HESI Version 2 of dental hygiene final exam latest and updated version

The nurse assumes care of a postoperative adult client with diabetes mellitus and learns that the client has a current blood glucose level of 720 mg. When assessing the client what is the priority? A. Assess for vital signs of fluid volume deficit. B. Observe wound drainage characteristics. C. Measure the level of acute pain. D. Determine when the client last ate. - CORRECT ANSWER-A. Assess for vital signs of fluid volume deficit. A male client tells the nurse that he is concerned that he may have a stomach ulcer because he is experiencing heartburn and a dull gnawing pain. Which is the *best* response by the nurse? A. Encourage the client to obtain a complete physical exam since these symptoms are consistent with an ulcer. B. Assure the client that his symptoms may only reflect reflux, since ulcer pain is not relieved with food. C. Instruct the client that these mild symptoms can generally be controlled with changes in his diet. D. Advise the client that he needs to seek immediate medical evaluation and treatment for these symptoms. - CORRECT ANSWER-A. Encourage the client to obtain a complete physical exam since these symptoms are consistent with an ulcer. A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer' IV. One hour after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client's heart rate is 155 beats/minute. In addition to reporting the findings to the surgeon, which action should the nurse implement *first?* A. Measure and document the client's urinary output. B. Request the client's reserved unit of packed red blood cells. C. Prepare for the placement of central venous catheter. D. Increase the infusion rate of Lactated Ringer's solution. - CORRECT ANSWER-D. Increase the infusion rate of Lactated Ringer's solution. A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80 units/kg the nurse calculates infusion rate for the heparin solution at 18 units/kg/hour. The available solution is Heparin Sodium 25,000 Units in 5% Dextrose Injection 250 mL. The nurse should program the infusion pump to how many mL/hour? - CORRECT ANSWER-18 An adult male who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). The nurse notes that the suction control chamber is bubbling at the -10 cm H2O mark with fluctuation in the water seal, and over the past hour 75 mL of bright red blood is measured in the collection chamber. Which intervention should the nurse implement? A. Add sterile water to the suction control chamber B. Give blood from the collection chamber as autotransfusion C. Manipulate blood in tubing to drain into the chamber D. Increase wall suction to eliminate fluctuation in water seal - CORRECT ANSWER-A. Add sterile water to the suction control chamber. An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. Which is the *best* response by the nurse?