest tube inserted. What is the primary purpose of the chest tube? Restores negative pressure in the pleural space Potassium supplements are prescribed for a client receiving diuretic therapy. What client statement indicates that the teaching about potassium supplements is understood? I will report any abdominal distress." A client is hospitalized with a diagnosis of emphysema. The nurse provides teaching and should begin with which aspect of care? The disease process and breathing exercises A nurse is reviewing the laboratory results of and collecting a health history from a client with a diagnosis of colitis. Which common clinical manifestation of colitis should the nurse expect? Weight loss A nurse is caring for a client with a hiatal hernia. Which risk factor is associated most commonly with this diagnosis? Obesity A client with rheumatoid arthritis is scheduled to participate in an exercise program that is established at the extended care facility where the client resides. The nurse evaluates that the client understands the purpose of the program when the client states: After I eat breakfast, I do one set of exercises slowly, and then I space the rest of them throughout the day." Six hours after major abdominal surgery, a client complains of severe abdominal pain and feeling faint. The nurse identifies a thready, rapid pulse. The nurse checks the Physiological Aspects of Care record and determines that the client can receive another injection of pain medication in an hour. What is the most appropriate action by the nurse? Call the health care provider and report the client's symptoms. A client with a history of seizures is admitted with a partial occlusion of the left common carotid artery. The client has been taking phenytoin (Dilantin) for 10 years. When planning care for this client, what should the nurse do first? Obtain a history of seizure type and incidence. A nurse is providing discharge instructions for a client with angina who has a prescription for sublingual nitroglycerin tablets. The nurse should teach the client that the nitroglycerin sublingual tablets have lost their potency when: The tablets are more than three months old. A nurse is preparing a teaching plan for a client with a history of cholelithiasis. Which information about why the ingestion of fatty foods will cause discomfort should the nurse include in the teaching plan? Bile flow into the intestine is obstructed. Some clients self-prescribe over-the-counter glucosamine to help relieve joint pain and stiffness. Which condition should the nurse identify as a reason for a client to reconsider taking this medication? Diabetes mellitus A health care provider prescribes a sigmoidoscopy for one client and a barium enema for another client. What is a nursing responsibility common to preparing both of these clients for these procedures? Ensuring an understanding of the procedure The health care provider prescribes isosorbide dinitrate (Isordil) 10 mg as needed three times a day and a nitroglycerin transdermal disk once a day for a client with chronic angina pectoris. The client asks the nurse why the isosorbide dinitrate is prescribed. The nurse's best response is, "The isosorbide dinitrate: Allows more oxygen to get to heart tissue. Which statement by a client who is scheduled for bariatric surgery indicates to the nurse that further preoperative teaching is necessary? I'm going to have a figure like a model in about a year." A client who is complaining of severe midsternal pain is brought to the emergency department. The client is diagnosed with a myocardial infarction. Which drug can the nurse expect to be prescribed to control this client's pain? Morphine sulfate (MS Contin) Before a client with syphilis can be treated, what should be determined? Existence of allergies An older adult client states, "I walk 2 miles a day for exercise, but now that the weather is hot, I am worried about becoming dehydrated." What should the nurse teach the client? Fluids should be increased if the urine is getting darker. Before administering preoperative medication to a client, the nurse plans to: Verify the consent A client is admitted to the hospital for a total hip replacement. The nurse is planning preoperative teaching about the nursing care to be delivered during the immediate postoperative period. Which is the most important factor that the nurse should focus on regarding immediate postoperative care? Abducting the operative hip A client with a parotid tumor and enlarged lymph nodes in the neck is undergoing radiation therapy on an outpatient basis. For what physiological response to the radiation should the nurse assess the client during the return visit to the radiology department? Dysphagia A client is admitted to the hospital with jaundiced skin and acute abdominal pain. What is the nurse's most therapeutic response when the client refuses all visitors? Listen to the client's fears Each year, a client takes many trips to other countries. The client reports leg swelling during the long flights. The nurse should advise the client to, during the flights: Walk around at least every hour A client has a new colostomy. The nurse has provided teaching related to when the client should irrigate the colostomy. Which client statement indicates correct understanding of the teaching? "I plan to irrigate it in the late morning, the same time I had a bowel movement every day before I had my surgery." A nurse is administering oxygen to a client with chest pain who is restless. What method of oxygen administration will most likely prevent a further increase in the client's anxiety level? Cannula A client has chronic obstructive pulmonary disease (COPD). To decrease the risk of CO2 intoxication (CO2 narcosis), the nurse should: Administer oxygen at a low concentration to maintain respiratory drive What should the nurse assess to determine if a client is experiencing the therapeutic effect of valsartan (Diovan)? Blood pressure