HESI MED SURG V1 EXIT EXAM HESI MED SURG V1 EXIT EXAM

HESI MED SURG V1 EXIT EXAM HESI MED SURG V1 EXIT EXAM HESI MED SURG V1 EXIT EXAM HESI MED SURG V1 EXIT EXAM HESI MED SURG V1 EXIT EXAM HESI MED SURG V1 EXIT EXAM HESI MED SURG V1 EXIT EXAM Version 1. 1. a client with stage IV bone cancer is admitted to the hospital for a 1 to 10 scale. Which intervention should the nurse implement Answer: administer opioid and non-opioid medication simultaneously 2. During spring break, a young adult presents at the urgent care clinic and report headache. Which intervention is most important for the nurse to implement? Answer: initiate isolation precautions 3. After a colon resection for colon cancer, a male client is moaning while being transported to unit (PACU). Which intervention should the nurse implement first? Answer: determine clients pulse, blood pressure, and respirations 4. Which nursing problem has the highest priority when planning care for a client with osteomalacia? Answer: risk for injury 5. A client who took a camping vacation two weeks ago in a country with a tropical climate comes symptoms and diarrhea for the past week. Which finding is most important for the nurse report? Answer: jaundice sclera 6. a client admitted to a surgical unit is being evaluated for an intestinal obstruction . the healthcare prescribed nasogatric tube(NGT) to be inserted and placed to intermittent low wall suction. Which intervention –to facilitate proper tube placement? Answer: elevate head of bed 60 to 90 degrees 7. when explaining dietary quidelines to a client with acute glomerulonepheritis (AGN) , which instruction should the nurse include in the dietary teaching ? Answer: restrict sodium intake 8. a client with chronic kidney disease is started on hemodialysis, during the first treatment the client’s blood pressure 150/90 mm hg to 80/30 mm hg. Which action should the nurse take first? Answer: lower the head of the chair and elevate feet 9. a client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse spostoperative discharge instruction? Answer: monitor urinary stream for decrease in output 10. a client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood notifying the healthcare provider, what information should the nurse provide first using the SBAR (situation, background, assessment, and recommendation ) communication process? Answer: preface the report by stating the clients name and admitting diagnosis 11. Intermittent claudiation with leg pain… Answer: Encourage progressive exercise. 12. Three months after Dx of T2DM pt and nocompliance to Tx regimen….. Answer: Check A1c. 13. Client with SIADH complains of dry mouth and thirsty…. Answer: Give hard candy. 14. Client with emphysema with CT drain change from green to clear liquid. Answer: Tx is effective, document, continue to monitor pt. 15. Pt with multiple transplant reaction to report to HCP (healthcare prosional) Answer: Lower back pain and hypotension. 16. Fracture of left femur + fixation complain of pain. Answer: Assess peripheral pulse. 17. Nursing care goal for preop client. Answer: A physical and emotional preparedness. 18. Iron deficiency anemia client selected food requiring further teaching. Answer: Orange. Help in iron absorption but not reach in iron. 19. CVA client with expressive aphasia frustrated. Answer: Use communication board. 20. 2hrs Post op laparoscopy client demanding for food. Answer: Auscultate bowel sound in all 4 quadrant. 21. Nurse assisting PD client ambulate in hallway. Answer: Confirm that this is an effective technique. 22. Xenograft for a Jewish clent with burn. Answer: Taken from nonhuman source. 23. Laryngectomy and tracheostomy expectorate copious purulent secretion. Answer: Leave the old ties in place till the new one is secured. 24. Client with emphysema and HF has edema, coughing and SOB. BNP is elevated. Answer: Furosemide. 25. Client with Blood glucose of 50mg/dl, before action. Answer: Check level of consciousness. (ALOC). 26: Med order = 0.1875 mg; Available= 0.3mg per 1.2 ml Answer = 0.75 27. Heparin infusion order= 900 Unit per hr; Available= 25,000 Unit per 250 ml Answer = 9 28. Nurse calling HCP for client complaining of pain, SBAR report pattern. Answer: Preface the Client information to HCP. 29. Nursing care with higher priority when giving care. Answer: Altered tissue perfusion. 30. Bone cancer client with constipation complain of pain of 8 on 1-10 scale. Answer: Give opioid and non opioid simultaneously. 31. Pt with potassium level of 6.0, med to give. Answer: Kayaxalate (used to lower hyperkalamia) 32. In teaching a client newly diagnosed with multiple sclerosis (MS), which approach should the nurse emphasize as most likely to prevent an exacerbation of symptoms? Answer: develop preplanned mechanisms to avoid or minimize the effects of triggers 33. While assessing a client in a supine position, the nurse observes jugular vein distention. The client’s vital signs are: heart rate 110 beats/minute, respirations 28 breaths/minute, and blood pressure 160/88. What should the nurse take? Answer: raise the head of the bed 45 degrees 34. A client is recovering from a transurethral prostectomy. Which activity should be limited until after the first postoperative visit with his healthcare provider/; Answer: driving a car 35. a client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse? Answer: further decline in level of consciousness 36. after a computer tomography (CT) scan with intravenous medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement? Answer: prepare a dose of epinephrine (adrenalin) 37. a client with newly diagnosed crohn’s disease asks the nurse about dietary restrictions. How should the nurse respond? Answer: describe the use of an elimination diet to find trigger foods 38. A female college student comes to the school’s health clinic complaining of urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first? Answer: measure her temperature and pulse rate 39. when preparing a teaching plan for a client newly diagnosed with diabetes mellitus, the nurse should describe which situation as requiring the most immediate action by the client or family? Answer: hypoglycemic shock 40. Client is about to go to physical therapy but before that is having a wound debridement(whirlpool therapy)? What should the nurse do? Give analgesic. 41. Patient taking ferrous sulfate Answer -check serum iron and ferritin 42. Patient complaining of pain in the back/sacrum area Answer -check vital signs first 43. Patient complaining of leg pain Answer -check peripheral pulses 44. Emesis basin of coffee-ground vomit Answer -check vital signs 45. Dosage calculation/Heparin Drip: answer: 9ml/hr 46. Dosage calculation: answer: 1 mL 47. Patient complaining of abdominal pain Answer -auscultate bowel sounds 48. Pt with eczema how will you know the medication is working Answer -the skin is being hydrated 49. COPD patient with ABGs and elevated CO2 answer- the value is normal, document it 51) After a colon resection for colon cancer, a male client is moaning while being transported to unit (PACU). Which intervention should the nurse implement first? Answer: determine client's pulse, blood pressure, and respirations 52) SIADH : Give hard candy for thrist 53) Emotional prepareness before surgery