REAL HESI RN Med SURG  ALL VERSIONS IN ONE DEAL  QUESTIONS FROM REAL TEST  (I scored 1413!!!)

 REAL HESI RN Med SURG  ALL VERSIONS IN ONE DEAL  QUESTIONS FROM REAL TEST  (I scored 1413!!!) SAMPLES/PREVIEWS 2022 HESI Med-Surg v2 16. an older adult male is admitted three days after a fall because his wife called 911 this morning when he became confused. the client has a history of chronic kidney disease and diabetes and has vital signs on admission heart rate 120 beats respirations 12 breaths and blood pressure 180/96. which assessment finding warrants immediate intervention by the nurse? 6. A client who is receiving external beam radiation therapy to the spine for cancer palliation develops a reddened area on the back and reports of it itching. Which intervention should the nurse implement to ease the itching? Parkland formula question: 4L for the whole 8 hours. You will need to divide by 8 to get the total mLs per hour (round to nearest whole number). 4L = 4,000 mL / 8 hours = 500 mL per hour S - The Marketplace to Buy and Sell your Study Material #47 rest of question: On admission to the intensive care unit for sepsis caused by a ruptured appendix, the clients temperature is 103.6 F and blood pressure is and white blood cell count of which classification of prescribed medication should the nurse evaluate for client 1. Which problem, reported to the nurse by a 70-year-old male client, requires the most immediate intervention by the nurse? A. Urinary hesitancy B. Slow urinary stream C. Frequent nocturia D. Painless hematuria Downloaded by: CHRISJAY | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material 2. when conducting assessments at an assisted living community, the nurse finds that an older adult client for the nurse to implement? a) obtain a clean voided urine sample using a urinal hat b) evaluate the client’s response to bladder training efforts c) place a protective undergarment on the client d) encourage increased fluid for 24 hours 3. A is receiving procarpme hydrochlonde ophthalmic drops for glaucoma. The client calls the clinic nurse and reports difficulty seeing at night explanation should the nurse provide? a) The medication causes pupils to dilate, which reduces night vision b) The drops increase the in the eyes and cloud the visual field c) The eye drops slow pupil response to accommodate for darkness d) The drug can cause the lens to become more opaque 4. A patient who is receiving external beam radiation therapy to the spine for cancer palliation develops a reddened area on the back and 5. A client is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires immediate intervention? 6. The nurse observes a newly admitted older adult client take short steps and walk very slowly while pushing a walker. Which action 7. When reviewing an older client’s daily laboratory findings, the nurse notes the blood urea nitrogen (BUN) level is 23mg / d * L; (8.2 mmoll) should the nurse take first 8. An older female who is complaining of pain in her arm and back is brought to the Emergency Department last year for a variety of superficial injuries. Which nursing action has the highest priority? Ask if she has considered living in an assisted living facility 9. On the postoperative day the nurse an older client and the bed The first Downloaded by: CHRISJAY | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material 10.The nurse is caring for a client with the sexually transmitted infection (STI) chlamydia. The client reports having sex with multiple partners which response the nurse provide 11.A 55-yearold client reports a sudden onset of seeing flashing lights and floating spots Which is the best nursing action? common physiological change that occurs with aging is likely to influence an older adult's nutritional status? 13.An older client being admitted to a using acute care hospital following a cerebrovascular accident (CVA) When reviewing the client's prescribed implement first? 14.An older adult male is admitted three days a because his wife called 911 this morning when he became confused The has a history of kidney disease a 120 beats 12 breaths minute, and blood pressure 180/96. assessment finding warrants immediate Intervention by the nurse 15.A. female client returns to the clinic after being treated for chlamydia with azithromycin IM and reports that she still has symptoms. The client reports maintaining a monogamous relationship when the laboratory results are positive for the sexually transmitted infection Ask the client if the complete course of antibiotics was taken 16.A A client has a prescription for a fentanyl transdermal patch to be applied every 72 hours’ implement? a) А Leave the patch in place and administer a prescribed PRN b) B Advise the client that it is too soon to apply a new transdermal c) Remove the patch and notify the healthcare provider d) Replace the transdermal patch with a new patch. Downloaded by: CHRISJAY | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material 17. An older client with no cognitive impairment had a left hip arthroplasty 72 hours ago and now confused and lethargic. Which action 18.AA 148-pound adult female is admitted to the emergency center with burns to 30 percent of her body. Using burn) the client should receive one half of the 24-hour volume within the first 8 hours. The nurse should s is required round to the nearest whole number)  30 of 55 A center percent of her the Parkland formula for requirement for the 24 after the (home pump to (is the wole) 19. The nurse is visiting an older client who is homebound which finding about the client's nutritional status requires additional follow-up? 1,200 calorie diet Patient dying of cancer and receives RT radiation therapy. Why? – Palliative measure Question about fluid ounces 4 ounces 6 ounces 1 cup - 8 ounces How many mLs total Math question 250 mL was in the problem - A client with deep vein thrombosis (DVT) is receiving a continues infusion of heparin sodium 25,000 unit in 5% dextrose injection 250ml. The prescription indicates the dosage should be increase 900 units/hr. The nurse should program the infusion pump to deliver how many ml/hr.? 9 mL/hour 1. Which problem reported to a nurse by a 70-year-old client requires the most immediate intervention by a nurse? A = painless hematuria Downloaded by: CHRISJAY | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material 2. When conducting assessments at an assisted living community. The nurse finds that an older adult client who is normally alert and oriented and continent is confused and incontinent of urine. Which intervention is most important for the nurse to implement? Obtain a clean voided urine sample using a urinal hat 3. The nurse is preparing a client for discharge following cataract extraction. Which instruction should the nurse include in the discharge teaching? Avoid straining to stool, stooping, or lifting heavy objects 4. An older male client who has been talking to his deceased mother has been referred to the psychiatric clinic for evaluation. Which assessment is most important for the nurse to complete first? Determine cognitive status (I think) 5. A male client is receiving pilocarpine hydrochloride (Isopto Carpine) ophthalmic drops for glaucoma. He calls the clinic and ask the nurse why he has difficulty seeing at night. What explanation should the nurse provide? a. The eye drops slow pupil response to accommodate for darkness b. The drops increase the fluid in the eyes and cloud the visual field (possible answer) c. The drug can cause lens to become more opaque d. The medication causes pupils to dilate which reduces night vision 6. When treating a patient with a hospital acquired infection with Vancomycin, what would you do? a) report the HAI to Medicare b) assess patient's response c) obtain WBC count d) ensure to obtain a peak and trough 7. The healthcare provider adds the anticonvulsant topiramate to the medication regimen of a client who has been taking phenytoin the first week after the client has started topiramate? a) Alter the client's meal times to facilitate administration of both of the medications OB b) Draw a complete blood) assess for the expected abnormal findings c) Collect blood for a serum phenytoin level to assess for elevated drug concentration d) No specific nursing intervention is needed after the client has started topiramate Downloaded by: CHRISJAY | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material 8. an older client is being admitted to a skilled nursing facility from an acute care hospital following a CVA. When reviewing the clients prescribed medications, which intervention should the nurse implement first? a) determine which medications may be given generic form rather than brand name only b) compare admission prescriptions with the list of medications previously taken by the client c) provide client teaching regarding the desired effects of the client’s admission prescriptions d) Reconcile prescribed medication dosages with the published recommended dosage ranges 9. During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. What intervention is most important for the RN to implement during the admission process? Assist the client in developing alternative coping skills. 10. An elderly woman comes to the clinic because of vaginal bleeding. The healthcare provider finds a vaginal tear, which the client reports is likely to have occurred during unprotected sexual intercourse. Which content is most important for the nurse to include in the client's teaching plan? The importance of using vaginal lubricants. 11. The nurse observes a newly admitted older adult female take short steps and walk very slowly while pushing a walker in front of her. What action should the nurse take in response to these observations? Complete a full fall risk assessment of the client. 12. A 60-year-old female client with a positive family hx for ovarian cancer has developed an abdominal mass is being evaluated for passible ovarian cancer. Her PAP smear results are negative. What information should the nurse include in the client's teaching plan? Further evaluation involving surgery may be needed B. A pelvic exam is also needed before cancer is ruled out C. Pap smear evaluation should be continued every six months D. One additional negative pap smear is six months is needed Further evaluation involving surgery may be needed 13. A client is admitted to the hospital with symptoms consistent with right hemisphere stroke. Which neurovascular assessment requires immediate intervention by the nurse? Unequal bilateral hand grip strengths Downloaded by: CHRISJAY | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material 14. A client has been taking oral corticosteroids for the past five days because of seasonal allergies. Which assessment finding is of most concern to the nurse? A) White blood count of 10,000 mm3. B) Serum glucose of 115 mg/dl. C) Purulent sputum. D) Excessive hunger. 15. The wife of a client diagnosed with Parkinson's disease calls the clinic and tells the nurse her husband is having involuntary jerky movements of the legs and arms and is confused. Which action should the clinic nurse implement first? Ask the clients wife to list all medications her husband is currently taking 16.AA 48-yearold female client who has been treated for metastasized breast cancer the past year is told by her healthcare provider the and asks the nurse, "Who will care my children?" Which response is best for the nurse to provide? a) "What would you like to see happen with your children?" b) "Try to think about getting well Someone will care for your children c) "Your husband will have to be there for your children." d) "Have you talked to your family about who will be responsible for your children?" 17.A client with a respiratory has been receiving an antibiotic and an antipyretic for five days. Which current result is the best indication that the antibiotic is effective? A client with a respiratory infection has been receiving an antibiotic and an antipyretic for five days. What current datum is the best indication that the antibiotic is effective? The sputum specimen culture report shows no growth 18.A male client comes to the clinic with a complaint dysfunction (ED) Which information is most important for the nurse to obtain? Current Medication Regimen 19. The nurse is preparing to teach a class on breast self-examination. In describing an "at risk" individual, the nurse should describe which woman as having the highest risk of developing breast cancer? A 32-year-old woman whose mother had breast cancer Downloaded by: CHRISJAY | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material 20.At bedtime client with dementia becomes increasingly confused and agitated because she believes someone is standing in her room. Which action is best for the nurse to implement? a. Put a night light on in the room b. Provide soft music at bedtime c. Reassure her that she is alone d. Give an anxiolytic at bedtime 21. Question about a provider discussing end of life options with a family who agrees to end of life measures for their family member who was in an accident. The question asked which intervention should the nurse implement and the choices were:  turn off the ventilator and write down time of death  ask the family if they would like to be there during this process (maria said this one?!)  request a living will be put in the client’s record  discuss the withdrawal process and offer support to the family. 22. Question about a patient starting to take topiramate after already taking been taking phenytoin for 20 years. (The pt. would now be taking both). The question was asking what should the nurse do the first week after the patient starts taking this medication? - telling the patient to take the meds after mealtime - drawing a CBC to look for expected abnormal results - collect blood for serum phenytoin to check levels (maria said this one too) - no interventions needed 23. A female client is admitted to the hospital with a diagnosis of right lower quadrant (RLQ) abdominal pain and a possible ectopic pregnancy. She tells the nurse that the pain is gone but she is now experiencing generalized abdominal aching Her blood pressure has decreased and her pulse has increased over the past two hours. while waiting for the healthcare provider to arrive, which intravenous solution is best for the nurse to initiate? Lactated Ringers 150 mL/hour 24. The nurse-manager observes that the stair nurse has used wrist restraints to help secure an elderly female in her wheelchair. The client is that the client needs to be restrained in the wheelchair so that the nurse can change her bed linens. What is the priority action by the nurse? Advise the staff nurse to remove the restraints from the client’s wrists Downloaded by: CHRISJAY | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material 25. On the first postoperative day. The nurse finds an older male client disoriented and trying to climb over the bed railing. Previously he was oriented to person place and time on admission. Which intervention should the nurse implement first? Assess the client for pain. 26. A female client returns to the clinic after being treated for chlamydia with Azithromycin IM and reports that she still has symptoms. The HCP obtains a swab of the discharge from the cervix for testing for chlamydia. The client reports maintaining a monogamous relationship when the laboratory result are positive for the sexually transmitted infection. Which information should the nurse obtain to evaluate the ineffective results of treatment? Ask the client if the complete course of antibiotics was taken. 27. Which common physiological change that occurs with aging is likely to influence and older adult’s nutritional status? Diminished sense of smell 28. A young adult who suffered a severe brain injury in an automobile collision has been mechanically ventilated for the past three days and has no spontaneous respiratory effort. After serial electroencephalograms reveal no brain activity, the healthcare provider discusses end of life options with the family who agrees to discontinue life support. Which intervention should the nurse implement? Discuss the withdrawal procedure with the family and offer support 29. The nurse is visiting an older client who is homebound. Which finding about the client’s nutritional status requires additional followup? Ate approximately 1,200 calories daily for the past two weeks 30. An older female who is complaining of pain in her arm and back is brought to the emergency department by her son who states she fell out of her chair. The nurse notes that the client has been in the ED five times in the last for a variety of superficial injuries. Which nursing action has the highest priority? Take mom to pDr oiwvnalot aeder doboy:mCHRaISnJdAYa|smkarr i jof ns18o2m@s hurting her Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material 31. When conducting assessments at an assisted living community, the nurse finds that an older adult client who is normally alert, oriented, and continent, is confused and incontinent of urine. Which intervention is MOST important for the nurse to implement? Obtain a clean, voided urine sample using a urinal hat 32. A client has a prescription for a fentanyl transdermal patch to be applied every 72 hours. The patch was applied 48 hours ago and the client now reports experiencing breakthrough pain. What action should the nurse implement? a. Replace the transdermal patch with a new patch b. Remove the patch and notify the HCP c. Advise the client that is too soon to apply a new transdermal patch Leave the patch in place and administer a prescribed PRN analgesic 33. During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. What intervention is most important for the RN to implement during the admission process? Assist the client in developing alternative coping skills 34. total mL question = 4 ounces + 6 ounces + 8 ounces = 540 total mL 35. Burn total percentage formula question - Parkland formula question: 4L for the whole 8 hours. You will need to divide by 8 to get the total mLs per hour (round to nearest whole number). 4L = 4,000 mL / 8 hours = 500 mL per hour 36. An older client with no cognitive impairment had a left hip arthroplasty 72 hours ago and is now confused and lethargic. Which action should the nurse implement? Observe the surgical incision 37. When reviewing an older client’s daily laboratory findings, the nurse notes that the blood urea nitrogen (BUN) level is 23 mg/dk (8.2mmol/L). Which action should the nurse take first? Review prior BUN findings in the client’s record. Downloaded by: CHRISJAY | Distribution of this document is illegal S - The Marketplace to Buy and Sell your Study Material 38. An older adult is admitted to an acute medical unit from a long-term care facility. When reviewing the client’s prescribed medications, which intervention should the nurse implement first? Compare admission prescriptions with the list of medications previously taken by the client 39. On admission to the ICU for sepsis the client’s temperature is 104 and blood pressure is 68/42. Other hemodynamic findings are cardiac output of 10.7L/min, systemic vascular resistance of 480 dynes/sec/cm, and white blood cell count 28,000. Which classification of prescribed medication should the nurse evaluate for client stabilization? Vasoconstrictor 40. A client who is receiving NS at 75 mL/h has dry, sticky mucous membranes and inelastic skin turgor. Which action should the nurse implement? Continue the NS at 75 mL/h and encourage oral fluids intake (wasn’t this a Q?) I think it was 41. On the first postoperative day. The nurse finds an older male client disoriented and trying to climb over the bed railing. Previously he was oriented to person place and time on admission. Which intervention should the nurse implement first? Assess the client for pain Downloaded by: CHRISJAY | Distribution of this document is illegal HESI RN MED SURG/ACTUAL EXAM THIS FILE WAS TESTED LASTWEEK SCORED 1026 Answers included 1- A male client who reports feeling chronically fatigued has a hemoglobin of 11.0 grams/dl (110 mmol/L or SI), hematocrit of 34% and microcytic and hypochromic red blood cells. Based on the findings, which dinner selection should the nurse suggest for the patient? A. Beef steak with steam broccoli and orange slices B. Cheese pasta and a lettuce and tomato salad C. Broil white fish with a baked sweet potato D. Grill shrimp and seasoned rice with asparagus salad. 2- Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires the most immediate action by the nurse? A. Surgical consent form is not signed B. Preoperative serum potassium level is 2.8 mEq/L (2.8mmol/L) C.Preoperative chest x-ray report is not available D. Client's pulse oximeter reading is 96% 3- The nurse is assessing a client's arteriovenous (AV) fistula. Which finding provides evidence of its normal function? A. Ecchymotic area B. Enlarged vein C. Pulselessness D. Redness 4- Following a transurethral resection of the prostate (TURP), a client is discharged from the hospital with an indwelling urinary catheter. Which instruction is important for the nurse to include in the discharge teaching plan? A. Avoid driving a car for 2 weeks B. Drink 3 liters of water each day C. Eliminate all spicy foods from your diet D. Clamp the catheter when taking a shower 5- A client is receiving chemotherapy for treatment of metastatic carcinoma. When monitoring the client for systemic side effects, which assessment finding warrants intervention by the nurse? A. Leukopenia B. Polycythemia C. Ascites D. Nystagmus 6- A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse? A. Irregular apical pulse B. Pitting ankle edema C. Quarter size blood spot on dressing D. Purple marks on skin of the abdomen 7- ( Algo de esto, pero fue que el paciente tenia dolor y los dedos cianoticos )A client who fractured the right femur from a fall at home is placed in a skeletal traction while awaiting surgery. When the client tells the nurse the need to urinate, which intervention should the nurse implement? A. Insert an indwelling catheter preoperatively B.Release the traction so the client can use a bedpan C. Log roll the client and place adult disposable briefs beneath the client D. Maintain traction while the client uses a female urinal 8- The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition? A. Has everyone at home already had varicella? B. Have the anti fungal creams been effective? C. Do your family members share combs and brushes? D. Do you have any dry patches on your feet and hands? 9- Which instruction should the nurse include in the discharge teaching for a client who has gastroesophageal reflux? A. Encourage the client to lie down and rest after meals B. Remind the client to avoid high-fiber foods C. Teach the client to elevate the head of the bed on blocks D. Instruct the client to use antacids only as a last resort 10- The nurse prepares a teaching plan for an adult client with metabolic syndrome. Which findings should the nurse address to help the client reduce the risk for diabetes mellitus and vascular disease? (Select all that apply) A. Hypothyroidism B. Increased triglyceride levels C. Hyperglycemia D. Blood pressure of 150/96 E. Elevated high density lipoproteins F. Abdominal obesity 11- A client is admitted with a deep and productive cough, hemoptysis, and a low-grade fever. The client's Mantoux skin test has a 15mm induration. Which intervention should the nurse implement first? A. Administer the initial dose of rifampin and isoniazid B. Collect a sputum specimen for acid-fast bacillus C. Provide a mask for the client to wear in public areas D. Initiate airborne particulate isolation precautions 12- ? While caring for a client with a full-thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provide, the nurse should review which of the client's laboratory values? A. White blood cell count B. Blood pH level C. Platelet count D. Hematocrit 13- The home health nurse is evaluating a male client who manages his asthma and measures his peak expiratory flow rate (PEFR). Today he is experiencing an acute exacerbation and tells the nurse his PEFR is 60% of his personal-best reading. He is experiencing expiratory and inspiratory wheezes and has a RR of 24 breaths/minute, and oxygen saturation rate of 94% on room air. Which PRN medication should the nurse instruct the client to use? A. Albuterol 2.5 to 5 mg per nebulization B. Epinephrine auto-injector 0.15 mg C. Salmeterol 2 puffs per measured-dose inhaled D. Oxygen at 6 liter/minute by nasal cannula 14- Which food is most important for the nurse to encourage a client with osteomalacia to include in a daily diet? A. Fortified milk and cereals B. Citrus fruits and juices C. Red meats and eggs D. Green leafy vegetables 15- After several days of coughing and taking acetaminophen to treat temperature of 101 F, a client with diabetes mellitus (DM) is admitted to the hospital with an upper respiratory infection. Several hours after admission, the client reports having a severe headache and feeling dizzy. Which intervention should the nurse implement first? A. Reassess vital signs B. Administer an antipyretic C. Obtain a sputum for culture D. Obtain a fingerstick glucose 16- An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI) Prescriptions for intravenous antibiotics and insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse? A. blood ph of 7.30 B. glucose of 350 mg /dl C. white blood cell count of 15000mm D. potassium of 2.5 meq/l 17- ( La que salio fue si esta tomando warfarin que test se tiene que revisar)The nurse is caring for a patient prescribed warfarin (Coumadin) orally. The nurse reviews the patient’s prothrombin time (PT) level to evaluate the effectiveness of the medication. The nurse should also evaluate which of the following laboratory values? a) International normalized ratio (INR) b) Partial thromboplastic time (PTT) c) Sodium d) Complete blood count (CBC) a) International normalized ratio (INR) Explanation: The INR, reported with the PT, provides a standard method for reporting PT levels and eliminates the variation of PT results from different laboratories. The INR, rather than the PT alone, is used to monitor the effectiveness of warfarin. The therapeutic range for INR is 2 to 3.5, although specific ranges vary based on diagnosis. The other laboratory values are not used to evaluate the effectiveness of Coumadin. 18- The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a Thoracotomy two hours ago. The nurse observes the following vital signs: heart rate 140 beats/minute, respirations 26 breaths/minute, and blood pressure 140/90 mmHg. Which intervention is most important for the nurse to implement? A. Administer IV fluid bolus as prescribed by the healthcare provider B. Medicate for pain and monitor vital signs according to protocol C. Encourage the client to splint the incision with a pillow to cough and deep breathe??? D. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter 19- An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI) Prescriptions for intravenous antibiotics and insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse? A. blood ph of 7.30 B. glucose of 350 mg /dl C. white blood cell count of 15000mm D. potassium of 2.5 meq/l 20- An older female client with long term type 2 diabetes mellitus (DM) is seen in the client for a routine health assessment. To determine if the client is experiencing any long – term complications of DM, which assessments should the nurse obtain? (Select all that apply) a. Serum creatinine and blood urea nitrogen (BUN). b. Sensation in feet and legs. c. Skin condition of lower extremities. d. Signs of respiratory tract infection e. Visual acuity. 21- The nurse determines that an adult client who is admitted to the post anesthesia care unit (PACU) following abdominal surgery has a tympanic temperature of 94.6 F(34.8*C), a pulse rate of 88 beast/minute, a respiratory rate of 14 breaths/minute, and a blood pressure of 94/64 mmHg. Which action should the nurse implement? a. Take the client’s temperature using another method. b. Raise the head of the bed to 60 to 90 degrees. c. Ask the client to cough and deep breathe. d. Check the blood pressure every five minutes for one hour. 22- The nurse teaching a client how to collect a sputum specimen. Which steps should the nurse instruct the client to follow when collecting sputum? a. Restrict fluids before expectorating the sputum specimen. b. Obtain the specimen before bedtime. c. Avoid mouth care prior to collecting the sputum. d. Breathe deeply, followed by coughing up the sputum. 23- While caring for a client with Guillain-Barre syndrome, the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse? a. Lower leg weakness. b. Sensory loss at T-8. c. Leg pain worsening at night. d. Profuse diaphoresis. 24- 25- 26- Solo puse b y d 27- 28- Yo puse c 29- 30- 31- 32- 33- Cambio algo me parece que era cancer y no hernia 34- 35- After teaching a female client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Elimination of which food choices by the client indicates teaching is successful R/ Whole milk and daily ice cream servings 36- A client with a bariatric surgery 2 months ago, and a week ago, has vomiting, nausea anorexia, fever, put in NPO. What should the nurse do next? R/Insert nasogastric tube with low suction intermittent 37- A client with chronic kidney disease (CDK) arrives at the clinic reporting shortness of breath on exertion and extreme weakness. Vital signs are temperature 100.4 F (38 C), heart rate 110beats/minute, respirations 28 breaths/minute, and blood pressure 175/98 mmHg. The client usually receives dialysis three times a week but missed the last treatment. STAT blood specimens are sent to the laboratory for analysis. Which laboratory results should the nurse report to the healthcare provider immediately? Potassium 6.5 mEq/L (mmol/L) 38- A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care? Teach the client techniques for performing intermittent catheterization 39- A client with Parkinson Disease presenting mask like face. What other sign alert the nurse for rapid intervention? Swallowing inability 40- A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 1 to 10 scale. Which intervention should the nurse implement? Administer opioid and non-opioid medication simultaneously 41- A nurse assists a male client with Parkinson's disease (PD) to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. He tells the nurse that he is pretending to step over a crack on the floor. How should the nurse respond? Confirm that this is an effective technique to help with ambulation 42- A nurse is caring for a client with Diabetes Insipidus (DI). Which data warrants the most immediate intervention by the nurse? Serum sodium of 185 mEq/L 43- An older adult with heart failure is hospitalized during an acute exacerbation. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care? Provide a bedside commode for toileting 44- An older client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement? Provide an eye shield to be worn while sleeping 45- An older female client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment. To determine if the client is experiencing any long-term complication of DM, which assessments should the nurse obtain? (selectall that apply) Serum creatinine and blood urea nitrogen (BUN) Sensation in feet and legs Skin condition of lower extremities Visual acuity 46- An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action? A. Encourage turning and deep breathing. B. Auscultate for presence of bowel sounds C. Monitor hemoglobin and hematocrit D. Administer IV antibiotics as prescribed 47- The nurse is caring for a client diagnosed with psoriasis vulgaris who receiving a psoralen and ultraviolet a light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment? A. Thick skin plaques topped by silvery white scales B. Requires sunglasses because sunlight hurts eyes C. Tenderness upon palpation and generalized erythema D. Brown, rough, greasy, wart-like papules on the face 48- The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a trans-urethral resection of the prostate (TURP) .What is the best initial nursing action? A. Administer a PRN dose of an antispasmodic agent B. Measure the client’s intake and output C. Provide additional oral fluid intake D. Increase the flow of the bladder irrigation 49- HESI RN MED SURG/ACTUAL EXAM THIS FILE WAS TESTED APRIL 2022 Answers included 1. An adult client is diagnosed with restlessleg syndrome and isreferred to the sleep clinic. The healthcare provider prescribes ferrous sulfate 325 mg pO daily. Which laboratory values should the nurse monitor? a. Serum iron and ferritin b. Platelet count and hematocrit c. Neutrophils and eosinophils d. Serum electrolytes 2. The nurse is caring for a client who is newly diagnosed with adrenocortical insufficiency. The client is experiencing chronic fatigue and weakness. Which intervention should the nurse implement? a. Begin education about fluid restriction and waysto incorporate into ongoing therapy b. Explain that the hormone therapy will be needed for a time until adrenal glands are stimulated c. Provide encouragement that symptoms will rapidly improve as hormone therapy is initiated d. Advise the client to schedule energy intensive activities for later in the day 3. the nurse is caring for an immobile client after spinal surgery. Which action is most important for the nurse to take to prevent postoperative complications? a. Maintain intervascular infusion rate b. Progress diet slowly from ice chipsto clear liquid c. Apply intermittent pneumatic compression devices d. Obtain frequent pain level assessments 4. An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action? a. Encourage turning and deep breathing b. Auscultate for presence of bowelsounds c. Administer IV antibiotics as prescribed d. Monitor hemoglobin and hematocrit 5. The nurse is obtaining a health history from a new client who has a history of kidney stones. Which statement by the client indicates an increased risk for renal calculi? a. Eats a vegetarian diet with cheese 2 to 3 times a day b. Experiences additional stresssince adopting a child c. Jogs more frequently than usual daily routine d. Drinksseveral bottles of carbonated water daily 6. A client with orthopnea expresses concern about the ability to “get enough air” during a scheduled thoracentesis. On which information should the nurse’s response be based on? a. Extra pillows can be used if needed to elevate the client’s head b. Orthopnea is frequently caused by a clients uncontrolled anxiety c. The procedure is performed with the client in an upright position d. A thoracentesis is a brief procedure that has minimal discomfort 7. The nurse is performing the postoperative assessment of a client with an abdominal aortic aneurysm. Which finding is most important for the nurse to provide in the preoperative report? a. Respirations 20 breaths/minute b. Diminished peripheral pulses c. Hypoactive bowelsounds d. S3 hear sound on auscultation 8. The nurse is providing teaching to a client with type 2 diabetes mellitus about managing care at home. Which information stated by the client indicates understanding? a. Avoid seasoning foods with salt and salt-containing spices b. Keep any wounds covered with an antibiotic ointment c. Check blood sugar levels every four to six hours every day d. Soak feet daily in hot water no longer than 10 minutes 9. The home health nurse providesteaching about insulin self-injecting to a client who was recently diagnosed with diabetes mellitus. When the client begins to perform a return demonstration of an insulin injection into the abdomen as seen in the video, which instruction should the nurse provide? a. Lie down flat for betterskin exposure b. Select a different injection site c. Keep the skin flat rather than bunched d. Continue with the insulin injection 10. The nurse is collecting information from a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain? a. Color and consistency of feces b. Eating patterns and dietary intake c. Level and amount of physical activity d. Presence and activity of bowel sounds 11. A client with herpeszoster (shingles) on the thorax tellsthe nurse of having difficulty sleeping. Which is the probable etiology of this problem? a. Noctuia b. Dyspnea c. Frequent cough d. Pain 12. The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this medical diagnosis? a. Marked loss of weight and appetite over the last 3 or 4 months b. Upper mid-abdominal pain described as gnawing and burning c. Frequent use of chewable and liquid antacidsfor indigestion d. Severe abdominal cramps and diarrhea after eating spicy foods 13. An obese client with emphysema who smokes at least a pack of cigarettes daily is admitted after experiencing a sudden increase in dyspnea and activity intolerance. Oxygen therapy isinitiated and is determined that the client will be discharged with oxygen. Which information is most important for the nurse to emphasize in the discharge teaching plan? a. Methodsfor weight gain b. Guidelinesfor oxygen used c. Strategiesfor smoking cessation d. Approachesto conserve energy 14. A hospitalized client with peripheral arterial disease (PAD) isinstructed regarding leg and foot care. Which statement by the client indicates to the nurse that learning has occurred? a. “whenever I am sitting in a chair I will keep my legs up to reduce swelling” b. “I can use a mirror to check the bottoms of my feet for any signs of breakdown” c. “I will try to keep moving if leg pain occursto help promote good circulation” d. “I will use my swimming pool early in the day while the water is still very cool. 15. To reduce the risk for pulmonary complication for a client with amyotrophic lateral sclerosis (ALS), which interventions should the nurse implement? SATA a. Perform chest physiotherapy b. Initiate passive range of motion exercise e. Establish a regular bladder routine 16. An adult who was recently diagnosed with glaucoma tells the nurse, “It feels like I am driving through a tunnel”. The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client? a. Wear prescription glasses b. Maintain prescribed eye drop regimen c. Avoid frequent eye pressure measurements d. Eat a diet high in carotene (vit C) 17. The nurse observes an increase number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a trans-urethral resection of the prostate (TURP). What is the best initial nursing action? a. Provide additional oral fluid intake b. Administer a PRN dose of an antispasmodic agent c. Measure the clientsintake and output d. Increase the flow of bladder irrigation 18. The healthcare provider prescribes diagnostic test for a client whose chest xray indicates pneumonia. Which diagnostic test should the nurse review for implementation in the most therapeutic treatment of the pneumonia? a. Arterial blood gases (ABG) b. Sputum culture and sensitivity c. Computerized tomography (CT) of the chest d. Blood cultures 19. The family suspects that acquired immune deficiency syndrome (AIDS) dementia is occurring in their son who is human immunodeficiency virus (HIV) positive. Which symptom confirms their suspicions? a. He refusesto see any of his friends or to return their phone calls b. He has begun to sleep 19 out of 24 hours c. He exhibits angry outburst when the subject of dying is approached c. Encourage use of incentive spirometer d. Teach the client breathing exercises d. A change hasrecently occurred in his handwriting 20. The nurse is providing discharge instructions to a client who is receiving prednisone 5 mg PO daily for a rash due to contact with poison ivy. Which symptom should the nurse tell the client to report to the health care provider? a. Moon facies b. Gastric irritation c. Abdominal striae d. Rapid weight gain 21. The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observesthe following vitalsigns: heart rate 140 breaths/minute, respirations 26 breaths/minute, and blood pressure 140/90 mmHG. Which intervention is most important for the nurse to implement? a. Medicate for pain and monitor vitalsigns according to protocol b. Administer intravenousfluid bolus as prescribed by the healthcare provider c. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter d. Encourage the client to splint the incision with a pillow to cough and deep breathe. 22. A client with lung cancer who wears a subcutaneous morphine sulfate patch for pain is short of breath and is difficult to arouse. When performing a head to toe assessment, the nurse discovers four analgesic patches on the client’s body. Which intervention should the nurse implement first? a. Remove all of the morphine patches b. Administer a narcotic antagonist c. Measure the clients blood pressure d. Apply oxygen per face mask 23. The nurse assess a client who is newly diagnosed with hyperthyroidism and observes that the clients eyeballs are protuberant, causing a wide-eyed appearance and eye discomfort. Based on thisfinding, which action should the nurse include in the clients plan of care? a. Assessfor signs of increased ICP b. Prepared to administer intravenouslevothyroxine c. Obtain a prescription for artificial tear drops d. Review the clients serum electrolyte value 24. A client with Cushing’ssyndrome isrecovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse? a. Purple marks on skin of the abdomen b. Pitting ankle edema c. Quartersize blood spot on dressing d. Irregular apical pulse 25. Four daysfollowing an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities and pedal pulses are not palpable. Which action should the nurse implement first? a. Wrap the feet with warmed blankets b. Elevate extremities on pillows c. Assess pulses with a vascular doppler d. Evaluate edema for pitting 26. A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened, tenacious mucous, and the inability to walk up a flight ofstairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care? a. Call the clinic if undesirable side effects of medication occur b. Increase the daily intake of oral fluids to liquefy secretions c. Teach anxiety reduction methodsforfeelings ofsuffocation d. Avoid crowded enclosed areasto reduce pathogen exposure 27. A client tellsthe clinic nurse about experiencing burning on urination, and assessment reveals that the client had sexual intercourse four days ago with a person who was casually met. Which action should the nurse implement? a. Observe the perineal area for chancroid like lesion b. Obtain a specimen of urethral drainage for culture c. Assessfor perineal itching, erythema, and excoriation d. Identify allsexual partners in the last 4 days 28. A client is hospitalized with heart failure (HF). Which intervention should the nurse implement to improve ventilation and reduce venous return? a. Place the client in high fowler position b. Perform passive range of motion exercises c. Increase the clients activity level d. Administer oxygen per nasal cannula 29. During spring break, a young adult presents to the urgent care clinic and reports a stiff neck, a fever for the past 6 hours and a headache. Which intervention is most important for the nurse to implement first? a. Draw blood cultures b. Administer an antipyretic c. Prepare for a lumbar puncture d. Initiate isolation precautions 30. The nurse is providing teaching to a client with type 2 diabetes mellitus and peripheral neuropathy. Which information should the nurse provide? a. Aching feet may be soaked in lukewarm water for one hour or more b. Family members can help with regular foot exams c. Heat pads are useful if on the lowestsetting d. Shoes should be worn outside the house, but it isfine to be barefoot inside 31. The nurse is planning care for an older adult client who experienced a cerebrovascular accident several weeks ago. The client has expressive aphasia and often becomes frustrated with the nursing staff. Which intervention should the nurse implement? a. Encourage clients use of picture charts b. Ask the client simple questions c. Speak slowly to the client d. Teach the client use of basic sign language 32. Which client hasthe highest risk for developing skin cancer? a. a 25 year old dark skinned client whose mother had skin cancer b. a 70 year old fair skinned client who works as a secretary c. a 65 year old fair skinned client who is a construction worker d. a 16 year old dark skinned client who tans in tanning beds once a week 33. The nurse is preparing a client for surgery who was admitted to the emergency center following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that client currently receives heparin sodium 5,000 units subcutaneously daily. What isthe priority nursing action? a. Notify the health care provider of the clients medication history b. Have the client sign the surgical and transfusion permits c. Observe the heparin injection sitesforsigns of bruising d. Ensure that the potential for bleeding is explain to the client. 34. What food is most important for the nurse to encourage a client with osteomalacia to include in a daily diet? a. Citrus fruits and juices b. Green leafy vegetables c. Fortified milk and cereals d. Red meats and eggs 35. While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting thisfinding to the healthcare provider, the nurse should review which of the client’s laboratory values? a. White blood cell (WBC) count b. Blood pH level c. Platelet count d. Hematocrit 36. A client with gout arthritisreports tenderness and swelling of the right ankle and great toe. The nurse observes the area of inflammation above the ankle area. The client receives prescription for colchicine and indomethacin. Which instruction should the nurse include in the discharge teaching? a. Encourage active range of motion to limitstiffness b. Drink at least 8 cups (1920 mL) of water per day c. Use electric heating pad when pain is at its worse d. Eat high protein foodsto achieve ideal body weight 37. A client with acute renal injury (AKI) weights 50 kg and has potassium level of 6.7 mEq/L is admitted to the hospital. Which prescribed medication should the nurse administer first? a. Sodium polystyrene sulfonate 15 grams by mouth b. Sevelamer one table by mouth c. Calcium acetate one tablet by mouth d. Epoetin alfa, recombinant 2,500 unit subcutaneously 38. While completing a health assessment for a client with migraine headaches, the nurse assesses bilateral weakness in the client’s hand grips. The client reports join pain and trouble twisting a doorknob due to weakness. Which action should the nurse take in response to these findings? a. Explain the relief of the migraine pain will reduce related symptoms b. Consult with the occupational therapist for a functional assessment c. Implement fall precautionsto reduce the client’srisk for injury d. Gather additional assessment data about the pain and weakness 39. The nurse assesses a client with petechiae and ecchymosisscattered across the arms and legs. Which laboratory result should the nurse review? a. Platelet count b. Red blood cell count c. White blood cell count d. Hemoglobin levels 40. An older client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment. Which assessments would the nurse complete to determine if a patient with type 2 diabetes mellitus (DM) is experiencing long term complications? SATA a. Signs of respiratory tractinfection b. Serum creatine and blood urea nitrogen (BUN) c. Skin condition of lower extremities d. Sensation in feet and legs e. Visual acuity 41. A client in the operating room received succinylcholine. The client is experiencing muscle rigidity and has an extremely high temperature. Which action should the nurse implement? a. Call the PACU nurse to prepare for prolonged ventilatory support b. Hold a prescription for dantrolene until fever isreduced c. Prepare ice packs for placement in the client’s axillary area d. Determine if prescribed antibiotics were administered preoperatively 42. A client with chronic kidney disease is started on hemodialysis. During the first dialysis treatment, the clients blood pressure dropsfrom 150/90 mmHG to 80/30 mmHG. Which action should the nurse take first? a. Administer 5% albumin IV b. Monitor blood pressure q45 minutes c. Stop the dialysis treatment d. Lower the head of the chair and elevate feet 43. After three days of persistent epigastric pain, a female presents to the clinic, she has been taking oral antacids without relief. Her vitalsigns are heart rate 122 beats/minute, respirations 16 breaths/minute, oxygen saturation 96% and blood pressure 116/70 mmHG. The nurse obtains a 12-lead electrocardiogram (ECG). Which assessment finding is most critical? a. Complaint of radiating jaw pain b. Irregular pulse rate c. ST elevation in three leads d. Bile colored emesis 44. A nurse is caring for a client with diabetesinsipidus (DI). Which data warrants the most immediate intervention by the nurse? a. Serum sodium 185 mEq/L b. Apical rate of 110 beats per minute c. Dry skin with inelastic turgor d. Polyuria and excessive thirst 45. A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit? a. Profuse diaphoresis and severe, pounding headache b. Complaints of chest pain and shortness of breath c. Pain and a burning sensation upon urination and hematuria d. Hypotension and venous pooling in the extremities 46. The nurse observes pitting edema in both hands and all fingers of a client with diffuse systemic sclerosis (Scleroderma). Which action should the nurse include in the plan of care? a. Cover areasliberally with lubricant b. Examine skin for ulcerations c. Observe forscleral jaundice d. Apply cold packs as needed 47. When conducting discharge teaching for a client with diverticulosis, which diet instruction should the nurse include? a. Have small frequent meals and sit up for at least two hours after meals b. Eat a soft diet with increased intake of milk and milk products c. Eat a high-fiber diet and increase fluid intake d. Eat a bland diet and avoid spicy foods 48. An older client with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. The client is anxious and is complaining of a dry mouth. Which intervention should the nurse implement? a. Administer a prescribed sedative b. Assist client to an upright position c. Apply a high-flow venturi mask d. Encourage client to drink water 49. A client with cholelithiasis is admitted with jaundice due to obstruction of the common bile duct. Which finding is most important for the nurse to report to the healthcare provider? a. Clay colored stool b. Radiating sharp pain in right shoulder c. Distended, hard and ridged abdomen d. Bile-stained emesis 50. The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis a. Decreased renin-angiotensin response related to an increase in renal blood flow b. Decreased portacaval pressure with greater collateral circulation c. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules d. Hypoalbuminemia that results in decreased colloidal oncotic pressure 51. The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portalsite should the nurse provide? a. Apply moisture lotions daily to the radiation portalsite b. Protect the skin of the radiation portalsite from sunlight exposure c. Avoid washing the skin inside the radiation portalsite d. Remove the ink marks of the portal after each radiation treatment. 52. MATH 53. MATH HESI RN NEW MED SURG EXAM 2022 -MULTIPLE QUESTIONS -QUESTIONS&ANSWERS -55 QUESTIONS -TESTED 2022 1.The client who experiences angina has been told to follow a low cholesterol diet. Which of the following meals would be best? 1. Hamburger, salad, and milkshake. 2. Baked liver, green beans, and coffee. 3. Spaghetti with tomato sauce, salad, and coffee. 4. Fried chicken, green beans, and skim milk. 2. The nurse should caution the client with diabetes mellitus who is taking a sulfonylurea (GLIPAZIDE, GLYBURIDE) that alcoholic beverages should be avoided while taking these drugs because they can cause which of the following? 1. Hypokalemia. 2. Hyperkalemia. 3. Hypocalcemia. 4. Disulfiram (Antabuse)–like symptoms. 3. Which of the following conditions is the most significant risk factor for the development of type 2 diabetes mellitus? 1. Cigarette smoking. 2. High-cholesterol diet. 3. Obesity. 4. Hypertension. 4. Which of the following indicates a potential complication of diabetes mellitus? 1. Inflamed, painful joints. 2. Blood pressure of 160/100 mm Hg. 3. Stooped appearance. 4. Hemoglobin of 9 g/dL (90 g/L). 5. The nurse is teaching the client about home blood glucose monitoring. Which of the following blood glucose measurements indicates hypoglycemia? 1. 59 mg/dL (3.3 mmol/L). 2. 75 mg/dL (4.2 mmol/L). 3. 108 mg/dL (6 mmol/L). 4. 119 mg/dL (6.6 mmol/L). 6. Assessment of the diabetic client for common complications should include examination of the: 1. Abdomen. 2. Lymph glands. 3. Pharynx. 4. Eyes.- Diabetic retinopathy, cataracts, and glaucoma are common complications. Feet should also be examined at each encounter. 7. The client with type 1 diabetes mellitus is taught to take isophane insulin suspension NPH (Humulin N) at 5 PM each day. The client should be instructed that the greatest risk of hypoglycemia will occur at about what time? 1. 11 AM, shortly before lunch. 2. 1 PM, shortly after lunch. 3. 6 PM, shortly after dinner. 4. 1 AM, while sleeping. – eat a bedtime snack to help prevent hypoglycemia while sleeping. 8. A nurse is teaching a client with type 1 diabetes mellitus who jogs daily about the preferred sites for insulin absorption. What is the most appropriate site for a client who jogs? 1. Arms. 2. Legs. 3. Abdomen. 4. Iliac crest. 9. A client with diabetes is taking insulin lispro (Humalog) injections. The nurse should advise the client to eat: 1. Within 10 to 15 minutes after the injection. 2. 1 hour after the injection. 3. At any time, because timing of meals with lispro injections is unnecessary. 4. 2 hours before the injection. 10. The best indicator that the client has learned how to give an insulin self-injection correctly is when the client can: 1. Perform the procedure safely and correctly. 2. Critique the nurse's performance of the procedure. 3. Explain all steps of the procedure correctly. 4. Correctly answer a posttest about the procedure. 11. The nurse is instructing the client on insulin administration. The client is performing a return demonstration for preparing the insulin. The client's morning dose of insulin is 10 units of regular and 22 units of NPH. The nurse checks the dose accuracy with the client. The nurse determines that the client has prepared the correct dose when the syringe reads how many units? 32 units. 12. Angiotensin-converting enzyme (ACE) inhibitors may be prescribed for the client with diabetes mellitus to reduce vascular changes and possibly prevent or delay development of: 1. Chronic obstructive pulmonary disease (COPD). 2. Pancreatic cancer. 3. Renal failure. – ACEI increase renal blood flow and are effective in decreasing diabetic neuropathy. 4. Cerebrovascular accident. 13. Which nursing intervention is most important in preventing septic shock? 1. Administering IV fluid replacement therapy as prescribed. 2. Obtaining vital signs every 4 hours for all clients. 3. Monitoring red blood cell counts for elevation. 4. Maintaining asepsis of indwelling urinary catheters. 14. Which of the following is an indication of a complication of septic shock? 1. Anaphylaxis. 2. Acute respiratory distress syndrome (ARDS). 3. Chronic obstructive pulmonary disease (COPD). 4. Mitral valve prolapse. 15. A nurse has two middle-aged clients who have a prescription to receive a blood transfusion of packed red blood cells at the same time. The first client's blood pressure dropped from the preoperative value of 120/80 mm Hg to a postoperative value of 100/50. The second client is hospitalized because he developed dehydration and anemia following pneumonia. After checking the patency of their IV lines and vital signs, what should the nurse do next? 1. Call for both clients' blood transfusions at the same time. 2. Ask another nurse to verify the compatibility of both units at the same time. 3. Call for and hang the first client's blood transfusion. 4. Ask another nurse to call for and hang the blood for the second client. 16. The nurse identifies deficient knowledge when the client undergoing induction therapy for leukemia makes which of the following statements? 1. “I will pace my activities with rest periods.” 2. “I can't wait to get home to my cat!” 3. “I will use warm saline gargle instead of brushing my teeth.” 4. “I must report a temperature of 100°F (37.7°C).” 17. A client with acute myeloid leukemia (AML) reports overhearing one of the other clients say that AML had a very poor prognosis. The client has understood that the client's physician informed the client that his physician told him that he has a good prognosis. Which is the nurse's best response? 1. “You must have misunderstood. Who did you hear that from?” 2. “AML does have a very poor prognosis for poorly differentiated cells.” 3. “AML is the most common nonlymphocytic leukemia.” 4. “Your doctor stated your prognosis based on the differentiation of your cells.” 18. The goal of nursing care for a client with acute myeloid leukemia (AML) is to prevent: 1. Cardiac arrhythmias. 2. Liver failure. 3. Renal failure. 4. Hemorrhage. 19. The nurse is assessing a client with chronic myeloid leukemia (CML). The nurse should assess the client for: 1. Lymphadenopathy. 2. Hyperplasia of the gum. 3. Bone pain from expansion of marrow. 4. Shortness of breath. 20. Which of the following individuals is most at risk for acquiring acute lymphocytic leukemia (ALL)? The client who is: 1. 4 to 12 years. 2. 20 to 30 years. 3. 40 to 50 years. 4. 60 to 70 years. 21. The client with acute lymphocytic leukemia (ALL) is at risk for infection. The nurse should: 1. Place the client in a private room. 2. Have the client wear a mask. 3. Have staff wear gowns and gloves. 4. Restrict visitors. 22. In assessing a client in the early stage of chronic lymphocytic leukemia (CLL), the nurse should determine if the client has: 1. Enlarged, painless lymph nodes. 2. Headache. 3. Hyperplasia of the gums. 4. Unintentional weight loss. 23. The nurse is planning care with a client with acute leukemia who has mucositis. The nurse should advise the client that after every meal and every 4 hours while awake the client should use: 1. Lemon-glycerin swabs. 2. A commercial mouthwash. 3. A saline solution. 4. A commercial toothpaste and brush 24. The client with acute leukemia and the health care team establish mutual client outcomes of improved tidal volume and activity tolerance. Which measure would be least likely to promote outcome achievement? 1. Ambulating in the hallway. 2. Sitting up in a chair. 3. Lying in bed and taking deep breaths. 4. Using a stationary bicycle in the room. 25. 1) When assessing a patient'srespiratory status, which of the following nonrespiratory data are most important for the nurse to obtain? A. Height and weight B. Neck circumference C. Occupation and hobbies D. Usual daily fluid intake 26.If a nurse is assessing a patient whose recent blood gas determination indicated a pH of 7.32 and respirations are measured at 32 breaths/min, which of the following isthe most appropriate nursing assessment? A. The rapid breathing is causing the low pH. B. The nurse should sedate the patient to slow down respirations. C. The rapid breathing is an attempt to compensate for the low pH. D. The nurse should give the patient a paper bag to breathe into to correct the low pH. 27) If a patient with an uncuffed tracheostomy tube coughs violently during suctioning and dislodges the tracheostomy tube, a nurse should first A. call the physician. B. attempt to reinsert the tracheostomy tube. C. position the patient in a lateral position with the neck extended. D. cover the stoma with a sterile dressing and ventilate the patient with a manual bag-mask until the physician arrives. 28.) Upon entering the room of a patient who has just returned from surgery for total laryngectomy and radical neck dissection, a nurse should recognize a need for intervention when finding A. a gastrostomy tube that is clamped. B. the patient coughing blood-tinged secretionsfrom the tracheostomy. C. the patient positioned in a lateral position with the head of the bed flat. D. 200 ml ofserosanguineous drainage in the patient's port