Med surg hesi Study guides, Revision notes & Summaries

1. The nurse is assessing a 48-year-old client with a history of smoking during a routine clinic visit. The client, who exercises regularly, reports having pain in the calf during exercise that disappears at rest. Which of the following findings requires further evaluation? 1. Heart rate 57 bpm. 2. SpO2 of 94% on room air. 3. Blood pressure 134/82. 4. Ankle-brachial index of 0.65. ANS 4 2. A client with peripheral vascular disease has undergone a right femoralpopliteal bypass graft. The b...

1. The nurse is assessing a client's laboratory values following administration of chemotherapy. Which lab value leads the nurse to suspect that the client is experiencing tumor lysis syndrome (TLS)? a. Serum PTT of 10 seconds. b. Serum calcium of 5 mg/dL. c. Oxygen saturation of 90%. d. Hemoglobin of 10 g/Dl ANS B - Tumor lysis syndrome (TLS) results in hyperkalemia, hypocalcemia, hyperuricemia, and hyperphosphatemia. A serum calcium level of 5, which is low, is an indicator of possible t...

1. A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching? A. Take temperature once a day. B. Wash the armpits and genitals with a gentle cleanser daily. C. Change the litter boxes while wearing gloves. D. Wash dishes in warm water. ANS A. 2. A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the follo...

1. A nurse is caring for a client with diabetes insipidus (DI). Which data war- rants the most immediate intervention by the nurse? A. Serum sodium of 185 mEq/L B. Dry skin with inelastic turgor C. Apical rate of 110 beats per minute D. Polyuria and excessive thirst ANS A. 2. The nurse is obtaining the admission history for a client with suspected peptic ulcer disease. Which subjective data reported by the client supports the medical diagnosis? A. Frequent use of chewable and liquid ant...

1. The nurse assesses a patient with shortness of breath for evidence of long-standing hypoxemia by inspecting A. Chest excursion B. Spinal curvatures C. The respiratory pattern D. The fingernail and its base ANS D. The fingernail and its base Clubbing, a sign of long-standing hypoxemia, is evidenced by an increase in the angle between the base of the nail and the fingernail to 180 degrees or more, usually accompanied by an increase in the depth, bulk, and sponginess of the end of the fin...

1. While shopping, a woman is observed to clutch her chest and fall to the ground. A group of people gather around the woman. A few in the group state that they are health care professionals and begin a primary survey by looking for life-threatening injuries. Once it is determined that no life-threatening injuries have occurred, they begin to intervene. The first intervention is A) Initiate cardiopulmonary resuscitation B) Look for uncontrolled bleeding C) Assess airway, breathing, and circ...

1. The nurse is completing a health assessment of a 42-year-old female with suspected Graves' Disease. The nurse should assess this client for: 1. anorexia 2. tachycardia 3. weight gain 4. cold skin ANS : 2. tachycardia Graves' disease, the most common type of thyrotoxicosis, is a state of hypermetab- olism. The increased metabolic rate generates heat and produces tachycardia and fine muscle tremors. Anorexia is associated with hypothyroidism. Loss of weight, despite a good appetite and ...

1. The nurse is preparing to assist a client with a cuffed tracheostomy tube to eat. What intervention is the priority before the client is permitted to drink or eat ANS Inflate the cuff Rationale: If a client with a tracheostomy is allowed to eat and the tracheostomy has a cuff, the nurse should inflate the cuff to prevent aspiration of food or fluids. The cuff would not be deflated because of the risk of aspiration. 2. The nurse has implemented a bowel maintenance program for an uncon- scio...

1. 1. A nurse is visiting a client who is receiving home health care, focusing on medication and dietary instructions and management of heart failure. The nurse should reinforce which instruction? A.) If you feel tired and short of breath, lie down flat and prop up your feet. B.) Eating liver several times a week will help build up your strength. C.) Your daily dose of furosemide should be taken first thing in the morning. D.) The dose of enalapril will help prevent vasodilation from occurr...

1. What Information should the nurse include in the teaching plan of a client diagnosed with GERD? A. Sleep without pillows B. Adjust food intake to three full meals per day with no snacks C. Minimize symptoms by wearing loose, comfortable clothing D. Avoid Participation in any aerobic exercise program ANS C. Minimize symptoms by wearing loose, comfortable clothing 2. After a hospitalization for SIADH, a client develops pontine myelinolysis. Which Intervention should the nurse implement fi...