HESI MED SURG #1 TEST :solution
graded A+
The nurse is providing care to a client after a percutaneous transluminal coronary
angioplasty (PTCA). What actions will the nurse include in the client's plan of care?
(Select all that apply.) - ANSWERSA.Frequent vital signs.
B.Determine if the client is allergic to aspirin.
D.Offer fluids of choice.
F.Monitor infusion of IV nitroglycerine.
In assessing a client diagnosed with primary aldosteronism, the nurse expects the
laboratory test results to indicate a decreased serum level of which substance? -
ANSWERSC.Potassium
Clients with primary aldosteronism exhibit a profound decline in serum levels of
potassium; hypokalemia; hypertension is the most prominent and universal sign.
The nurse is providing care for a client diagnosed with trigeminal neuralgia (tic
douloureux). Which symptoms will the nurse be looking for in the focused assessment
related to this condition? (Select all that apply.) - ANSWERSA.Facial muscle spasms
B.Sudden facial pain
Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock,
in the area innervated by one or more branches of the trigeminal nerve (cranial V).
A 74-year-old male client is admitted to the intensive care unit (ICU) with a diagnosis of
respiratory failure secondary to pneumonia. Currently, the client is ventilator-dependent,
with settings of tidal volume (VT) of 750 mL and an intermittent mandatory ventilation
(IMV) rate of 10 breaths/min. Arterial blood gas (ABG) results are as follows: pH, 7.48;
PaCO2, 30 mm Hg; PaO2, 64 mm Hg; HCO3, 25 mEq/L; and FiO2, 0.80. Which action
should the nurse take first? - ANSWERSD.Add 5 cm positive end-expiratory pressure
(PEEP)
Adding PEEP helps improve oxygenation while reducing FiO2 to a less toxic level
The clinic nurse is providing post-operative teaching for a client scheduled for a
myringoplasty. Which client statements indicate to the nurse that the teaching has been
effective? (Select all that apply.) - ANSWERSB."I will avoid forceful and deep coughing
until my post-op checkup.
C."I must lay flat on my non-operative side for the first 12 hours after surgery."
D."My hearing may be less or muffled until the packing comes out."
The client must keep the ear bandage clean and dry until the packing is removed.
Showering and hair washing is discouraged.
During the shift report, the charge nurse informs a nurse of a reassignment to another
unit for the day. The nurse begins to sigh deeply and tosses about her belongings when
, preparing to leave. What is the best immediate action for the charge nurse to take? -
ANSWERSA.
Continue with the shift report and talk to the nurse about the incident at a later time.
Continuing with the shift report is the best immediate action because it allows the nurse
who was floated some cooling off time. At a later time (after the nurse has cooled off)
the charge nurse should discuss the conduct of the nurse in private.
The nurse is completing an admission interview for a client with Parkinson disease.
Which question will provide additional information about manifestations that the client is
likely to experience? - ANSWERSC."Have you ever been frozen in one spot, unable to
move?"
Clients with Parkinson 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 teaches a client with type 2 diabetes nutritional strategies to decrease
obesity. Which food items chosen by the client indicate understanding of the teaching?
(Select all that apply.) - ANSWERSB.Salmon
C.Broccoli
E.Banana
Options B, C, and E provide fresh fruits, lean meats and fish, vegetables, whole grains,
and low-fat dairy products. All are recommended by the American Diabetes Association
(ADA) and are a part of the My Plate guidelines recommended by the U.S. Department
of Agriculture (USDA).
Which nursing action would be appropriate for a client who is newly diagnosed with
Cushing syndrome? - ANSWERSA.Monitor blood glucose levels daily.
Cushing syndrome results from a hypersecretion of glucocorticoids in the adrenal
cortex. Clients with Cushing syndrome often develop diabetes mellitus. Monitoring of
serum glucose levels assesses for increased blood glucose levels so that treatment can
begin early
A resident in a long-term care facility is diagnosed with hepatitis B. Which action should
the nurse take with the staff caring for this client? - ANSWERSA.Determine if all
employees have had the hepatitis B vaccine series.
Hepatitis B vaccine should be administered to all health care providers. Hepatitis A (not
hepatitis B) can be transmitted by fecal-oral contamination.
A client in the emergency department is bleeding profusely from a gunshot wound to
the abdomen. What action should the nurse immediately? - ANSWERSC.Maintain the
client in a supine position to reduce diaphragmatic pressure and visualize the wound.
Placing the client in a supine position reduces diaphragmatic pressure, thereby
enhancing oxygenation, and allows for visualization of the abdominal wound.
While at a home game, the mother of a 6-year-old is heard screaming, "My child is
having an asthma attack! Can anyone help?" The nurse arrives and finds the child
graded A+
The nurse is providing care to a client after a percutaneous transluminal coronary
angioplasty (PTCA). What actions will the nurse include in the client's plan of care?
(Select all that apply.) - ANSWERSA.Frequent vital signs.
B.Determine if the client is allergic to aspirin.
D.Offer fluids of choice.
F.Monitor infusion of IV nitroglycerine.
In assessing a client diagnosed with primary aldosteronism, the nurse expects the
laboratory test results to indicate a decreased serum level of which substance? -
ANSWERSC.Potassium
Clients with primary aldosteronism exhibit a profound decline in serum levels of
potassium; hypokalemia; hypertension is the most prominent and universal sign.
The nurse is providing care for a client diagnosed with trigeminal neuralgia (tic
douloureux). Which symptoms will the nurse be looking for in the focused assessment
related to this condition? (Select all that apply.) - ANSWERSA.Facial muscle spasms
B.Sudden facial pain
Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock,
in the area innervated by one or more branches of the trigeminal nerve (cranial V).
A 74-year-old male client is admitted to the intensive care unit (ICU) with a diagnosis of
respiratory failure secondary to pneumonia. Currently, the client is ventilator-dependent,
with settings of tidal volume (VT) of 750 mL and an intermittent mandatory ventilation
(IMV) rate of 10 breaths/min. Arterial blood gas (ABG) results are as follows: pH, 7.48;
PaCO2, 30 mm Hg; PaO2, 64 mm Hg; HCO3, 25 mEq/L; and FiO2, 0.80. Which action
should the nurse take first? - ANSWERSD.Add 5 cm positive end-expiratory pressure
(PEEP)
Adding PEEP helps improve oxygenation while reducing FiO2 to a less toxic level
The clinic nurse is providing post-operative teaching for a client scheduled for a
myringoplasty. Which client statements indicate to the nurse that the teaching has been
effective? (Select all that apply.) - ANSWERSB."I will avoid forceful and deep coughing
until my post-op checkup.
C."I must lay flat on my non-operative side for the first 12 hours after surgery."
D."My hearing may be less or muffled until the packing comes out."
The client must keep the ear bandage clean and dry until the packing is removed.
Showering and hair washing is discouraged.
During the shift report, the charge nurse informs a nurse of a reassignment to another
unit for the day. The nurse begins to sigh deeply and tosses about her belongings when
, preparing to leave. What is the best immediate action for the charge nurse to take? -
ANSWERSA.
Continue with the shift report and talk to the nurse about the incident at a later time.
Continuing with the shift report is the best immediate action because it allows the nurse
who was floated some cooling off time. At a later time (after the nurse has cooled off)
the charge nurse should discuss the conduct of the nurse in private.
The nurse is completing an admission interview for a client with Parkinson disease.
Which question will provide additional information about manifestations that the client is
likely to experience? - ANSWERSC."Have you ever been frozen in one spot, unable to
move?"
Clients with Parkinson 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 teaches a client with type 2 diabetes nutritional strategies to decrease
obesity. Which food items chosen by the client indicate understanding of the teaching?
(Select all that apply.) - ANSWERSB.Salmon
C.Broccoli
E.Banana
Options B, C, and E provide fresh fruits, lean meats and fish, vegetables, whole grains,
and low-fat dairy products. All are recommended by the American Diabetes Association
(ADA) and are a part of the My Plate guidelines recommended by the U.S. Department
of Agriculture (USDA).
Which nursing action would be appropriate for a client who is newly diagnosed with
Cushing syndrome? - ANSWERSA.Monitor blood glucose levels daily.
Cushing syndrome results from a hypersecretion of glucocorticoids in the adrenal
cortex. Clients with Cushing syndrome often develop diabetes mellitus. Monitoring of
serum glucose levels assesses for increased blood glucose levels so that treatment can
begin early
A resident in a long-term care facility is diagnosed with hepatitis B. Which action should
the nurse take with the staff caring for this client? - ANSWERSA.Determine if all
employees have had the hepatitis B vaccine series.
Hepatitis B vaccine should be administered to all health care providers. Hepatitis A (not
hepatitis B) can be transmitted by fecal-oral contamination.
A client in the emergency department is bleeding profusely from a gunshot wound to
the abdomen. What action should the nurse immediately? - ANSWERSC.Maintain the
client in a supine position to reduce diaphragmatic pressure and visualize the wound.
Placing the client in a supine position reduces diaphragmatic pressure, thereby
enhancing oxygenation, and allows for visualization of the abdominal wound.
While at a home game, the mother of a 6-year-old is heard screaming, "My child is
having an asthma attack! Can anyone help?" The nurse arrives and finds the child
