HESI RN MEDICAL SURGICAL EXAM Questions Answers

HESI RN MEDICAL SURGICAL EXAM Questions Answers & Rationales The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is very restless and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which intervention should the nurse implement first? A. Measure the urine specific gravity. B. Obtain IV fluids for infusion per protocol. C. Prepare for insertion of a central venous catheter. D. Auscultate the client's breath sounds. B The client is at risk for hypovolemic shock because of the postoperative status and is exhibiting early signs of shock. A priority intervention is the initiation of IV fluids (B) to restore tissue perfusion. (A, C, and D) are all important interventions, but are of less priority than (B). During a health fair, a male client with emphysema tells the nurse that he fatigues easily. Assessment reveals marked clubbing of the fingernails and an increased anteroposterior chest diameter. Which instruction is best to provide the client? A. "Pace your activities and schedule rest periods." B. "Increase the amount of oxygen you use at night." C. "Obtain medical evaluation for antibiotic therapy." D. "Reduce your intake of fluids containing caffeine." A Manifestations of emphysema include an increase in AP diameter (referred to as a barrel chest), nail bed clubbing, and fatigue. The nurse can provide instructions to promote energy management, such as pacing activities and scheduling rest periods (A). (B) may result in a decreased drive to breathe. The client is not exhibiting any symptoms of infection, so (C) is not necessary. (D) is less beneficial than (A). During the change of shift report, the charge nurse reviews the infusions being received by clients on the oncology unit. The client receiving which infusion should be assessed first? A. Continuous IV infusion of magnesium B. One-time infusion of albumin C. Continuous epidural infusion of morphine D. Intermittent infusion of IV vancomycin C All four of these clients have the potential to have significant complications. The client with the morphine epidural infusion (C) is at highest risk for respiratory depression and should be assessed first. (A) can cause hypotension. The client receiving (B) is at lowest risk for serious complications. Although (D) can cause nephrotoxicity and phlebitis, these problems are not as immediately life threatening as (C). The nurse is planning care for a client with diabetes mellitus who has gangrene of the toes to the midfoot. Which goal should be included in this client's plan of care? A. Restore skin integrity. B. Prevent infection. C. Promote healing. D. Improve nutrition. B The prevention of infection is a priority goal for this client (B). Gangrene is the result of necrosis (tissue death). If infection develops, there is insufficient circulation to fight the infection and the infection can result in osteomyelitis or sepsis. Because tissue death has already occurred, (A and C) are unattainable goals. (D) is important but of less priority than (B). The nurse is conducting an osteoporosis screening clinic at a health fair. What information should the nurse provide to individuals who are at risk for osteoporosis? (Select all that apply.) A. Encourage alcohol and smoking cessation. B. Suggest supplementing diet with vitamin E. C. Promote regular weight-bearing exercises. D. Implement a home safety plan to prevent falls. E. Propose a regular sleep pattern of 8 hours nightly. A, C, D (A, C, and D) are factors that decrease the risk for developing osteoporosis. Vitamin D and calcium are important supplements to aid in the decrease of bone loss (B). Regular sleep patterns are important to overall health but are not identified with a decreasing risk for osteoporosis (E). An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that this client's tongue is somewhat cracked and his eyeballs appear sunken into his head. Which nursing intervention is indicated? A.Help the client determine ways to increase his fluid intake. B.Obtain an appointment for the client to have an eye examination. C.Instruct the client to use oxygen at night and increase the humidification. D.Schedule the client for tests to determine his sensitivity to cat hair. A Clients with COPD should ingest 3 L of fluids daily but may experience a fluid deficit because of shortness of breath. The nurse should suggest creative methods to increase the intake of fluids (A), such as having fruit juices in disposable containers readily available. (B) is not indicated. Humidified oxygen will not effectively treat the client's fluid deficit, and there is no indication that the client needs supplemental oxygen at night (C). These symptoms are not indicative of (D) and may unnecessarily upset the client, who depends on his pet for socialization. The nurse is assessing a client who presents with jaundice. Which assessment finding is most important for the nurse to follow up? A.Urine specific gravity of 1.03 B.Frothy, tea-colored urine C.Clay-colored stools D.Elevated serum amylase and lipase levels D Obstructive cholelithiasis and alcoholism are the two major causes of pancreatitis, and elevated serum amylase and lipase levels (D) indicate pancreatic injury. (A) is a normal finding. (B and C) are expected findings related to jaundice. Which content about self-care should the nurse include in the teaching plan of a female client who has genital herpes? (Select all that apply.) A.Encourage annual physical and Pap smear. B.Take antiviral medication as prescribed. C.Use condoms to avoid transmission to others. D.Warm sitz baths may relieve itching. E.Use Nystatin suppositories to control itching. F.Use a douche with weak vinegar solution to decrease itching. A, B, C, D The nurse should include (A, B, C, and D) in the teaching plan of a female client with genital herpes. (E) is specific for Candida infections, and (F) is used to treat Trichomonas. The nurse is interviewing a client who is taking interferon-alfa-2a (Roferon-A) and ribavirin (Virazole) combination therapy for hepatitis C. The client reports experiencing overwhelming feelings of depression. Which action should the nurse implement first? A.Recommend mental health counseling. B.Review the medication actions and interactions. C.Assess for the client's daily activity level. D.Provide information regarding a support group. B Interferon-alfa-2a and ribavirin combination therapy can cause severe depression (B); therefore, it is most important for the nurse to review the medication effects and report these to the health care provider. (A, C, and D) might be implemented after the physiologic aspects of the situation have been assessed. A client in the emergency department is bleeding profusely from a gunshot wound to the abdomen. In what position should the nurse immediately place the client to promote maintenance of the client's blood pressure above a systolic pressure of 90 mm Hg? A.Place the client in a 45-degree Trendelenburg position to promote cerebral blood flow. B.Turn the client prone to place pressure on the abdominal wound to help staunch the bleeding. C.Maintain the client in a supine position to reduce diaphragmatic pressure and visualize the wound. D.Put the client on the right side to apply pressure to the liver and spleen to stop hemorrhaging. C Placing the client in a supine position (C) reduces diaphragmatic pressure, thereby enhancing oxygenation, and allows for visualization of the abdominal wound. (A) compromises diaphragmatic expansion and inhibits pressoreceptor activity. (B) places the client at risk of evisceration of the abdominal wound and increased bleeding. (D) will not stop internal bleeding in the liver and spleen caused by the gunshot wound. The nurse assesses a client who has been prescribed furosemide (Lasix) for cardiac disease. Which electrocardiographic change would be a concern for a client taking a diuretic? A.Tall, spiked T waves B.A prolonged QT interval C.A widening QRS complex D.Presence of a U wave D A U wave (D) is a positive deflection following the T wave and is often present with hypokalemia (low potassium level). (A, B, and C) are all signs of hyperkalemia. When a nurse assesses a client receiving total parenteral nutrition (TPN), which laboratory value is most important for the nurse to monitor regularly? A.Albumin B.Calcium C.Glucose D.Alkaline phosphatase C TPN solutions contain high concentrations of glucose, so the blood glucose level is often monitored as often as q6h because of the risk for hyperglycemia (C). (A) is monitored periodically because an increase in the albumin level, a serum protein, is generally a desired effect of TPN. (B) may be added to TPN solutions, but calcium imbalances are not generally a risk during TPN administration. (D) may be decreased in the client with malnutrition who receives TPN, but abnormal values, reflecting liver or bone disorders, are not a common complication of TPN administration. Upgrade to remove ads Only $3.99/month A 62-year-old woman who lives alone tripped on a rug in her home and fractured her hip. Which predisposing factor most likely contributed to the fracture in the proximal end of her femur? A.Failing eyesight resulting in an unsafe environment B.Renal osteodystrophy resulting from chronic kidney disease (CKD) C.Osteoporosis resulting from declining hormone levels D.Cerebral vessel changes causing transient ischemic attacks C The most common cause of a fractured hip in older women is osteoporosis, resulting from reduced calcium in the bones as a result of hormonal changes in the perimenopausal years (C). (A) may or may not have contributed to the accident, but eye changes were not involved in promoting the hip fracture. (B) is not a common condition of older people but is associated with CKD. Although (D) may result in transient ischemic attacks (TIAs) or stroke, it will not result in fragility of the bones, as does osteoporosis. The nurse receives the client's next scheduled bag of TPN labeled with the additive NPH insulin. Which action should the nurse implement? A.Hang the solution at the current rate. B.Refrigerate the solution until needed. C.Prepare the solution with new tubing. D.Return the solution to the pharmacy. D Only regular insulin is administered by the IV route, so the TPN solution containing NPH insulin should be returned to the pharmacy (D). (A, B, and C) are not indicated because the solution should not be administered. A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff? A.Immediately after feeding B.Just prior to tube feeding C.Continuous inflation is required D.Inflation is not required B The cuff should be inflated before the feeding to block the trachea and prevent food from entering (B) if oral feedings are started while a cuffed tracheostomy tube is in place. It should remain inflated throughout the feeding to prevent aspiration of food into the respiratory system. (A and D) place the client at risk for aspiration. (C) places the client at risk for tracheal wall necrosis. A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid ventricular response. Based on this finding, the nurse anticipates assisting the physician with which treatment? A.Administer lidocaine,75 mg intravenous push. B.Perform synchronized cardioversion. C.Defibrillate the client as soon as possible. D.Administer atropine, 0.4 mg intravenous push. B With uncontrolled atrial fibrillation, the treatment of choice is synchronized cardioversion (B) to convert the cardiac rhythm back to normal sinus rhythm. (A) is a medication used for ventricular dysrhythmias. (C) is not for a client with atrial fibrillation; it is reserved for clients with life-threatening dysrhythmias, such as ventricular fibrillation and unstable ventricular tachycardia. (D) is the drug of choice in symptomatic sinus bradycardia, not atrial fibrillation. A 63-year-old client with type 2 diabetes mellitus is admitted for treatment of an ulcer on the heel of the left foot that has not healed with wound care. The nurse observes that the entire left foot is darker in color than the right foot. Which additional symptom should the nurse expect to find? A.Pedal pulses will be weak or absent in the left foot. B.The client will state that the left foot is usually warm. C.Flexion and extension of the left foot will be limited. D.Capillary refill of the client's left toes will be brisk. A Symptoms associated with decreased blood supply are weak or absent pedal and tibial pulses (A). The client with diabetes experiences vascular scarring as a result of atherosclerotic changes in the peripheral vessels. This results in compromised perfusion to the dependent extremities, which further delays wound healing in the affected foot. Although flexion and extension may be limited (C), depending on the degree of damage, this is not always the case. (B and D) are signs of adequate perfusion of the foot, which would not be expected in this client. A client with cirrhosis develops increasing pedal edema and ascites. Which dietary modification is most important for the nurse to teach this client? A.Avoid high-carbohydrate foods. B.Decrease intake of fat-soluble vitamins. C.Decrease caloric intake. D.Restrict salt and fluid intake. D Salt and fluid restrictions are the first dietary modifications for a client who is retaining fluid as manifested by edema and ascites (D). (A, B, and C) will not affect fluid retention. During report, the nurse learns that a client with tumor lysis syndrome is receiving an IV infusion containing insulin. Which assessment should the nurse complete first? A.Review the client's history for diabetes mellitus. B.Observe the extremity distal to the IV site. C.Monitor the client's serum potassium and blood glucose levels. D.Evaluate the client's oxygen saturation and breath sounds. C Clients with tumor lysis syndrome may experience hyperkalemia, requiring the addition of insulin to the IV solution to reduce the serum potassium level. It is most important for the nurse to monitor the client's serum potassium and blood glucose levels to ensure that they are not at dangerous levels (C). (A, B, and D) provide valuable assessment data but are of less priority than (C). A resident in a long-term care facility is diagnosed with hepatitis B. Which intervention should the nurse implement with the staff caring for this client? A.Determine if all employees have had the hepatitis B vaccine series. B.Explain that this type of hepatitis can be transmitted when feeding the client. C.Assure the employees that they cannot contract hepatitis B when providing direct care. D.Tell the employees that wearing gloves and a gown are required when providing care. A Hepatitis B vaccine should be administered to all health care providers (A). Hepatitis A (not hepatitis B) can be transmitted by fecal-oral contamination (B). There is a chance that staff could contract hepatitis B if exposed to the client's blood and/or body fluids; therefore, (C) is incorrect. There is no need to wear gloves and gowns except with blood or body fluid contact (D). The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours after chest tube insertion for hemothorax. What is the best initial action for the nurse to take? A.Document this expected decrease in drainage. B.Clamp the chest tube while assessing for air leaks. C.Milk the tube to remove any excessive blood clot buildup. D.Assess for kinks or dependent loops in the tubing. D The least invasive nursing action should be performed first to determine why the drainage has diminished (D). (A) is completed after assessing for any problems causing the decrease in drainage. (B) is no longer considered standard protocol because the increase in pressure may be harmful to the client. (C) is an appropriate nursing action after the tube has been assessed for kinks or dependent loops. The nurse notes that a client who is scheduled for surgery the next morning has an elevated blood urea nitrogen (BUN) level. Which condition is most likely to have contributed to this finding? A.Myocardial infarction 2 months ago B.Anorexia and vomiting for the past 2 days C.Recently diagnosed type 2 diabetes mellitus D.Skeletal traction for a right hip fracture B The blood urea nitrogen (BUN) level indicates the effectiveness of the kidneys in filtering waste from the blood. Dehydration, which could be caused by vomiting, would cause an increased the BUN level (B). (A) would affect serum enzyme levels, not the BUN level. (C) would primarily affect the blood glucose level; renal failure that could increase the BUN level would be unlikely in a client newly diagnosed with type 2 diabetes. Effects of (D) might affect the complete blood count (CBC) but would not directly increase the BUN level. Upgrade to remove ads Only $3.99/month The nurse is reviewing routine medications taken by a client with chronic angle closure glaucoma. Which medication prescription should the nurse question? A.Antianginal with a therapeutic effect of vasodilation B.Anticholinergic with a side effect of pupillary dilation C.Antihistamine with a side effect of sedation D.Corticosteroid with a side effect of hyperglycemia B Clients with angle-closure glaucoma should not take medications that dilate the pupil (B) because this can precipitate acute and severely increased intraocular pressure. (A, C, and D) do not cause increased intracranial pressure, which is the primary concern with angle-closure glaucoma. A 58-year-old client who has no health problems asks the nurse about receiving the pneumococcal vaccine (Pneumovax). Which statement given by the nurse would offer the client accurate information about this vaccine? A.The vaccine is given annually before the flu season to those older than 50 years. B.The immunization is administered once to older adults or those at risk for illness. C.The vaccine is for all ages and is given primarily to those persons traveling overseas to areas of infection. D.The vaccine will prevent the occurrence of pneumococcal pneumonia for up to 5 years. B It is usually recommended that persons older than 65 years and those with a history of chronic illness should receive the vaccine once in their lifetime (B). Some recommend receiving the vaccine at 50 years of age. The influenza vaccine is given once a year, not Pneumovax (A). Although the vaccine might be given to a person traveling overseas, that is not the main rationale for administering the vaccine (C). The vaccine is usually given once in a lifetime (D), but with immunosuppressed clients or clients with a history of pneumonia, revaccination is sometimes required. The nurse is assessing a male client with acute pancreatitis. Which finding requires the MOST immediate intervention by the nurse? A.The client's amylase level is three times higher than the normal level. B.While the nurse is taking the client's blood pressure, he has a carpal spasm. C.On a 1 to 10 scale, the client tells the nurse that his epigastric pain is at 7. D.The client states that he will continue to drink alcohol after going home. B A positive Trousseau sign (B) indicates hypocalcemia and always requires further assessment and intervention, regardless of the cause (40% to 75% of those with acute pancreatitis experience hypocalcemia, which can have serious, systemic effects). A key diagnostic finding of pancreatitis is serum amylase and lipase levels that are two to five times higher than the normal value (A). Severe boring pain is an expected symptom for this diagnosis (C), but dealing with the hypocalcemia is a priority over administering an analgesic. Long-term planning and teaching (D) do not have the same immediate importance as a positive Trousseau sign. During assessment of a client in the intensive care unit, the nurse notes that the client's ARE CLEAR UPON AUSCULTATION, but jugular vein distention and muffled heart sounds are present. Which intervention should the nurse implement? A.Prepare the client for a pericardial tap. B.Administer intravenous furosemide (Lasix). C.Assist the client to cough and breathe deeply. D.Instruct the client to restrict the oral fluid intake. A The client is exhibiting symptoms of cardiac tamponade, a collection of fluid in the pericardial sac that results in a reduction in cardiac output, which is a potentially fatal complication of pericarditis. Treatment for tamponade is a pericardial tap (A). Lasix IV is not indicated for treatment of pericarditis (B). Because the client's breath sounds are clear, (C) is not a priority. Fluids are frequently increased (D) in the initial treatment of tamponade to compensate for the decrease in cardiac output, but this is not the same priority as (A). After attending a class on reducing cancer risk factors, a client selects bran flakes with 2% milk and orange slices from a breakfast menu. In evaluating the client's learning, the nurse affirms that the client has made good choices and makes what additional recommendation? A.Switch to skim milk. B.Switch to orange juice. C.Add a source of protein. D.Add herbal tea. A Dietary recommendations to reduce cancer risk include reduced consumption of fats, with increased consumption of fruits, vegetables, and fiber. (A) promotes reduced fat consumption. Orange slices provide more fiber than orange juice (B, C, and D) are not standard recommendations for reducing cancer risk. A client diagnosed with angina pectoris complains of chest pain while ambulating in the hallway. Which action should the nurse implement first? A.Support the client to a sitting position. B.Ask the client to walk slowly back to the room. C.Administer a sublingual nitroglycerin tablet. D.Provide oxygen via nasal cannula. A The nurse should safely assist the client to a resting position (A) and then perform (C and D). The client must cease all activity immediately, which will decrease the oxygen requirement of the myocardial muscle. After these interventions are implemented, the client can be escorted back to the room via wheelchair or stretcher (B). A client is diagnosed with an acute small bowel obstruction. Which assessment finding requires the most immediate intervention by the nurse? A.Fever of 102° F B.Blood pressure of 150/90 mm Hg C.Abdominal cramping D.Dry mucous membranes A A sudden increase in temperature is an indicator of peritonitis. The nurse should notify the health care provider immediately (A). (B, C, and D) are also findings that require intervention by the nurse, but are of less priority than (A). (B) may indicate a hypertensive condition but is not as acute a condition as peritonitis. (C) is an expected finding in clients with small bowel obstruction and may require medication. (D) indicates probable fluid volume deficit, which requires fluid volume replacement. A tornado warning alarm has been activated at the local hospital. Which action should the charge nurse working on a surgical unit implement first? A.Instruct the nursing staff to close all window blinds and curtains in clients' rooms. B.Move clients and visitors into the hallways and close all doors to clients' rooms. C.Visually confirm the location of the tornado by checking the windows on the unit. D.Assist all visitors with evacuation down the stairs in a calm and orderly manner. B In the event of a tornado, all persons should be moved into the hallways, away from windows, to prevent flying debris from causing injury (B). Although (A) may help decrease the amount of flying debris, it is not safe to leave clients in rooms with closed blinds; (B) is a higher priority at this time. Hospital staff should stay away from windows to avoid injury and should focus on client evacuation into hallways rather than (C). (D) is not the first action that should be taken. A client with alcohol-related liver disease is admitted to the unit. Which prescription should the nurse call the health care provider about for reverification for this client? A.Vitamin K1 (AquaMEPHYTON), 5 mg IM daily B.High-calorie, low-sodium diet C.Fluid restriction to 1500 mL/day D.Pentobarbital (Nembutal sodium) at bedtime for rest D Sedatives such as Nembutal (D) are contraindicated for clients with liver damage and can have dangerous consequences. (A) is often prescribed because the normal clotting mechanism is damaged. (B) is needed to help restore energy to the debilitated client. Sodium is often restricted because of edema. Fluids are restricted (C) to decrease ascites, which often accompanies cirrhosis, particularly in the later stages of the disease. A female client who received a nephrotoxic drug is admitted with acute renal failure and asks the nurse if she will need dialysis for the rest of her life. Which pathophysiologic consequence should the nurse explain that supports the need for temporary dialysis until acute tubular necrosis subsides? A.Azotemia B.Oliguria C.Hyperkalemia D.Nephron obstruction D CKD is characterized by progressive and irreversible destruction of nephrons, frequently caused by hypertension and diabetes mellitus. Nephrotoxins cause acute tubular necrosis, a reversible acute renal failure, which creates renal tubular obstruction from endothelial cells that are sloughed or become edematous. The obstruction of urine flow will resolve (D) with the return of an adequate glomerular filtration rate and, when it does, dialysis will no longer be needed. (A, B, and C) are manifestations seen in the acute and chronic forms of kidney disease. Upgrade to remove ads Only $3.99/month Which instruction should the nurse teach a female client about the prevention of toxic shock syndrome? A."Get immunization against human papillomavirus (HPV)." B."Change your tampon frequently." C."Empty your bladder after intercourse." D."Obtain a yearly flu vaccination." B Certain strains of Staphylococcus aureus produce a toxin that can enter the bloodstream through the vaginal mucosa. Changing the tampon frequently (B) reduces the exposure to these toxins, which are the primary cause of toxic shock syndrome. (A) helps prevent cervical cancer, not toxic shock syndrome. (C) can lessen the incidence of urinary tract infection. (D) can help prevent some individuals from contracting the flu and pneumonia, but no relationship to toxic shock syndrome has been proven. A postoperative client receives a Schedule II opioid analgesic for pain. Which assessment finding requires the most immediate intervention by the nurse? A.Hypoactive bowel sounds with abdominal distention B.Client reports continued pain of 8 on a 10-point scale C.Respiratory rate of 12 breaths/min, with O2 saturation of 85% D.Client reports nausea after receiving the medication C Administration of a Schedule II opioid analgesic can result in respiratory depression (C), which requires immediate intervention by the nurse to prevent respiratory arrest. (A, B, and D) require action by the nurse but are of less priority than (C). A client is being discharged following radioactive seed implantation for prostate cancer. What is the most important information that the nurse should provide to this client's family? A.Follow exposure precautions. B.Encourage regular meals. C.Collect all urine. D.Avoid touching the client. Clients being treated for prostate cancer with radioactive seed implants should be instructed regarding the amount of time and distance needed to prevent excessive exposure (A) that would pose a hazard to others. (B) is a good suggestion to promote adequate nutrition but is not as important as (A). (C) is unnecessary. Contact with the client (D) IS permitted but should be BRIEF to limit radiation exposure. An emaciated homeless client presents to the emergency department complaining of a productive cough, with blood-tinged sputum and night sweats. Which action is most important for the emergency department triage nurse to implement for this client? A.Initiate airborne infection precautions. B.Place a surgical mask on the client. C.Don an isolation gown and latex gloves. D.Start protective (reverse) isolation precautions. This client is exhibiting classic symptoms of tuberculosis (TB), and the client is from a high-risk population for TB. Therefore, airborne infection precautions (A), which are indicated for TB, should be used with this client. (B) is used with DROPLET precautions. There is no evidence that (C or D) would be warranted at this time. Which abnormal laboratory finding indicates that a client with diabetes needs further evaluation for diabetic nephropathy? A.Hypokalemia B.Microalbuminuria C.Elevated serum lipid levels D.Ketonuria B Microalbuminuria (B) is the earliest sign of diabetic nephropathy and indicates the need for follow-up evaluation. Hyperkalemia, not (A), is associated with end-stage renal disease caused by diabetic nephropathy. (C) may be elevated in end-stage renal disease. (D) may signal the onset of diabetic ketoacidosis (DKA). An older client is admitted with a diagnosis of bacterial pneumonia. Which symptom should the nurse report to the health care provider after assessing the client? A.Leukocytosis and febrile B.Polycythemia and crackles C.Pharyngitis and sputum production D.Confusion and tachycardia D The onset of pneumonia in the older client may be signaled by general deterioration, confusion, increased heart rate, and/or increased respiratory rate (D). (A, B, and C) are often absent in the older client with bacterial pneumonia. Which nursing action is necessary for the client with a flail chest? A.Withhold prescribed analgesic medications. B.Percuss the fractured rib area with light taps. C.Avoid implementing pulmonary suctioning. D.Encourage coughing and deep breathing. D Treatment of flail chest is focused on preventing atelectasis and related complications of compromised ventilation by encouraging coughing and deep breathing (D). This condition is typically diagnosed in clients with three or more rib fractures, resulting in paradoxic movement of a segment of the chest wall. (C) should not be avoided because suctioning is necessary to maintain pulmonary toilet in clients who require mechanical ventilation. (A) should not be withheld. (B) should not be applied because the fractures are clearly visible on the chest radiograph. When assigning clients on a medical-surgical floor to an RN and a PN, it is best for the charge nurse to assign which client to the PN? A.A young adult with bacterial meningitis with recent seizures B.An older adult client with pneumonia and viral meningitis C.A female client in isolation with meningococcal meningitis D.A male client 1 day postoperative after drainage of a brain abscess B The most stable client is (B). (A, C, and D) are all at high risk for increased intracranial pressure and require the expertise of the RN for assessment and management of care. When educating a client after a total laryngectomy, which instruction would be most important for the nurse to include in the discharge teaching? A.Recommend that the client carry suction equipment at all times. B.Instruct the client to have writing materials with him at all times. C.Tell the client to carry a medical alert card that explains his condition. D.Caution the client not to travel outside the United States alone. C Neck breathers carry a medical alert card (C) that notifies health care personnel of the need to use mouth to stoma breathing in the event of a cardiac arrest in this client. Mouth to mouth resuscitation will not establish a patent airway. (A and D) are not necessary. There are many alternative means of communication for clients who have had a laryngectomy; dependence on writing messages (B) is probably the least effective. A central venous catheter has been inserted via a jugular vein, and a radiograph has confirmed placement of the catheter. A prescription has been received for a medication STAT, but IV fluids have not yet been started. Which action should the nurse take prior to administering the prescribed medication? A.Assess for signs of jugular venous distention. B.Obtain the needed intravenous solution. C.Flush the line with heparinized solution. D.Flush the line with normal saline. D Medication can be administered via a central line without additional IV fluids. The line should first be flushed with a normal saline solution (D) to ensure patency. Insufficient evidence exists on the effectiveness of flushing catheters with heparin (C). (A) will not affect the decision to administer the medication and is not a priority. Administration of the medication STAT is of greater priority than (B). Upgrade to remove ads Only $3.99/month In caring for a client with acute diverticulitis, which assessment data warrants immediate nursing intervention? A.The client has a rigid hard abdomen and elevated WBC. B.The client has left lower quadrant pain and an elevated temperature. C.The client is refusing to eat any of the meal and is complaining of nausea. D.The client has not had a bowel movement in 2 days and has a soft abdomen. A A hard rigid abdomen and elevated WBC is indicative of peritonitis (A), which is a medical emergency and should be reported to the health care provider immediately. (B and C) are expected clinical manifestations of diverticulitis. (D) does not warrant immediate intervention. The nurse is giving preoperative instructions to a 14-year-old client scheduled for surgery to correct a spinal curvature. Which statement by the client best demonstrates that learning has taken place? A."I will read all the teaching booklets you gave me before surgery." B."I have had surgery before, so I know what to expect afterward." C."All the things people have told me will help me take care of my back." D."Let me show you the method of turning I will use after surgery." D The outcome of learning is best demonstrated when the client not only verbalizes an understanding but can also provide a return demonstration (D). A 14-year-old client may or may not follow through with (A), and there is no measurement of learning. (B) may help the client understand the surgical process, but the type of surgery may have been very different, with differing postoperative care. In (C), the client may be saying what the nurse wants to hear without expressing any real understanding of what to do after surgery. The nurse on a medical surgical unit is receiving a client from the postanesthesia care unit (PACU) with a Penrose drain. Before choosing a room for this client, which information is most important for the nurse to obtain? A.If suctioning will be needed for drainage of the wound B.If the family would prefer a private or semiprivate room C.If the client also has a Hemovac in place D.If the client's wound is infected D The fact that the client has a Penrose drain should alert the nurse to the possibility that the surgical wound is infected (D). Penrose drains provide a sinus tract or opening and are often used to provide drainage of an abscess. To avoid contamination of another postoperative client, it is most important to place any client with an infected wound in a private room. A Penrose drain does not require (A). Although (B) is helpful information, it does not have the priority of (D). A Hemovac (C) is used to drain fluid from a dead space and is not a determinant for the room assignment. The nurse is completing an admission interview for a client with Parkinson's disease. Which question will provide additional information about manifestations that the client is likely to experience? A."Have you ever experienced any paralysis of your arms or legs?" B."Do you have frequent blackout spells?" C."Have you ever been frozen in one spot, unable to move?" D."Do you have headaches, especially ones with throbbing pain?" C Clients with Parkinson's disease frequently experience difficulty in initiating, maintaining, and performing motor activities. They may even experience being rooted to the spot and unable to move (C). Parkinson's disease does not typically cause (A, B, or D). A hospitalized client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He begins to cough and produces a moderate amount of white sputum. Which action should the nurse take FIRST? A.Auscultate the client's breath sounds. B.Turn off the continuous feeding pump. C.Check placement of the nasogastric tube. D.Measure the amount of residual feeding. B A productive cough may indicate that the feeding has been aspirated. The nurse should first stop the feeding (B) to prevent further aspiration. (A, C, and D) should all be performed before restarting the tube feeding if no evidence of aspiration is present and the tube is in place. The nurse is caring for a critically ill client with cirrhosis of the liver who has a nasogastric tube draining bright red blood. The nurse notes that the client's serum hemoglobin and hematocrit levels are decreased. Which additional change in laboratory data should the nurse expect? A.Increased serum albumin level B.Decreased serum creatinine C.Decreased serum ammonia level D.Increased liver function test results C The breakdown of glutamine in the intestine and the increased activity of colonic bacteria from the digestion of proteins increase ammonia levels in clients with advanced liver disease, so removal of blood, a protein source, from the intestine results in a reduced level of ammonia (C). (A, B, and D) will not be significantly affected by the removal of blood. During the shift report, the charge nurse informs a nurse that she has been assigned to another unit for the day. The nurse begins to sigh deeply and tosses about her belongings as she prepares to leave, making it known that she is very unhappy about being floated to the other unit. What is the best immediate action for the charge nurse to take? A.Continue with the shift report and talk to the nurse about the incident at a later time. B.Ask the nurse to call the house supervisor to see if she must be reassigned. C.Stop the shift report and remind the nurse that all staff are floated equally. D.Inform the nurse that her behavior is disruptive to the rest of the staff. A Continuing with the shift report (A) is the best immediate action because it allows the nurse who was floated some cooling off time. At a later time (after the nurse has cooled off) the charge nurse should discuss the conduct of the nurse in private. (B) encourages the nurse to shirk the float assignment. (C) is disruptive. Reprimanding the nurse in front of the staff would increase the nurse's hostility, so the nurse should be counseled in private (D). The nurse is administering a nystatin suspension (Mycostatin) for stomatitis. Which instruction will the nurse provide to the client when administering this medication? A."Hold the medication in your mouth for a few minutes before swallowing it." B."Do not drink or eat milk products for 1 hour prior to taking this medication." C."Dilute the medication with juice to reduce the unpleasant taste and odor." D."Take the medication before meals to promote increased absorption." A Mycostatin is prescribed for fungal infections of the mouth. The client should swish the medication in the mouth for 2 minutes and then swallow (A). (B) does not affect administration of this medication. The medication should not be diluted because this will reduce its effectiveness (C). (D) is not necessary. Which condition should the nurse anticipate as a potential problem in a female client with a neurogenic bladder? A.Stress incontinence B.Infection C.Painless gross hematuria D.Peritonitis B Infection (B) is the major complication resulting from stasis of urine and subsequent catheterization. (A) is the involuntary loss of urine through an intact urethra as a result of a sudden increase in intraabdominal pressure. (C) is the most common symptom of bladder cancer. (D) is the most common and serious complication of peritoneal dialysis. A client is ready for discharge following the creation of an ileostomy. Which instruction should the nurse include in discharge teaching? A.Replace the stoma appliance every day. B.Use warm tap water to irrigate the ileostomy. C.Change the bag when the seal is broken. D.Measure and record the ileostomy output. C A seal must be maintained to prevent leakage of irritating liquid stool onto the skin (C). (A) is excessive and can cause skin irritation and breakdown. Ileostomies produce liquid fecal drainage, so (B) is not necessary. (D) is not needed. Upgrade to remove ads Only $3.99/month In assessing a client with an arteriovenous (AV) shunt who is scheduled for dialysis today, the nurse notes the ABSENCE of a thrill or bruit at the shunt site. What action should the nurse take? A.Advise the client that the shunt is intact and ready for dialysis as scheduled. B.Encourage the client to keep the shunt site elevated above the level of the heart. C.Notify the health care provider of the findings immediately. D.Flush the site at least once with a heparinized saline solution. C Absence of a thrill or bruit indicates that the shunt may be obstructed. The nurse should notify the health care provider (C) so that intervention can be initiated to restore function of the shunt. (A) is incorrect. (B) will not resolve the obstruction. An AV shunt is internal and cannot be flushed (D) without access using special needles. The nurse is preparing a 45-year-old client for discharge from a cancer center following ileostomy surgery for colon cancer. Which discharge goal should the nurse include in this client's discharge plan? A.Reduce the daily intake of animal fat to 10% of the diet within 6 weeks. B.Exhibit regular, soft-formed stool within 1 month. C.Demonstrate the irrigation procedure correctly within 1 week. D.Attend an ostomy support group within 2 weeks. D Attending a support group (D) will be beneficial to the client and should be encouraged because adaptation to the ostomy can be difficult. This goal is attainable and is measurable. (A) is not specifically related to ileostomy care. The client with an ileostomy will not be able to accomplish (B). (C) is not necessary. A client with hypertension has been receiving ramipril (Altace), 5 mg PO, daily for 2 weeks and is scheduled to receive a dose at 0900. At 0830, the client's blood pressure is 120/70 mm Hg. Which action should the nurse take? A.Administer the prescribed dose at the scheduled time. B.Hold the dose and contact the health care provider. C.Hold the dose and recheck the blood pressure in 1 hour. D.Check the health care provider's prescription to clarify dose. A The client's blood pressure is within normal limits, indicating that the ramipril, an antihypertensive, is having the desired effect and should be administered (A). (B and C) would be appropriate if the client's blood pressure was excessively low (<100 mm Hg systolic) or if the client were exhibiting signs of hypotension such as dizziness. This prescribed dose is within the normal dosage range, as defined by the manufacturer; therefore, (D) is not necessary. A client with type 2 diabetes takes metformin (Glucophage) daily. The client is scheduled for major surgery requiring general anesthesia the next day. The nurse anticipates which approach to manage the client's diabetes best while the client is NPO during the perioperative period? A.NPO except for metformin and regular snacks B.NPO except for oral antidiabetic agent C.Novolin N insulin subcutaneously twice daily D.Regular insulin subcutaneously per sliding scale D Regular insulin dosing based on the client's blood glucose levels (sliding scale) is the best method to achieve control of the client's blood glucose while the client is NPO and coping with the major stress of surgery (D). (A) increases the risk of vomiting and aspiration. (B and C) provide less precise control of the blood glucose level. The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which symptom of hyperglycemia is an OLDER adult most likely to exhibit? A.Polyuria B.Polydipsia C.Weight loss D.Infection D Signs and symptoms of hyperglycemia in older adults may include fatigue, infection (D), and evidence of neuropathy (e.g., sensory changes). The nurse needs to remember that classic signs and symptoms of hyperglycemia, such as (A, B, and C) and polyphagia, may be absent in older adults. The nurse teaches a client with type 2 diabetes nutritional strategies to decrease obesity. Which food item(s) chosen by the client INDICATES UNDERSTANDING of the teaching? (Select all that apply.) A.White bread B.Salmon C.Broccoli D.Whole milk E.Banana B, C, E (B, C, and E) provide fresh fruits, lean meats and fish, vegetables, whole grains, and low-fat dairy products. All are recommended by the American Diabetes Association (ADA) and are a part of the My Plate guidelines recommended by the U.S. Department of Agriculture (USDA). Whole milk (D) is high in fat and is not recommended by ADA. White bread is milled, a process that removes the essential nutrients. It should be avoided for weight loss and is a poor choice for the client with diabetes (A). A practical nurse (PN) tells the charge nurse in a long-term facility that she does not want to be assigned to one particular resident. She reports that the male client keeps insisting that she is his daughter and begs her to stay in his room. What is the best managerial decision? A.Notify the family that the resident will have to be discharged if his behavior does not improve. B.Notify administration of the PN's insubordination and need for counseling about her statements. C.Ask the PN what she has done to encourage the resident to believe that she is his daughter. D.Reassign the PN until the resident can be assessed more completely for reality orientation. D Temporary reassignment (D) is the best option until the resident can be examined and his medications reviewed. He may have worsening cerebral dysfunction from an infection or electrolyte imbalance. (A) is not the best option because the family cannot control the resident's actions. The administration may need to know about the situation, but not as a case of insubordination (B). Implying that the PN is somehow creating the situation is inappropriate until a further evaluation has been conducted (C). The nurse is preparing a teaching plan for a group of healthy adults. Which individual is most likely to maintain optimum health? A.A teacher whose blood glucose levels average 126 mg/dL daily with oral antidiabetic drugs B.An accountant whose blood pressure averages 140/96 mm Hg and who says he does not have time to exercise C.A stock broker whose total serum cholesterol level dropped to 290 mg/dL with diet modifications D.A recovering IV heroin user who contracted hepatitis more than 10 years ago A The diabetic teacher (A) has assumed responsibility for self-care, so among those listed, is the most likely to maintain optimum health. (B) has expressed a lack of interest in health promotion. (C) continues to demonstrate a high-risk cholesterol level despite a reported attempt at dietary modifications. Previous IV drug use and a history of hepatitis (D) make this individual a health risk despite the fact that the individual is in recovery. What is the most important nursing priority for a client who has been admitted for a possible kidney stone? A.Reducing dairy products in the diet B.Straining all urine C.Measuring intake and output D.Increasing fluid intake B Straining all urine (B) is the most important nursing action to take in this case. Encouraging fluid intake (D) is important for any client who may have a kidney stone, but is even more important to strain all urine. Straining urine will enable the nurse to determine when the kidney stone has been passed and may prevent the need for surgery. (C) is not the highest priority action. (A) is usually not recommended until the stone is obtained and the content of the stone is determined. Even then, dietary restrictions are controversial. A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which nursing intervention has the highest priority? A.Place the client on NPO status. B.Assess the client's temperature. C.Obtain a stool specimen. D.Administer IV fluids. A A client with acute severe diverticulitis is at risk for peritonitis and intestinal obstruction and should be made NPO (A) to reduce risk of intestinal rupture. (B, C, and D) are important but are less of a priority than (A), which is implemented to prevent a severe complication. The nurse includes frequent oral care in the plan of care for a client scheduled for an esophagogastrostomy for esophageal cancer. This intervention is included in the client's plan of care to address which nursing diagnosis? A.Fluid volume deficit B.Self-care deficit C.Risk for infection D.Impaired nutrition C The primary reason for performing frequent mouth care preoperatively is to reduce the risk of postoperative infection (C) because these clients may be regurgitating retained food particles, blood, or pus from the tumor. Meticulous oral care should be provided several times a day before surgery. Although oral care will be of benefit to the client who may also be experiencing (A, B, or D), these problems are not the primary reason for the provision of frequent oral care. A family member was taught to suction a client's tracheostomy prior to the client's discharge from the hospital. Which observation by the nurse indicates that the family member is capable of correctly performing the suctioning technique? A.Turns on the continuous wall suction to −190 mm Hg B.Inserts the catheter until resistance or coughing occurs C.Withdraws the catheter while maintaining suctioning D.Reclears the tracheostomy after suctioning the mouth B (B) indicates correct technique for performing suctioning. Suction pressure should be between −80 and −120 mm Hg, not −190 mm Hg (A). The catheter should be withdrawn 1 to 2 cm at a time with intermittent, not continuous, suction (C). (D) introduces pathogens unnecessarily into the tracheobronchial tree. A client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly treated at a community hemodialysis facility. Before his scheduled dialysis treatment, which electrolyte imbalance should the nurse anticipate? A.Hypophosphatemia B.Hypocalcemia C.Hyponatremia D.Hypokalemia B Hypocalcemia (B) develops in CKD because of chronic hyperphosphatemia, not (A). Increased phosphate levels cause the peripheral deposition of calcium and resistance to vitamin D absorption needed for calcium absorption. Prior to dialysis, the nurse would expect to find the client hypernatremic and hyperkalemic, not with (C or D).