Med Surg V2 PN HESI

47. A nurse is caring for a client who is having an allergic reaction to a blood transfusion. In what order should the nurse provide care for this client? 1. Stop the transfusion. 2. Send the blood bag and blood slip to the blood bank. 3. Keep the vein open with normal saline solution. 4. Administer an antihistamine as directed.

1,3,4,2

53. While assessing a neonate 30 minutes after birth, the nurse observes that the child has a short neck covered with webbing. The nurse should further assess the client for: 1. Genetic deviations. 2. Cleft palate. 3. Potter's syndrome. 4. Neural tube defects.

3. Potter's syndrome.

26. A client is diagnosed with genital herpes, (herpes simplex virus type 2, or HSV-2). The nurse should instruct the client that: 1. Using occlusive ointments may decrease the pain from the lesions. 2. Reducing stressful life events may decrease the incidence of herpetic outbreaks. 3. There are no effective drug therapies to manage herpes symptoms. 4. Herpes is transmitted to partners only when lesions are weeping.

2. Reducing stressful life events may decrease the incidence of herpetic outbreaks.

39. A 7-year-old child is admitted to the hospital with acute rheumatic fever. When discussing long-term care for the child with the parents, the nurse should teach them that a necessary part of this care is: 1. Physical therapy. 2. Antibiotic therapy. 3. Psychological therapy. 4. Anti-inflammatory therapy.

2. Antibiotic therapy.

54. A client has severe diarrhea that has lasted for 2 days. The nurse should now assess the client for: 1. Muscle spasms. 2. Thirst. 3. Arrhythmia. 4. Confusion.

3. Arrhythmia.

52. A child with sickle cell crisis is being discharged. As part of discharge teaching to prevent further crisis, the nurse advises the parent to do which of the following? 1. Encourage the child to drink lots of liquids. 2. Take the child's temperature every morning. 3. Weigh the child every day. 4. Offer the child a high-protein diet.

1. Encourage the child to drink lots of liquids.

28. A young adult has been bitten by a human, and the skin on the forearm is broken. The client's last tetanus shot was about 8 years ago. The nurse should prepare the client for: 1. An injection of tetanus toxoid. 2. An application of a corticosteroid cream. 3. Closure of the wound with sutures. 4. Testing for tuberculosis.

1. An injection of tetanus toxoid.

33. The nurses in the neonatal intensive care unit are not identifying important clinical changes in the clients that need to be documented. The unit director should initiate which of the following actions? Select all that apply. 1. Identify the problem at a staff meeting without placing blame on any individual or group. 2. Ask the unit staff to develop a plan that they think will work for the unit members. 3. Ask an experienced nurse to spend time reorienting newer staff members. 4. Collaborate with the staff development educator to develop a plan. 5. Ask the neonatologist to give a presentation about assessing newborns.

1,2,4

55. The nursing staff on the antepartal unit has Depo Lupron and Depo Provera in the pharmacy for their clients. The nursing staff observed that the vials are similar in size and shape and could be confused. In order to promote client safety, the nursing staff should take which of the following actions? Select all that apply. 1. Petition the pharmacy to relocate one drug away from the other product. 2. Move the drugs to a new position within the medication administration system during the night shift. 3. Communicate concerns, measures to remedy, and final decisions to all staff. 4. Leave repositioning of drugs to pharmacy staff to resolve. 5. Collaborate with pharmacy staff to develop a location that works well for both groups.

1,3,5

32. Which of the following indicates that a 5-month-old weighing 15 lb (6.8 kg) and being treated for dehydration has a normal urine output? The urine output is: 1. 1 to 2 mL/kg/h. 2. 3 to 5 mL/kg/h. 3. 6 to 8 mL/kg/h. 4. 10 to 12 mL/kg/h.

1. 1 to 2 mL/kg/h.

41. A client is admitted to the hospital with a diagnosis of suspected pulmonary embolism. Physician prescriptions include the following: oxygen 2 to 4 L/min per nasal cannula, oximetry at all times, and IV administration of 5% dextrose in water at 100 mL/h. The client has increasing dyspnea and has a respiratory rate of 32 breaths/min. The nurse should first: 1. Increase the oxygen flow rate from 2 to 4 L/min. 2. Call the physician immediately. 3. Provide reassurance to the client. 4. Obtain a sample for arterial blood gas analysis.

1. Increase the oxygen flow rate from 2 to 4 L/min.

45. A client is at risk for development of metabolic alkalosis because of persistent vomiting. The nurse should assess the client specifically for: 1. Irritability. 2. Hyperventilation. 3. Diarrhea. 4. Edema.

1. Irritability.

37. The nurse is assessing an infant diagnosed with bacterial meningitis. The nurse should ask the parent if the infant has which of the following? Select all that apply. 1. Fever. 2. Vomiting. 3. Diarrhea. 4. Poor feeding. 5. Abdominal pain.

1. Fever. 2. Vomiting. 4. Poor feeding.

44. A primary care provider is calling the pediatric unit and asking the nurse to go into the electronic medical record (EMR) for test results of a fellow pediatrician. How should the nurse respond to this request? 1. Identify if the caller is the primary care provider of record or has a need to know. 2. Access the EMR and give the primary care provider the test results. 3. Decline to give the primary care provider the information requested. 4. Determine whether the nurse can access the EMR.

1. Identify if the caller is the primary care provider of record or has a need to know.

21. The nurse should assess the child with nephrotic syndrome for which of the following? Select all that apply. 1. Normal blood pressure. 2. Generalized edema. 3. Normal serum lipid levels. 4. No red blood cells in the urine. 5. Elevated streptococcal antibody titers.

1. Normal blood pressure. 2. Generalized edema. 4. No red blood cells in the urine.

7. A mother who is breast-feeding and has known food sensitivities is asking the nurse what foods she should avoid in her diet. The nurse should advise her to avoid which foods? Select all that apply. 1. Shellfish. 2. Eggs. 3. Peanuts. 4. Beef. 5. Lamb.

1. Shellfish. 2. Eggs. 3. Peanuts.

16. When witnessing an adult client's signature on a consent for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. The nurse should verify which of the following? Select all that apply. 1. That there was adequate disclosure of information. 2. That the client understood the information. 3. That there was voluntary consent on the client's part. 4. That the client has full awareness of the potential complications. 5. That the client's relative, spouse, or legal guardian was present.

1. That there was adequate disclosure of information. 2. That the client understood the information. 3. That there was voluntary consent on the client's part. 4. That the client has full awareness of the potential complications.

9. After the client has a temporary pacemaker inserted, the nurse should verify that which of the following has been documented? 1. The client's cardiovascular status. 2. The client's emotional state. 3. The type of sedation used. 4. Pacemaker rate, type, and settings.

1. The client's cardiovascular status.

27. The client is having ototoxic effects of the vestibular branch of the acoustic nerve. The nurse should assess the client for which of the following? Select all that apply. 1. Vertigo. 2. Tinnitus. 3. Nausea. 4. Ataxia. 5. Hearing loss.

1. Vertigo. 3. Nausea. 4. Ataxia.

2. A client at a follow-up appointment after having a miscarriage 2 weeks previously yells at the nurse, "How could God do this to me? I've never done anything wrong." Which of the following responses by the nurse would be most appropriate at this time? 1. "God can handle your anger. It's okay." 2. "I know you are angry. It's so hard to lose your baby." 3. "It isn't God's fault. It was an accident." 4. "You're a strong person. You will get through this."

2. "I know you are angry. It's so hard to lose your baby."

15. A client asks the nurse why it is necessary to complete an advance directive on admission to the hospital. The nurse's best response is which of the following? 1. "This will provide a substitute for informed discussion with your primary care provider." 2. "It is your chance to make your wishes known if you ever become incapable of making your own decisions." 3. "Your primary care provider will make the best decisions for you in an emergency." 4. "Are you worried that extraordinary means will be taken if you are dying?"

2. "It is your chance to make your wishes known if you ever become incapable of making your own decisions."

20. A client with asthma asks the nurse if she should use her salmeterol inhaler when she exercises and experiences wheezing and shortness of breath. The nurse's best response is which of the following? 1. "Yes, use the inhaler immediately for these symptoms." 2. "No, this drug is a maintenance drug, not a rescue inhaler." 3. "Use the inhaler 5 minutes before you exercise to prevent the wheezing." 4. "This inhaler is for allergic rhinitis, not asthma."

2. "No, this drug is a maintenance drug, not a rescue inhaler."

31. A client with chronic obstructive pulmonary disease is bedridden at home and gets little exercise. The nurse should assess the client for which of the following? 1. Increased sodium retention. 2. Increased calcium excretion. 3. Increased insulin use. 4. Increased red blood cell production.

2. Increased calcium excretion.

19. A 2-month-old infant is at risk for an ileus after surgery to correct intussusception. Which of the following should be included in a focused assessment for this complication? Select all that apply. 1. Measurement of urine specific gravity. 2. Assessment of bowel sounds. 3. Characteristics of the first stool. 4. Measurement of gastric output. 5. Bilirubin levels.

2. Assessment of bowel sounds. 3. Characteristics of the first stool. 4. Measurement of gastric output.

46. Which of the following should first alert the nurse that a child is hemorrhaging after a tonsillectomy? 1. Mouth breathing. 2. Frequent swallowing. 3. Requests for a drink. 4. Increased pulse rate.

2. Frequent swallowing.

25. The nurse is watching two siblings, ages 7 and 9 years, verbally arguing over a toy. The nurse has counseled the parent before about how to handle this situation. The nurse should judge that the teaching has been effective when the parent does which of the following? 1. Tells the siblings to stop arguing and shake hands. 2. Ignores the arguing and continues what she is doing. 3. Tells the children they will be punished when they go home. 4. Says they will not go out to lunch now since they have argued.

2. Ignores the arguing and continues what she is doing.

38. Which of the following nursing interventions would best accomplish the goal of preventing atelectasis and pneumonia in a postoperative client? 1. Administering oxygen therapy as needed to maintain adequate oxygenation. 2. Offering pain medication before having the client deep-breathe and use incentive spirometry. 3. Encouraging the client to cough, deep-breathe, and turn in bed once every 4 hours. 4. Forcing fluids to 2,000 mL every 24 hours.

2. Offering pain medication before having the client deep-breathe and use incentive

42. A 10-month-old child has cold symptoms. The mother asks how she can clear the infant's nose. Which of the following would be the nurse's best recommendation? 1. Use a cool air vaporizer with plain water. 2. Use saline nose drops and then a bulb syringe. 3. Blow into the child's mouth to clear the infant's nose. 4. Administer a nonprescription vasoconstrictive nose spray

2. Use saline nose drops and then a bulb syringe.

30. A mother who is visibly upset tells the nurse she wants to take her child home because the child is dying. Which of the following would be the nurse's best response? 1. "I know how you feel, but the medication will make your child feel better." 2. "I can't let you do this without calling your physician first." 3. "Can you tell me why you want to take your child home now?" 4. "I can imagine how hard this is for you, but it's not what's best for the child."

3. "Can you tell me why you want to take your child home now?"

10. The nurse judges that the parent of a 9-month-old infant in a hip spica cast understands how to feed the child when the parent states which of the following? 1. "I can lay my child flat and feed that way." 2. "I'll raise my child's head up and leave the hips and legs on a pillow." 3. "I can borrow a special feeding table to use." 4. "It will take two of us, one to hold and one to feed."

3. "I can borrow a special feeding table to use."

6. A worried mother confides in the nurse that she wants to change primary care providers because her infant is not getting better. The best response by the nurse is which of the following? 1. "This doctor has been on our staff for 20 years." 2. "I know you are worried, but the doctor has an excellent reputation." 3. "You always have an option to change. Tell me about your concerns." 4. "I take my own children to this doctor."

3. "You always have an option to change. Tell me about your concerns."

12. Forty-eight hours after a ventriculoperitoneal shunt placement, an infant is irritable and vomits a large amount. The assessment reveals a bulging fontanel. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the primary health care provider with the recommendation for: 1. A dose of morphine (Astramorph). 2. A fluid bolus of normal saline. 3. A computerized tomography scan. 4. A dose of furosemide (Lasix).

3. A computerized tomography scan.

14. The nurse is caring for a client who has experienced severe multiple trauma. The client's arterial blood gases reveal low arterial oxygen levels that are not responsive to high concentrations of oxygen. This finding is an indicator of the development of which of the following conditions? 1. Hospital-acquired pneumonia. 2. Hypovolemic shock. 3. Acute respiratory distress syndrome (ARDS). 4. Asthma.

3. Acute respiratory distress syndrome (ARDS)

24. A nurse is assessing a client with a history of myocardial infarction who is in the surgical unit following a gastric resection. The client has chest pains. The nurse obtains the electrocardiogram (ECG) shown (see figure). What should the nurse do first? 1. Administer oxygen. 2. Inspect the client's incision. 3. Call the rapid response team. 4. Reposition the ECG electrodes.

3. Call the rapid response team.

13. The nursing staff has finished restraining a client. In addition to determining whether anyone was injured, the staff is mandated to evaluate the incident to obtain which of the following ultimate outcomes? 1. Coordinate documentation of the incident. 2. Resolve negative feelings and attitudes. 3. Improve the use of restraint procedures. 4. Calm down before returning to the other clients.

3. Improve the use of restraint procedures.

8. A widowed client who is receiving chemotherapy tells the nurse that he does not like to cook for himself. A community resource for this client is: 1. Hospice/palliative care association. 2. Home care/visiting nurses group. 3. Meals on Wheels. 4. Association for Retirees.

3. Meals on Wheels.

18. After a client undergoes a contraction stress test that is negative, which of the following should the nurse assess next? 1. Evidence of ruptured membranes. 2. Viability status of the fetus. 3. Indications that contractions have ceased. 4. Fetal heart rate variability.

3. Indications that contractions have ceased.

22. A client is receiving spironolactone (Aldactone) for treatment of bilateral lower extremity edema. The nurse should instruct the client to make which of the following nutritional modifications to prevent an electrolyte imbalance? 1. Increase intake of milk and milk products. 2. Restrict fluid intake to 1,000 mL/day. 3. Decrease foods high in potassium. 4. Decrease foods high in sodium.

3. Decrease foods high in potassium.

34. A 24-year-old client, diagnosed with acute osteomyelitis in the left leg, has acute pain in the leg that intensifies on movement. The client has a temperature of 101°F (38.3°C) and a reddened, warm area in the midcalf region over the shaft of the tibia. Based on this information, the nurse should do which of the following first? 1. Prepare the client for possible left lower leg amputation. 2. Instruct the client to keep the leg immobile. 3. Develop a plan for pain management. 4. Obtain a prescription for fluid replacement.

3. Develop a plan for pain management.

11. The nurse is assessing home care needs for a group of clients. Which clients qualify for home care services? The client who: (Select all that apply.) 1. Requires monitoring of prothrombin time due to Coumadin (warfarin) therapy. 2. Needs additional instruction regarding preparation of food on a low-sodium diet. 3. Has episodes of vertigo that result in falls. 4. Has multiple sclerosis with an open, draining lesion on a foot. 5. Needs stronger lenses for glasses.

3. Has episodes of vertigo that result in falls. 4. Has multiple sclerosis with an open, draining lesion on a foot.

43. A nurse is assessing a client with metastatic lung cancer. The nurse should assess the client specifically for: 1. Diarrhea. 2. Constipation. 3. Hoarseness. 4. Weight gain.

3. Hoarseness.

50. A client who has been vomiting for 2 days has a nasogastric tube inserted. The nurse notes that over the past 10 hours the tube has drained 2 L of fluid. The nurse should further assess the client for: 1. Hypermagnesemia. 2. Hypernatremia. 3. Hypokalemia. 4. Hypocalcemia.

3. Hypokalemia.

29. A client 6 weeks postpartum is asking the nurse about taking progesterone (Depo-Provera) for birth control. Prior to discussing options, what should the nurse determine? Select all that apply. 1. If the client has a sexually transmitted disease. 2. How willing her husband is to have her take the drug. 3. If the woman is experiencing postpartum depression. 4. That the woman is not currently pregnant. 5. If the woman is breast-feeding.

3. If the woman is experiencing postpartum depression. 4. That the woman is not currently pregnant. 5. If the woman is breast-feeding.

51. During the clinical breast examination, which of the following is a normal finding? 1. Pronounced unilateral venous pattern. 2. Peau d'orange breast tissue. 3. Long-term, bilateral nipple inversion. 4. Breast tissue that is darker than the areolae.

3. Long-term, bilateral nipple inversion.

4. A 4-year-old child is admitted for a cardiac catheterization. Which of the following is most important to include as the nurse teaches this child about the cardiac catheterization? 1. A plastic model of the heart. 2. A catheter that will be inserted into the artery. 3. The parents. 4. Other children undergoing a catheterization.

3. The parents.

36. Long-term administration of gentamicin sulfate (Garamycin) to a client has been discontinued. The nurse should assess which of the following? 1. Hemoglobin level in 2 weeks. 2. White blood cell count in 2 weeks. 3. Vestibular check in 3 to 4 weeks. 4. Serum potassium level in 1 week.

3. Vestibular check in 3 to 4 weeks.

35. A client has undergone a vasectomy. The nurse instructs the client that he can begin having unprotected intercourse: 1. When desired because sterilization is immediate. 2. As soon as scrotal edema and tenderness resolve. 3. When the sperm count reflects sterilization. 4. After 6 to 10 ejaculations.

3. When the sperm count reflects sterilization.

The nurse is to administer chloramphenicol (Chloromycetin) 50 mg IV in 100 mL of dextrose 5% in water over 30 minutes. The infusion set administers 10 gtt/mL. At what flow rate (in drops per minute) should the nurse set the infusion? _______________ gtt/min.

33

3. A client who has been prescribed chemotherapy is worried and wants to take herbal treatments instead. The nurse's best response to the client is which of the following? 1. "You are making a mistake and placing your life in jeopardy." 2. "Herbal treatments are not approved by the government's regulatory agency." 3. "Herbal treatments have not been researched with cancer." 4. "Tell me about your concerns with chemotherapy."

4. "Tell me about your concerns with chemotherapy."

40. The nurse is assessing the perineal changes of a woman in the second stage of labor. The figure below represents which of the following perineal changes? 1. Anterior-posterior slit. 2. Oval opening. 3. Circular shape. 4. Crowning.

4. Crowning.

1. A primigravid client at 26 weeks' gestation asks the nurse what causes heartburn during pregnancy. The nurse should explain to the client that heartburn during pregnancy is usually caused by which of the following? 1. Increased peristaltic action during pregnancy. 2. Displacement of the stomach by the diaphragm. 3. Decreased secretion of hydrochloric acid. 4. Backflow of stomach contents into the esophagus.

4. Backflow of stomach contents into the esophagus.

17. A pregnant woman at 22 weeks' gestation is diagnosed with gonorrhea. The physician prescriptions doxycycline (Vibramycin). The nurse should first: 1. Instruct the client about the effects of the drug. 2. Make sure the record notes that the baby must receive eyedrops when born. 3. Have the physician add a single dose of ceftriaxone (Rocephin). 4. Discuss with the physician the need to change the prescription.

4. Discuss with the physician the need to change the prescription

5. A client has a reddened area over a bony prominence. The nurse finds a nursing assistant massaging this area. The nurse should: 1. Reinforce the nursing assistant's use of this intervention over the bony prominence. 2. Explain to the nursing assistant that massage is effective because it improves blood flow to the area. 3. Inform the nursing assistant that massage is even more effective when combined with the use of lotion. 4. Instruct the nursing assistant that massage is contraindicated because it decreases blood flow to the area.

4. Instruct the nursing assistant that massage is contraindicated because it decreases blood flow to the area.

49. A client claims to have a "special mission from God." The nurse incorporates this religious delusion of grandeur into the client's plan of care based on the understanding that the primary purpose of such a delusion is to provide which of the following? 1. Sexual outlet. 2. Comfort. 3. Safety. 4. Self-esteem.

4. Self-esteem.

23. A nurse is assessing a client who is receiving clozapine. The nurse reviews the chart below. What should the nurse do next? 1. Give the clozapine, and tell the client to lie down. 2. Withhold the clozapine, and tell the client to go to an exercise group. 3. Administer the clozapine, and notify the physician. 4. Withhold the clozapine, and notify the primary care provider.

4. Withhold the clozapine, and notify the primary care provider.