2023 HESI PN MED SURGE /MED SURGE PN HESI EXIT EXAM TEST BANK NEWEST ACTUAL EXAM

2023 HESI PN MED SURGE /MED SURGE PN HESI EXIT EXAM TEST BANK NEWEST ACTUAL EXAM A nurse is caring for a client who is in the oliguric phase of acute kidney injury. Which of thefollowingactions should the nurse take? 1) Provide a diet high in protein. 2) Provide ibuprofen forretroperitoneal discomfort. 3) Monitor intake and output hourly 4) Encourage the client to consume at least 2 L of fluid daily. A nurseisreinforcingteachingaboutanesophagogastroduodenoscopy withaclientwhohasuppergastricpain.Whichofthefollowingstatements shouldthenurseincludeintheteaching? 1) "A flexible tube isintroduced through the nose during the procedure." 2) "During the procedure you are in a sitting position." 3) "You willremain NPO for 8 hours before the procedure." 4) "You will be awake while the procedure is performed." A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following ageneralized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record? 1) Aura phase 2) Presence of automatisms 3) Postictal phase 4) Presence ofabsence seizures A nurse is reinforcing teaching with a client who reports right shoulder pain following a laparoscopiccholecystectomy. Which of the following statements should the nurse make? 1) "The pain results from lying in one position too long during surgery." 2) "The pain occursasa residual pain from cholecystitis." 3) "The pain will dissipate if you ambulate frequently." 4) "The pain iscaused from the nitrous dioxide injected into the abdomen." A nurse is checking the suction control chamber of a client's chest tube and notes that there is nobubbling in the suction control chamber. Which of the following actions should the nurse take? 1) Notifythe provider. Answer Rationale: The nurse should check for kinks and take other measures before notifying the provider. 2) Verifythat the suction regulator is on. 3) Continue to monitorthe client because thisisan expected finding. 4) Milk the chest tube to dislodge anyclots in the tubing that may be occluding it. A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of thefollowing actions should the nurse take?(Selectall that apply.) 1) Encourage fluid intake. 2) Monitorthe puncture site for hematoma. 3) Inserta urinarycatheter. 4) Elevate the client’s head of bed. 5) Applyacervicalcollarto the client. A nurse is assisting with the care of a client who is postoperative following surgical repair of a fracturedmandible. The client’s jaw is wired shut to repair and stabilize the fracture. The nurseshould recognize which of thefollowing is thepriority action? 1) Relieve the client's pain. 2) Check the client’s pressure pointsforredness. 3) Provide oral hygiene. 4) Prevent aspiration. A nurse is collecting data from a client who has scleroderma. Which of the following findings should thenurse expect? 1) A dryraised rash 2) Excessive salivation 3) Periorbital edema 4) Hardened skin A nurse is caring for an older adult client who has dysphagia and left-sided weakness following astroke. Which of the following actions should the nurse take? 1) Instruct the client to tilt her head back when she swallows. 2) Place food on the leftside of the client's mouth. 3) Add thickenerto fluids. 4) Serve food atroom temperature. A nurse is caring for a client who has partial-thickness and full-thickness burns of his head, neck, andchest. The nurse shouldrecognize which of thefollowing is the priority risk tothe client? 1) Airway obstruction 2) Infection 3) Fluid imbalance 4) Contractures A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis and is to start taking neostigmine. Which of the following instructions should the nurse include in the teaching? 1) Take the medication 45 minutes before eating. 2) Expect diaphoresis asa side effect of the neostigmine. 3) If a medication dose is missed, wait until the next scheduled dose to take themedication. 4) Treat nasalrhinitis with an over-the-counterantihistamine. A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse notes there hasnot been any urinary output in the last hour. Which of the following actions should the nurse perform first? 1) Notifythe provider. 2) Administer a prescribed analgesic. 3) Offer oral fluids. 4) Determine the patency of the tubing. A nurse is caring for a client scheduled for a bone marrow biopsy. The client expresses fear about the procedure and asks the nurse if the biopsy will hurt. Which of the following responses should the nursemake? 1) "You must be very worried about what the biopsy will show." 2) "You'll be asleep for the whole biopsy procedure and won't be aware of what’shappening." 3) "Your provider scheduled this, so she will want to know you still have questions aboutthe procedure." 4) "The biopsy can be uncomfortable, but we will try to keep you as comfortable aspossible." pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Oxygen saturation 80% Bicarbonate 28 mEq/L Which of the following interpretations of the ABG values should the nurse make A nurse is assisting with planning care for a client who is recovering from a left-hemispheric stroke. Which of the following interventions should the nurse include in the plan? 1) Control impulsive behavior. 2) Compensate for left visual field deficits. 3) Re-establish communication. 4) Improve left-side motor function. A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should monitor the client for which of the following manifestations? 1) Hypotension 2) Polyphagia 3) Hyperglycemia 4) Bradycardia A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas (ABG) values include: 1) Metabolic acidosis 2) Respiratory acidosis 3) Metabolic alkalosis 4) Respiratoryalkalosis A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). The nurseshould recognize that which of the following statements by the client indicates a need for further teaching? 1) "I willavoid crossingmylegsat the knees." 2) "I will use athermometer to check the temperature of my bath water." 3) "I will not go barefoot." 4) "Iwillwearstockings with elastictops." A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease. The client becomes agitated and combative when the nurse approaches him. Which of the following actionsshould the nurse plan totake? 1) Turn the water on and ask the client to test the temperature. 2) Obtain assistance to place mitten restraints on the client. 3) Firmlytell the client that good hygiene isimportant. 4) Calmlyask the client if he would like to listen to some music. A nurse is collecting data on a client’s wound. The nurse observes that the wound surface is covered with soft, red tissue that bleeds easily. The nurse should recognize this is a manifestation of which of thefollowing? 1) Decreased perfusion 2) Infection 3) Granulation tissue 4) An inflammatory response A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3 . Which of the following food items brought by the family should the nurse prohibit from being given to the client? 1) Baked chicken 2) Bagels 3) A factory-sealed box ofchocolates 4) Fresh fruit basket A nurse is contributing to the plan of care for an older adult client who is postoperative following a righthip arthroplasty. Which of the following interventions should the nurse include in the plan? 1) Perform the client's personalcare activitiesfor her. 2) Limit the client’sfluid intake. 3) Monitor the Homan’s sign. 4) Maintain abduction of the right hip. A nurse is caring for a client who has heart failure and respiratory arrest. Which of the following actionsshould the nurse take first? 1) Establish IV access. 2) Feel foracarotid pulse. 3) Establish an open airway. 4) Auscultate for breath sounds. A nurse is caring for a client scheduled for coronary artery bypass grafting who reports he is no longercertain he wants to have the procedure. Which of the following responses should the nurse make? 1) "Why have you changed your mind about the surgery?" 2) "Bypass surgery must be very frightening for you." 1) Take temperature once a day. 2) Wash the armpits and genitals with a gentle cleanser daily. 3) Change the litter boxes while wearing gloves. 4) Wash dishes in warm water. 3) "Your provider would not have scheduled the surgery unless you needed it." 4) "I will call your doctor and have him discuss your surgery with you." A nurse is caring for a client who is postoperative following foot surgery and is not to bear weight onthe operative foot. The nurse enters the room to discover the client hopped on one foot to the bathroom, using an IVpole for support. Which of the following actions should the nurse take? 1) Walk the client back to bed immediatelyand get the client a bedpan. 2) Tell the client to remain in the bathroom aftertoileting and obtain a wheelchair. 3) Warn the client she might have to be restrained if she gets up without assistance. 4) Keep the bathroom door open to ensure the client is okay. A nurse is assisting with the care of a client who is postoperative and has a closed-wound drainagesystem in place. Which of the following actions should thenurse take? 1) Fullyrecollapse the reservoirafter emptying it. 2) Emptythe reservoir once per day. 3) Replace the drainage plug after releasing hand pressure on the device. 4) Irrigate the tubing with sterile normal saline solution at least once every 8 hr. A nurse is reinforcing discharge instructions with a client who has hepatitis A. Which of the followingstatements by the client indicates an understanding of the teaching? 1) "I will not eat fried foods." 2) "I will abstain from sexual intercourse." 3) "I willrefrain from international travel." 4) "I will not order a salad in a restaurant." A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosedwith emphysema. Which of the following instructions should be included in the teaching? 1) Rest in a supine position. 2) Consume alow-protein diet. 3) Breathe in through her nose and out through pursed lips. 4) Limit fluid intake throughout the day. A nurse is caring for a client who is postoperative and has a history Addison's disease. For which of thefollowing manifestations should thenurse monitor? 1) Hypernatremia2) Hypotension 3) Bradycardia 4) Hypokalemia VERSION 2 A nurse is reinforcing teaching with a client who has HIV and is being discharged to home.Whichof the following instructions should the nurse include inthe teaching? 1. A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for thenursetouse tothin this client's secretions? 1) Provide humidified oxygen. 2) Perform chest physiotherapy priorto suctioning. 3) Prelubricate the suction cathetertip with sterile saline when suctioning the airway. 4) Hyperventilate the client with 100% oxygen before suctioning the airway.. 2. Following admission, a client with a vascular occlusion of the right lower extremity callsthe nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should thenurse taketopromote the client's comfort? 1) Rub the client's feet brisklyforseveral minutes. 2) Obtain a pair ofslippersocks for the client. 3) Increase the client's oral fluid intake. 4) Place a moist heating pad underthe client's feet. 3. A nurse is caring for a client is who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for thenurse report to the provider? 1) Emesis of 100 mL 2) Oral temperature of 37.5° C (99.5° F) 3) Thick,red-colored urine 4) Pain level of 4 on a 0 to 10 rating scale 4. A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a hypothermia blanket. The nurse should monitor the client for which ofthefollowing adverseeffects of the hypothermia blanket? 1) Shivering 2) Infection 3) Burns 4) Hypervolemia 5. A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of theteaching? 1) "I willcarryacomplexcarbohydrate snack with me when I exercise." 2) "Ishould exercise first thing in the morning before eating breakfast." 3) "Ishould avoid injecting insulin into mythigh if Iam going to go running." 4) "I will not exercise if my urine is positive for ketones." 6. A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should thenurse take first? 1) Coverthe client's wound with a moist,sterile dressing. 2) Have the client lie supine with knees flexed. 3) Checkthe client's vitalsigns. 4) Inform the clientabout the need to return to surgery. 7. A nurse is collecting data from a client who has alcohol use disorder and is experiencingmetabolicacidosis. Whichof the following manifestations should thenurseexpect? 1) Cool, clammy skin.2) Hyperventilation 3) Increased blood pressure 4) Bradycardia 8. A nurse is reinforcingdischargeteaching withaclient followingacataractextraction.Which of the following should thenurse include in the teaching? 1) Avoid bending at the waist. 2) Remove the eye shield at bedtime. 3) Limit the use of laxatives ifconstipated. 4) Seeing flashes of light isan expected finding following extraction. 9. A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mgdaily. The client refuses breakfast and reports nausea. Which of the following actions should thenurse takefirst? 1) Suggest that the client rests before eating the meal. 2) Requesta dietaryconsult. 3) Checkthe client's vitalsigns. 4) Requestan order foran antiemetic. 10.A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. Thenurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found? 1) Sanguineous 2) Serous 3) Serosanguineous 4) Purulent 11.A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent postoperative complications which of the following actions should be reinforcedduringtheteaching? 1) Administeran opioid analgesicto the client 30 min priorto initiating CPM exercises. 2) Place the client’s affected leg into the CPM machine with the machine in the flexedposition. 3) Place the client into a high Fowler’s position when initiating the CPM exercises. 4) Align the joints of the CPM machine with the knee gatch in the client’s bed. 12.A nurse is collecting data from a client who has emphysema. Which of the followingfindings should the nurse expect? (Selectall that apply.) 1) Dyspnea 2) Barrelchest 3) Clubbing of the fingers4) Shallow respirations 5) Bradycardia 13.A nurse is caring for a client who sustained a basal skull fracture. When performing morning hygiene care, the nurse notices a thin stream of clear drainage coming from out oftheclient's rightnostril. Which of thefollowing actions should thenursetake first? 1) Take the client's temperature. 2) Place a dressing under the client's nose. 3) Notifythe charge nurse. 4) Test the drainage for glucose. 14.A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the followinginterventions should the nurse take toprevent autonomic dysreflexia? 1) Monitorfor elevated blood pressure. 2) Provide analgesia for headaches. 3) Prevent bladder distention. 4) Elevate the client's head. 15.A nurse is caring for a client who is being evaluated for endometrial cancer. Which of thefollowing findings should thenurseexpect theclient to report? 1) Hot flashes 2) Recurrent urinarytract infections 3) Blood in the stool 4) Abnormalvaginal bleeding