HESI 2020 MED SURG

A client who has developed acute kidney injury (AKI) due to an aminoglycoside antibiotic has moved from the oliguric phase to the diuretic phase of AKI Which parameters are most important for the nurse to plan to carefully monitor? A. Hypovolemia and electrocardiographic (ECG) changes. B. Uremic irritation of mucous membranes and skin surfaces. C. Side effects of total parental nutrition (TPN) and Intralipids. D. Elevated creatinine and blood urea nitrogen (BUN)

A. Hypovolemia and ECG changes

In assessing a client with ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin? A. Irregular ulcer shapes and severe edema. B. Hairless lower extremities and cool feet. C. Black ulcers and dependent rubor. D. Absent pedal pulses and shiny skin.

A. Irregular ulcer shapes and severe edema

A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117 mEq/L. Which nursing problem should the nurse include in this client's plan of care? A. Altered urinary elimination B. Impaired gas exchange C. Fluid volume excess D. Decreased cardiac output

C. Fluid volume excess

A client with cholelithiasis is admitted with jaundice due to obstruction of the common bile duct. Which finding is most important for the practical nurse to report to the healthcare provider? A) Pain radiating to the right shoulder. B) Clay-colored stool. C) Hard, rigid abdomen. D) Vomiting bile-stained emesis.

C. HARD RIGID ABDOMEN

In providing discharge teaching to a client with chronic obstructive pulmonary disease (COPD), which instruction is most important for the nurse to emphasize? A. Notify the healthcare provider of any change in sputum color. B. Stay in the house if the outdoor temperature is hot and humid. C. Avoid going outdoors whenever the pollen count is high. D. Keep a food diary for one week and bring to next appointment.

A. Notify the healthcare provider of any change in sputum color

. Which nursing problem should be included in the plan of care for a client with heart failure?

Activity intolerance related to oxygen deficit secondary to inefficient cardiac contractility

In an outpatient diabetic clinic, the nurse is assessing clients. Which entry provides the best indication that the client is adhering to the prescribed diabetic regimen? A. Hemoglobin A1C of 6.2%. B. Fasting plasma glucose of 189 mg/dL (10.49 mmol/L). C. High-density lipoprotein of 40 mg/dL (1.03 mmol/L). D. Postprandial plasma glucose of 225 mg/dL (12.49 mmol/L).

A. Hemoglobin A1C of 6.2%

A client with a right ulnar fracture and cast placement reports an increase in arm pain. Which action should the nurse take next? A. Implement distraction techniques. B. Assess right radial pulse volume. C. Administer a PRN analgesic. D. Measure the blood pressure.

B ASSESS RIGHT RADIAL PULSE VOLUME

During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and a high waist-hip ratio, with a body mass index of 32 kg/m2. Which action(s) should the nurse take in response to these findings? (Select all that apply.) A. Measure the client's blood pressure in both arms. B. Screen for a family history of diabetes mellitus. C. Arrange for immediate transport to a medical facility. D. Advise the client to restrict fluids and keep feet elevated. E. Discuss the importance of a regular exercise program.

E. Discuss the importance of a regular exercise program A. Measure the client's blood pressure in both arms B. Screen for a family history for diabetes mellitus

The nurse is evaluating a client's understanding of diet teaching about the DASH (Dietary Approaches to Stop Hypertension) eating plan. Which behavior indicates that the client is adhering to the eating plan? A. Carefully cleans and peels all fresh fruit and vegetables B. Uses only lactose-free dairy products. C. No longer includes grains in daily diet. D. Enjoys fat-free yogurt as an occasional snack food

Enjoys fat free yogurt as an occasional snack food.

A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the health care provider?

low back pain and hypotension

.The nurse is assessing a client who is receiving enteral feedings. Which clinical data indicates the client may not be tolerating the tube feedings? Select all that apply.

nausea and vomiting Abdominal cramping Absent bowel sounds

The nurse is assessing a client whose child was sent home with pediculosis capitis. The client reports having...which finding should the nurse associate with pediculosis on further investigation?

Small red bumps on the scalp, neck, and shoulders

.A client is admitted to the hospital for shortness of breath and chest pain after an episode of syncope. Which lab finding?

Troponin I

The nurse brings a scheduled dose of docusate calcium to a male client who has cirrhosis of the liver. The client states that he never had bowel problems and does not need a stool softener. Which action should the nurse take?

Withhold the medication until consulting with the healthcare provider