HESI RN Medical Surgical

HESI RN Medical Surgical EXAM The nurse is assessing a clients laboratory values following the administration of chemotherapy. Which lab value leads the nurse to suspect that the client is experiencing tumor lysis syndrome? A. Hemoglobin of 10 g/dl B. Serum calcium of 5mg/dl C. Serum PTT of 10 seconds D. Oxygen saturation of 90% Answer: B TLS results in hyperkalemia, hypocalcemia, hyperuricemia, and hyperphosphatemia. A serum calcium level of 5 is low and so is an indicator of possible TLS. A client is admitted to the hospital with severe acute diverticulitis. Which assessment finding should the nurse expect this client to exhibit? A. Severe pain at McBurney's point and nausea. B. Lower left quadrant pain and a low grade fever. C. Abdominal pain and intermittent tenesmus. D. Exacerbations of severe diarrhea. Answer: B Left lower quadrant pain occurs with diverticulitis because the sigmoid colon is the most common area for diverticula and the inflammation of diverticula causes a low grade fever. A is indicative of appendicitis. C and D are indicitive of ulcerative colitis. A client is placed on a mechanical ventilator following a cerebral hemorrhage, and vecuronium bromide (Norcuron) 0.04 mg/kg q12 hours IV is prescribed. What is the priority nursing diagnosis for this client? A. Potential for injury related to impaired lung expansion. B. Impaired communication related to paralysis of skeletal muscles. C. High risk for infection related to increased intracranial pressure. D. Social isolation related to inability to communicate. Answer: B To increase the client's tolerance of endotracheal intubation and/or mechanical ventilation, a skeletalmuscle relaxant, such as vecuronium, is usually prescribed. Impaired communication is a serious outcome because the client cannot communicate his/her needs due to intubation and diaphragmatic paralysis caused by the drug. The nurse would be correct in withholding a dose of digoxin in a client with congestive heart failure without specific instrucions from the healthcare provider if the client's A. Serum potassium level is a 3 B. Blood pressure is 104/68 C. Serum digoxin level is 1.5 D. apical pulse is 68/min Answer: A Hypokalemia can precipitate digoxin toxicity in persons receiving digoxin which will increase the chance of dangerous dysrhythmias. The therapeutic range for digoxin is 0.8 to 2 ng/ml. The nurse should also hold the digoxin if the apical pulse is below 60/min. After the fourth dose of gentamicin sulfate (Garamycin) IV, the nurse plans to draw blood samples to determine peak and trough levels. When are the best times to draw these samples? A) 15 minutes before and 15 minutes after the next dose. B) One hour before and one hour after the next dose. C) 5 minutes before and 30 minutes after the next dose. D) 30 minutes before and 30 minutes after the next dose. Answer: C Peak drug serum levels are achieved 30 minutes after IV administration of aminoglycosides. The best time to draw a trough is the closest time to the next administration. In preparing a discharge plan for a 22-year-old male client diagnosed with Buerger's disease (thromboangiitis obliterans), which referral is most important? A. A twelve step recovery program. B. Smoking cessation program. C. Genetic counseling. D. Clinical nutritionist. Answer: B Buerger's disease is strongly related to smoking. The most effective means of controlling the symptoms and disease progression is through smoking cessation. Which symptoms should the nurse expect a client to exhibit who is known to have a pheochromocytoma? A) Numbness, tingling, and cramps in the extremities. B) Headache, diaphoresis, and palpitations. C) Cyanosis, fever, and classic signs of shock. D) Nausea, vomiting, and muscular weakness. Answer: B Pheochromocytoma is a catecholamine secreting tumor of the adrenal medulla and B is the typical triad of symptoms depending upon the relative proportions of epinephrine and norepinephrine secretion. A-hypoparathyroidism C- addisonian adrenal crisis D- hyperparathyroidism A middle-aged male client with diabetes continues to eat an abundance of foods that are high in sugar and fat. According to the Health Belief Model, which event is most likely to increase the client's willingness to become compliant with the prescribed diet? A) He visits his diabetic brother who just had surgery to amputate an infected foot. B) He is provided with the most current information about the dangers of untreated diabetes. C) He comments on the community service announcements about preventing complications associated with diabetes. D) His wife expresses a sincere willingness to prepare meals that are within his prescribed diet. Answer: A The loss of a limb by a family member will be the strongest call to action and is most likely to increase the perceived seriousness of the disease. The nurse is taking the history of a newly diagnosed Type 2 diabetic patient who is beginning treatment. Which subjective information is most important for the nurse to note? A. An allergy to sulfa drugs. B. Cessation of smoking three years ago. C. A history of obesity. D. Numbness in the soles of the feet. Answer: A An allergy to sulfa drugs may make the client unable to use some of the most common antihyperglycemic agents (sulfonylureas). The nurse needs to highlight this allergy for the healthcare provider. The nurse is assessing a client with a history of Parkinson's disease for the past five years. What symptoms would this client most likely exhibit? A. Numbness of the extremities, loss of balance, and visual disturbances. B. Shuffeling gait, masklike facial expressions, and tremors of the head. C. Extreme muscular weakness, easy fatigability, and ptosis. D. Loss of short-term memory, facial tics and grimaces, and constant writhing movements. Answer: B Common clinical features of Parkinsonism. A-symptoms of chorea C-myasthenia gravis D- multiple scelorisis The nurse is completing an admission interview and assessment on a client with a history of Parkinson's disease. Which question provides information relevant to the client's plan of care? A. "Have you ever experienced any paralysis of your arms or legs?" B. "Have you ever been frozen in one spot, unable to move?" C. "Do you have headaches, especially ones with throbbing pain?" D. "Have you ever sustained a severe head injury?" Answer: A 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. The nurse is completing an admission interview and assessment on a client with a history of Parkinson's disease. Which question provides information relevant to the client's plan of care? A. "Have you ever experienced any paralysis of your arms or legs?" B. "Have you ever been frozen in one spot, unable to move?" C. "Do you have headaches, especially ones with throbbing pain?" D. "Have you ever sustained a severe head injury?" Answer: B 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. What is the correct procedure for performing an opthalmoscopic examination on a client's right retnia? A. For optimum visualization, keep the opthalmoscope at least three inches from the client's eye. B. Set opthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's right eye. C. From a distance of 12 to 15 inches and slightly to the side, shine the light into the client's pupil. D. Instruct the client to look at the examiner's nose and not move his/her eyes during the exam. Answer: C The client should focus on a distant object behind the examiner who should stand 12 to 15 inches away and to the side of his/her line of vision. The examiner should hold the opthalmoscope firmly against his/her face and then direct it at the client's pupil. During lung assessment, the nurse places a stethoscope on a client's chest and instructs him/her to say "99" each time the chest is touched with the stethoscope. What should be the correct interpretation if the nurse hears the spoken words "99" very clearly through the stethoscope? A) This is a normal auscultatory finding. B) May indicate pneumothorax. C) May indicate pneumonia. D) May indicate severe emphysema. Answer: C Whispered pectoriloquy demonstrates hyper-resonance and helps to determine the clarity with which words are heard upon auscultation. Normally the spoken word is not well transmitted through the lung tissue, and is heard as a muffled or unclear transmission. Increased clarity of the spoken word is indicative of some sort of consolidation process (tumor, pneumonia) and is not a normal finding. When lung tissue is filled with more air than normal, the voice sounds are absent or very diminished. A client has taken steroids for 12 years to help manage chronic obstructive pulmonary disease (COPD). When making a home visit, which nursing function is of greatest importance to this client? Assess the client's A) pulse rate, both apically and radially. B) blood pressure, both standing and sitting. C) temperature. D) skin color and turgor. Answer: C It is very important to check the client's temperature. Infection is the most common factor precipitating respiratory distress. Clients with COPD who are on maintenance doses of corticosteriods are particularly predisposed to infection. While working in the emergency room, the nurse is exposed to a client with active tuberculosis. When should the nurse plan to obtain a tuberculin skin test? A) Immediately after the exposure. B) Within one week of the exposure. C) Four to six weeks after the exposure. D) Three months after the exposure. Answer: D A tuberculin skin test is effective 4 to 6 weeks after an exposure, so the individual with a known exposure should wait 4 to 6 weeks before having a tuberculin skin test. The nurse knows that the lab values sometimes vary for the older client. Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old male? A. Increased WBC, decreased RBC B. Decreased serum sodium, an increased urine specific gravity C. Increased serum billirubin, slightly increased liver enzymes. D. Increased protein in the urine, slightly increased serum glucose levels. Answer: D In older adults, the protien found in urine slightly rises probably as a result of kidney changes or subclinical urinary tract infections. The serum glucose increases slightly due to changes in the kidney. The specific gravity declines by age 80 from 1.032 to 1.024. HESI Evolve Website 11/20/2019 An elderly male client comes to the geriatric screening clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg which is warm to the touch and suspects it might be thrombophlebitis. Which type of pain should further confirm this suspicion? A) Pain in the calf awakening him from a sound sleep. B) Calf pain on exertion which stops when standing in one place. C) Pain in the calf upon exertion which is relieved by rest and elevating the extremity. D) Pain upon arising in the morning which is relieved after some stretching and exercise. Answer: C Thrombophelbitis pain is relieved by rest and elevation of the extremity. It typically occurs with exercise at the site of the thrombus, and is aggravated by placing the extremity in a dependent position, such as standing in one place. An elderly patient is admitted with a diagnosis of bacterial pneumonia. The nurse's assessment of the client will most likely reveal which sign/symptom? A. Polycythemia and crackles. B. Pharyngitis and sputum production. C. Leukocytes and febrile. D. Confusion and tachycardia. Answer: D The onset of pneumonia in the elderly may be signaled by general deterioration, confusion, increased heart rate or increased respiratory rate. The nurse is assessing a client with bacterial menengitis. Which assessment finding indicates the client may have developed septic emboli? A. Cyanosis of the fingertips B. Bradycardia and bradypnea C. Presence of S3 and S4 heart sounds D. 3+ piting edema in the lower extremities Answer: A Septic emboli secondary to bacterial meningitis commonly lodge in the small arterioles of the extremities, causing a decrease in circulation to the hands which may lead to gangrene. The healthcare provider prescribes aluminum and magnesium hydroxide (Maalox), 1 Tab PO PRN, for a client with chronic kidney disease (CKD) who is complaining of indigestion. What intervention should the nurse implement? A. Instruct the client to swallow the tab whole. B. Question the healthcare providers prescription. C. Administer 30 minutes before eating D. Evaluate the effectiveness 1 hour after administration Answer: B Magnesium agents are not usually used for clients with CKD due to the risk of hypermagnesemia. A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which statement by the nurse provides the most accurate explanation for use of the splints? A) Prevention of deformities. B) Avoidance of joint trauma. C) Relief of joint inflammation. D) Improvement in joint strength. Answer: A Splints may be used at night by clients with rheumatoid arthritis to prevent deformities caused by muscle spasms and contractures. Only $3.99/month The nurse is assessing a client who smokes cigarettes and has been diagnosed with emphysema. Which finding would the nurse expect this client to exhibit? A. An absence of sputum B. Normal arterial blood gasses C. A decreased total lung capacity D. Normal skin coloring Answer: D The differentiation between the "pink puffer" and the "blue bloater" is a well known method of differentiating clients exhibiting symptoms of emphysema (normal coloring but puffing respirations) from those exhibiting symptoms of chronic bronchitis (edematous, cyanotic, shallow respirations). Total lung capacity is usually increased in patients with emphysema because they have over inflated lungs. An absence of suptum is characteristic of chronic bronchitis but emphysema is the opposite with copious amounts of thick, white sputum. An adult client is admitted to the hospital burn unit with partial-thickness and full-thickness burns over 40% of the body surface area. In assessing the potential for skin regeneration, what should the nurse remember about full-thickness burns? A) Regenerative function of the skin is absent because the dermal layer has been destroyed. B) Tissue regeneration will begin several days following return of normal circulation. C) Debridement of eschar will delay the body's ability to regenerate normal tissue. D) Normal tissue formation will be preceded by scar formation for the first year. Answer: A Full-thickness burns destroy the entire dermal layer. Included in this destruction is the regenerative tissue. For this reason, tissue regeneration does not occur, and skin grafting is necessary. A 51-year-old truck driver who smokes two packs of cigarettes a day and is 30 pounds overweight is diagnosed with having a gastric ulcer. What content is most important for the nurse to include in the discharge teaching for this client? A. Instructions on a weight loss program B. The importance of increasing milk in the diet. C. Information about smoking cessation. D. Diet instructions for a low-residue diet Answer: C Smoking has been associated with ulcer formation and stopping or decreasing the number of cigarettes smoked per day is an important aspect of ulcer management. Two days postoperative, a male client reports aching pain in his left leg. The nurse assesses redness and warmth on the lower left calf. What intervention should be most helpful to this client? A) Apply sequential compression devices (SCDs) bilaterally. B) Assess for a positive Homan's sign in each leg. C) Pad all bony prominences on the affected leg. D) Advise the client to remain in bed with the leg elevated. Answer: D The client is exhibiting signs of deep vein thrombosis, a complication of immobility. The initial care includes bed rest and elevation of the extremity. Despite several eye surgeries, a 78-year-old client who lives alone has persistent vision problems. The visiting nurse is discussing painting the house with the client. The nurse suggests that the edge of the steps should be painted which color? A) Black. B) White. C) Light green. D) Medium yellow. Answer: A Yellow is the easiest for a person living with failing vision to see. Despite several eye surgeries, a 78-year-old client who lives alone has persistent vision problems. The visiting nurse is discussing painting the house with the client. The nurse suggests that the edge of the steps should be painted which color? A) Black. B) White. C) Light green. D) Medium yellow. Answer: D Yellow is the easiest for a person living with failing vision to see. How should the nurse position the electrodes for modified chest lead one telemetry monitoring? A. Negative polarity left shoulder, positive polarity right chest nipple line, ground left chest nipple line. B. Positive polarity left shoulder, negative polarity right chest nipple line, ground left chest nipple line. C. Positive polarity right chest nipple line, negative polarity left chest nipple line, ground left shoulder. D. Positive polarity right shoulder, negative polarity left shoulder, ground left chest nipple line. Answer: A In MCL 1 monitoring, the positive electrode is placed on the client's mid-chest to the right of the sternum, and the negative electrode is placed on the upper left part of the chest. The ground may be placed anywhere, but is usually placed on the lower left portion of the chest. During suctioning, a client with an uncuffed tracheostomy tube begins to cough violently and dislodges the tracheostomy tube. Which action should the nurse implement first? A) Notify the healthcare provider for reinsertion. B) Attempt to reinsert the tracheostomy tube. C) Position the client in a lateral position with the neck extended. D) Ventilate client's tracheostomy stoma with a manual bag-mask. Answer: B The nurse should attempt to reinsert the tracheostomy tube by using a hemostat to open the tracheostomy or by grasping the retention sutures (if present) to spread the opening and insert a replacement tube (with it's obturator) into the stoma. Once in place, the obturator should immediately be removed. The nurse is planning care to prevent complication for a client with multiple myeloma. Which intervention is most important for the nurse to include? A. Assess for changes in size of lymph nodes B. Safety precautions during activity C. Administer narcotic analgesic around the clock D. Maintain a fluid intake of 3 to 4 L per day. Answer: D Preventions of complications related to hypercalcemia is most important. Multiple Myeloma is a malignancy of plasma cells that infiltrates bone causing demineralization and hypercalcemia, so maintaining a urinary output of 1.5 to 2 L per day requires an intake of 3 to 4 L to promote excretion of serum calcium. A client with a 16-year history with diabetes mellitus is having renal function tests because of recent fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels. Which finding should the nurse conclude as an early symptom of renal insufficiency? A. Confusion B. Nocturia C. Dyspnea D. Stomatitis Answer: A As the glomerular filtration rate decreases in early renal insufficiency, metabolic waste products, including urea, creatinine, and other substances, such as phenols, hormones, and electrolytes accumulate in the blood. In the early stage of renal insufficiency, polyuria results from the inability of the kidney's to concentrate urine and contribute to nocturia. The other symptoms listed are more common in the later stages of renal failure. Upgrade to remove ads Only $3.99/month A client with a 16-year history with diabetes mellitus is having renal function tests because of recent fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels. Which finding should the nurse conclude as an early symptom of renal insufficiency? A. Confusion B. Nocturia C. Dyspnea D. Stomatitis Answer: B As the glomerular filtration rate decreases in early renal insufficiency, metabolic waste products, including urea, creatinine, and other substances, such as phenols, hormones, and electrolytes accumulate in the blood. In the early stage of renal insufficiency, polyuria results from the inability of the kidney's to concentrate urine and contribute to nocturia. The other symptoms listed are more common in the later stages of renal failure. A 32-year-old female client with complaints of severe abdominal pain each month before her menstrual period, painful intercourse, and painful defecation. Which history should the nurse obtain that is consistent with the clients complaints? A. Frequent urinary tract infections B. Inability to get pregnant C. Chronic use of laxatives D. Premenstrual syndrome Answer: B Dysmenorrhea, dyspareunia, and difficult/painful defecation are common symptoms of endometriosis, which is the abnormal displacement of endometrial tissue in the dependent areas of the pelvic peritoneum. A history of infertility is another common finding associated with endometriosis. The nurse is teaching a female client who uses a contraceptive diaphragm about reducing the risk for toxic shock syndrome (TSS). Which information should the nurse include? (Select all that apply) A. Replace the old diaphragm every 3 months B. Do not leave the diaphragm in place longer than 8 hours after intercourse C. Remove the diaphragm immediately after intercourse D. Use the diaphragm to prevent contraception during the menstrual cycle E. Wash the diaphragm with an alcohol solution Answer: A, B The diaphragm needs to remain against the cervix for 6 to 8 hours to prevent pregnancy but should not remain for longer than 8 hours to avoid toxic shock syndrome. The diaphragm should be replaced every 3 months to maintain integrity. During an interview with a client planning elective surgery, the client asks the nurse, "What is the advantage of having a preferred provider organization insurance plan?" Which response is best for the nurse to provide? A) Long-term relationships with healthcare providers are more likely. B) There are fewer healthcare providers to choose from than in an HMO plan. C) Insurance coverage of employees is less expensive to employers. D) An individual can become a member of a PPO without belonging to a group. Answer: C The financial advantage is the feature of the PPO that is the most relevant to the average consumer. PPO's provide discounted rates to large employers who provide insurance coverage for their employees. In return, the insurance company receives a large pool of clients for their facilities. After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 ml for the last 2 hours. What priority nursing action should be implemented? A) Report the findings to the surgeon. B) Irrigate the indwelling urinary catheter. C) Apply manual pressure to the bladder. D) Increase the IV flow rate for 15 minutes. Answer: A An adult who weighs 60 kg should produce about 60 ml of urine an hour (1 ml/kg/hr). Dark, concentrated, and low volume urine output should be reported to the surgeon. Although the other actions may be indicated, the assessment findings should be reported to the healthcare provider. The nurse is assisting a client out of bed for the first time after surgery. What action should the nurse do first? A. Allow the client to sit with the bed in a high Fowler's position. B. Place the chair at a right angle to the bedside. C. Encourage deep breathing prior to standing D. Help the client to sit and dangle legs on the side of the bed. Answer: A The first step is to raise the head of the bed to a high Fowler's position which allows venous return to compensate from lying flat and vasodialating effects of perioperative drugs. A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client? A) Losing weight. B) Decreasing caffeine intake. C) Avoiding large meals. D) Raising the head of the bed on blocks. Answer: D Raising head of the bed on blocks (reverse Trendelenburg position) to reduce reflux and subsequent aspiration is the most effective recommendation for a client experiencing severe gastroesophageal reflux during sleep. The other choices might be helpful, but raising the head of the bed is the most helpful during sleep. When providing discharge teaching for a client with osteoporosis, the nurse should reinforce which home care activity? A) A diet low in phosphates. B) Skin inspection for bruising. C) Exercise regimen, including swimming. D) Elimination of hazards to home safety. Answer: D Discussion of fall prevention strategies is imperative for the discharged client with osteoporosis so that advice about safety measures can be given. The nurse is planning care for a client with newly diagnosed diabetes mellitus that requires insulin. Which assessment should the nurse identify before beginning the teaching session? A. Intelligence and developmental level of the client B. Present knowledge related to the skill of injection C. Willingness of the client to learn injection sites D. Financial resources available for the equipment. Answer: C If a client is incapable or does not want to learn, it is unlikely that learning will occur, so motivation is the first factor the nurse should assess before teaching. Which finding should the nurse identify as most significant for a client diagnosed with polycystic kidney disease (PKD)? A) Hematuria. B) 2 pounds weight gain. C) 3+ bacteria in urine. D) Steady, dull flank pain. Answer: C Urinary tract infections (UTI) for a client with PKD require prompt antibiotic therapy to prevent renal damage and scaring which may cause further progression of the disease, so bacteria in the urine is the most significant finding at this time. Upgrade to remove ads Only $3.99/month Which information about mammograms is the most important to provide to a post-menopausal female client? A. Yearly mammograms should be done regardless of previous normal x-rays. B. Women at high risk should have annual routine and ultrasound mammograms. C. Breast self-examinations are not needed if annual mammograms are obtained. D. Radiation exposure is minimized by shielding the abdomen with a lead-lined apron. Answer: A The current breast screening recommendation is a yearly mammogram after the age of 40. Breast selfexam continues to be a priority recommendation for all women. Which assessment finding by the nurse during a clients clinical breast examination requires follow-up? A. Tender lumpiness noted bilaterally throughout the breast. B. Whitish nipple discharge. C. A thickened area where the skin folds under the breast. D. Newly retracted nipple. Answer: D A newly retracted nipple, compared to a life-long finding may be an indication of breast cancer and requires follow-up. The inframammary ridge is a normal anatomic finding. Up to 80% of women may experience an intermittent nipple discharge and in most cases is not related to malignancy. Tender lumpiness is a classic finding for fibrocycstic breast disease which is a benign condition. What instruction should the nurse give a client who is diagnosed with fibrocystic changes of the breast? A. Notify the healthcare provider if whitish nipple discharge occurs. B. Observe cyst size fluctuations as a sign of malignancy. C. Perform a breast self-exam (BSE) procedure monthly. D. Use estrogen supplements to reduce breast discomfort. Answer: C Fibrocystic changes in the breast are related to excess fibrous tissue, proliferation of mammary ducts and cyst formation that cause edema and nerve irritation. These changes obscure typical diagnostic tests, such as mammography, due to an increased breast density. Women with fibrocystic breasts should be instructed to carefully perform monthly BSE and consider changes in any previous "lumpiness". A client has a staging procedure for cancer of the breast and asks the nurse which type of breast cancer has the poorest prognosis. Which information should the nurse offer the client? A. Invasive infiltrating ductal carcinoma. B. Inflammatory with peau d'orange C. T1N0M0 D. Stage II Answer: B Inflammatory breast cancer, which has a thickened appearance like an orange peel, is the most aggressive form of breast malignancies. Which postmenopausal client's complaint should the nurse refer to the healthcare provider? A) Breasts feel lumpy when palpated. B) History of white nipple discharge. C) Episodes of vaginal bleeding. D) Excessive diaphoresis occurs at night. Answer: C Postmenopausal bleeding may be an indication of endometrial cancer. A and B are normal findings in this case. D is concerning but as much as C. Small bowl obstruction is a condition characterized by which finding? A. Ribbon-like stools B. Intermittent lower abdominal cramping C. Severe fluid and electrolyte imbalances D. Metabolic acidosis Answer: C The presence of severe fluid and electrolyte imbalances are characteristic of small bowel obstruction. The other choices are characteristic of large bowl obstruction. A client's susceptibility to ulcerative colitis is most likely due to which aspect in the client's history? A. Age between 25 and 35 B. Family history of irritable bowl syndrome C. H. pylori infection D. Jewish European ancestry Answer: D Ulcerative colitis is 4 to 5 times more common among individuals of Jewish European or Ashkenazi ancestry. It has a peak occurrence between the ages of 15 and 25 and 55 yo 65 years old. H. pylori is associated with stomach inflammation and ulcer development. In preparing to administer intravenous albumin to a client following surgery, what is the priority nursing intervention? A. Assess for increased bleeding after administration B. Administer through a large gauge catheter. C. Set the infusion pump to infuse the albumin within four hours. D. Compare the client's blood type with the label on the albumin. E. Assign the UAP to monitor blood pressure q 15 minutes F. Monitor hemoglobin and hematocrit levels. Answer: A, B, C, F Albumin should be infused within four hours because it does not contain preservatives. Any fluid remaining after four hours should be discarded. Albumin administration does not require blood typing. Vital signs should be monitored periodically to assess for fluid volume overload, but every 15 min is not necessary. A large gauge catheter allows for a fast rate of infusion. Hemodilution may decrease hemoglobin and hematocrit levels, while increased blood volume and blood pressure may cause bleeding. Which milestone indicates to the nurse successful achievement of young adulthood? A) Demonstrates a conceptualization of death and dying. B) Completes education and becomes self-supporting. C) Creates a new definition of self and roles with others. D) Develops a strong need for parental support and approval. Answer: B A client is admitted to the hospital with a medical diagnosis of pneumococcal pneumonia. The nurse knows that the prognosis for gram-negative pneomonias (such as E. Coli, Klebsiella, Pseudomonas, and Proteus) is very poor because A. They occur in the lower lobe alveoli which are more sensitive to infection. B. Gram-negative organisms are more resistant to antibiotic therapy. C. They occur in healthy young adults who have recently been debilitated by an upper respiratory infection D. Gram-negative pneumonias usually affect infants and small children. Answer: B