HESI Med Surg

A client taking furosemide, reports difficulty sleeping. Which question is important for the nurse to ask the client?

"At what time do you take your medication?"

A client who is receiving chemotherapy asks the nurse, "Why is so much of my hair falling out each day?

"Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant."

The nurse is completing an admission interview and assessment on a client with a history of Parkinson's disease. Which question provides information relevant to the client's plan of care?

"Have you ever been 'frozen' in one spot, unable to move?"

A 20-year-old female client calls the nurse to report a lump she found in her breast. Which response is the best for the nurse to provide?

"Most lumps are benign, but it is always best to come in for an examination."

A 57-year-old male client is scheduled to have a stress-thallium test the following morning and is NPO after midnight. At 0130, he is agitated because he cannot eat and is demanding food. Which response is best for the nurse to provide to this client?

"The test you are having tomorrow requires that you have nothing by mouth tonight."

A male client who smokes two packs of cigarettes a day states he understands that smoking cigarettes is contributing to the difficulty that he and his wife are having in getting pregnant and wants to know if other factors could be contributing to their difficulty. What information is best for the nurse to provide? (Select all that apply.)

-Alcohol consumption can cause erectile dysfunction. -Low testosterone levels affect sperm production. -Cessation of smoking improves general health and fertility.

The nurse is teaching a female client who uses a contraceptive diaphragm about reducing the risk for toxic shock syndrome (TSS). Which information should the nurse include? (Select all that apply.)

-Do not leave the diaphragm in place longer than 8 hours after intercourse. - Replace the old diaphragm every 3 months.

Which information should the nurse obtain when performing an initial assessment of a client who presents to the emergency department with a painful ankle injury? (Select all that apply.)

-Quality of the pain - signs of inflammation - ankle range of motion - visible deformities of the joint

Which finding should the nurse identify as most significant for a client diagnosed with polycystic kidney disease (PKD)?

3+ bacteria in urine

In assessing cancer risk, the nurse identifies which woman as being at greatest risk of developing breast cancer?

A 50-year-old whose mother had unilateral breast cancer.

A client taking a thiazide diuretic for the past six months has a serum potassium level of 3. The nurse anticipates which change in prescription for the client?

A potassium supplement will be prescribed.

A client with diabetes mellitus is experiencing polyphagia. Which outcome statement is the priority for this client?

Adequate cellular nourishment.

A female client taking oral contraceptives reports to the nurse that she is experiencing calf pain. Which action should the nurse implement?

Advise the client to notify the healthcare provider for immediate medical attention.

Two days postoperative, a male client reports aching pain in his left leg. The nurse assesses redness and warmth on the lower left calf. Which intervention would be most helpful to this client?

Advise the client to remain in bed with the leg elevated.

A female client requests information about using the calendar method of contraception. Which assessment is most important for the nurse to obtain?

An accurate menstrual cycle diary for the past 6 to 12 months.

The nurse is taking a history of a newly diagnosed Type 2 diabetic who is beginning treatment. Which subjective information is most important for the nurse to note?

An allergy to sulfa drugs

During suctioning, a client with an uncuffed tracheostomy tube begins to cough violently and dislodges the tracheostomy tube. Which action should the nurse implement first?

Attempt to reinsert the tracheostomy tube.

A client presents with chronic venous insufficiency. Which assessment finding should the nurse anticipate?

Bilateral lower leg stasis dermatitis.

A client is newly diagnosed with diverticulosis. The registered nurse (RN) is assessing the client's basic knowledge about the disease process. Which statement by the client conveys an understanding of the etiology of diverticula?

Chronic constipation causes weakening of colon wall which result in out-pouching sacs.

A client is admitted to the emergency department after falling from a high roof. Which finding should the nurse report immediately?

Clear, watery drainage from the ear.

An older adult female client is brought to the clinic by her daughter for a flu shot. She has lost significant weight since the last visit. She has poor personal hygiene and inadequate clothing for the weather. The client states that she lives alone and denies problems or concerns. Which action should the nurse implement?

Collect further data to determine whether self-neglect is occurring.

A client experiencing uncontrolled atrial fibrillation is admitted to the telemetry unit. Which initial medication should the nurse anticipate administering to the client?

Digoxin

The nurse is initiating the client's fourth dose of gentamycin sulfate IV. The health care provider (HCP) has prescribed peak and trough levels. Which is the most important action for the nurse to implement next?

Draw the trough 5 minutes before and the peak 30 minutes after the next dose.

A client is admitted to the medical intensive care unit with a diagnosis of myocardial infarction. The client's history indicates the infarction occurred ten hours ago. Which laboratory test result would the nurse expect this client to exhibit?

Elevated CK-MB

When providing discharge teaching for a client with osteoporosis, the nurse should reinforce which home care activity?

Elimination of hazards to home safety.

Which intervention should the nurse implement for a female client diagnosed with pelvic relaxation disorder?

Encourage the client to perform Kegel exercises 10 times daily. Correct

Which postmenopausal client's complaint should the nurse refer to the healthcare provider?

Episodes of vaginal bleeding.

A client has undergone insertion of a permanent pacemaker. When developing a discharge teaching plan, the nurse writes a goal of, "The client will verbalize symptoms of pacemaker failure." Which symptoms are most important to teach the client?

Feelings of dizziness

While working in the emergency room, the nurse is exposed to a client with active tuberculosis. When should the nurse plan to obtain a tuberculin skin test?

Four to six weeks after the exposure

A client with a completed ischemic stroke has a blood pressure of 180/90 mmHg. Which action should the nurse implement?

Give an antihypertensive medication.

A client is admitted to the hospital with a medical diagnosis of pneumococcal pneumonia. The nurse knows that the prognosis for gram-negative pneumonias (such as E. coli, Klebsiella, Pseudomonas, and Proteus) is very poor. Which information relates most directly to the prognosis for gram-negative pneumonias?

Gram-negative organisms are more resistant to antibiotic therapy.

A middle-aged male client with diabetes continues to eat an abundance of foods that are high in sugar and fat. According to the Health Belief Model, which event is most likely to increase the client's willingness to become compliant with the prescribed diet?

He visits his diabetic brother who just had surgery to amputate an infected foot.

Which symptoms should the nurse expect a client to exhibit who is diagnosed with a pheochromocytoma?

Headache, diaphoresis, and palpitations

Which physical assessment finding should the nurse anticipate in a client with long-term gastroesophagealreflux disease (GERD)?

Hoarseness

The nurse is receiving report from surgery about a client with a penrose drain who is to be admitted to the postoperative unit. Before choosing a room for this client, which information is most important for the nurse to obtain?

If the client's wound is infected

A client is placed on a mechanical ventilator following a cerebral hemorrhage, and vecuronium bromide 0.04 mg/kg q12 hours IV is prescribed. Which is the priority nursing diagnosis for this client?

Impaired communication related to paralysis of skeletal muscles

The nurse is providing dietary instructions to a 68-year-old client who is at high risk for development of coronary heart disease (CHD). Which information should the nurse include?

Increase intake of soluble fiber to 10 to 25 grams per day.

The nurse knows that lab values sometimes vary for the older client. Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old male?

Increased protein in the urine, slightly increased serum glucose levels.

A client has a staging procedure for cancer of the breast and ask the nurse which type of breast cancer has the poorest prognosis. Which information should the nurse offer the client?

Inflammatory with peau d'orange

A 51-year-old truck driver who smokes two packs of cigarettes a day and is 30 pounds overweight is diagnosed with having a gastric ulcer. Which content is most important for the nurse to include in the discharge teaching for this client?

Information about smoking cessation.

The nurse is working with a 71-year-old obese client with bilateral osteoarthritis (OA) of the hips. Which recommendation should the nurse make that is most beneficial in protecting the client's joints?

Initiate a weight-reduction diet to achieve a healthy body weight.

A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L (2.9 mmol/L). Which action is most important for the nurse to implement?

Initiate continuous cardiac monitoring.

A client's susceptibility to ulcerative colitis is most likely due to which aspect in the client's history?

Jewish European ancestry.

Twenty four hours after a client returns from surgical gastric bypass, the registered nurse (RN) observes large amounts of blood in the nasogastric tube (NGT) cannister. Which assessment finding should the RN report as early signs of hypovolemic shock?

Lethargy.

A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which assessment finding should the nurse expect this client to exhibit?

Lower left quadrant pain and a low-grade fever.

A client is admitted for further testing to confirm sarcoidosis. Which diagnostic test provides definitive information that the nurse should report to the healthcare provider?

Lung tissue biopsy

The nurse is planning care to prevent complications for a client with multiple myeloma. Which intervention is most important for the nurse to include?

Maintain a fluid intake of 3 to 4 L per day.

During lung assessment, the nurse places a stethoscope on a client's chest and instructs him/her to say "99" each time the chest is touched with the stethoscope. Which would be the correct interpretation if the nurse hears the spoken words "99" very clearly through the stethoscope?

May indicate pneumonia.

Despite several eye surgeries, a 78-year-old client who lives alone has persistent vision problems. The visiting nurse is discussing home safety hazards with the client. The nurse suggests that the edges of the steps be painted which color?

Medium yellow.

During assessment of a client with amyotrophic lateral sclerosis (ALS), which finding should the nurse identify when planning care for this client?

Muscle weakness.

How should the nurse position the electrodes for modified chest lead one (MCL I) telemetry monitoring?

Negative polarity left shoulder, positive polarity right chest nipple line, ground left chest nipple line.

Which assessment finding by the nurse during a client's clinical breast examination requires follow-up?

Newly retracted nipple

A client with a 16-year history of diabetes mellitus is having renal function tests because of recent fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels. Which finding should the nurse conclude as an early symptom of renal insufficiency?

Nocturia

Which client should the nurse recognize as most likely to experience sleep apnea?

Obese older male client with a short, thick neck.

Which condition should the nurse suspect when a client reports vaginal dryness during intercourse?

Obstructed Bartholin's glands

A 67-year-old woman who lives alone tripped on a rug in her home and fractured her hip. Which predisposing factor probably led to the fracture in the proximal end of her femur?

Osteoporosis resulting from hormonal changes.

What instruction should the nurse give a client who is diagnosed with fibrocystic changes of the breast?

Perform a breast self-exam (BSE) procedure monthly.

When teaching diaphragmatic breathing to a client with chronic obstructive pulmonary disease (COPD), which information should the nurse provide?

Place a small book or magazine on the abdomen and make it rise while inhaling deeply.

The nurse is assessing a client with chronic kidney disease (CKD). Which finding is most important for the nurse to respond to first?

Potassium 6.0 mEq.

In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance?

Potassium.

A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which statement by the nurse provides the most accurate explanation for use of the splints?

Prevention of deformities.

During a health fair, a 72-year-old male client tells the nurse that he is experiencing shortness of breath. Auscultation reveals crackles and wheezing in both lungs. Suspecting that the client might have chronic bronchitis, which classic symptom would the nurse expect this client to have?

Productive cough with grayish-white sputum

A client with heart disease is on a continuous telemetry monitor and has developed sinus bradycardia. In determining the possible cause of the bradycardia, the nurse assesses the client's medication record. Which medication is most likely the cause of the bradycardia?

Propanolol.

A young adult male is diagnosed with Stage 4 Hodgkin's lymphoma in the abdominopelvic region and is scheduled for radiation therapy (RT). The client expresses concern about becoming infertile. How should the nurse respond?

Propose sperm banking before RT then artificial insemination is an option.

An adult client who is hospitalized after surgery reports sudden onset of chest pain and dyspnea. The client appears anxious, restless, and mildly cyanotic. The nurse should further assess the client for which condition?

Pulmonary embolism

A client has been taking oral corticosteroids for the past five days because of seasonal allergies. Which assessment finding is of most concern to the nurse?

Purulent sputum

The healthcare provider prescribes aluminum and magnesium hydroxide, 1 tablet PO PRN, for a client with chronic kidney disease (CKD) who is complaining of indigestion. Which intervention should the nurse implement?

Question the healthcare provider's prescription.

An adult client is admitted to the hospital burn unit with partial-thickness and full-thickness burns over 40% of the body surface area. In assessing the potential for skin regeneration, which should the nurse remember about full-thickness burns?

Regenerative function of the skin is absent because the dermal layer has been destroyed.

During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. Which action should the nurse take first?

Reposition the head to validate that the head is in the proper position to open the airway.

A client with multiple sclerosis has experienced an exacerbation of symptoms, including paresthesias, diplopia, and nystagmus. Which instruction should the nurse provide?

Schedule extra rest periods

A female client receiving IV vasopressin for esophageal varice rupture reports to the nurse that she feels substernal tightness and pressure across her chest. Which PRN protocol should the nurse initiate?

Start an IV nitroglycerin infusion.

A client with early breast cancer receives the results of a breast biopsy and asks the nurse to explain the meaning of staging and the type of receptors found on the cancer cells. Which explanation should the nurse provide?

The tumor's estrogen receptor guides treatment options

The nurse is teaching a female client about the best time to plan sexual intercourse in order to conceive. Which information should the nurse provide?

Two weeks before menstruation.

Healthcare workers must protect themselves against becoming infected with HIV. The Center for Disease Control has issued guidelines for healthcare workers in relation to protection from HIV. These guidelines include which recommendation?

Wear gloves when coming in contact with the blood or body fluids of any client.

The nurse is planning care for a client with newly diagnosed diabetes mellitus that requires insulin. Which assessment should the nurse identify before beginning the teaching session?

Willingness of the client to learn the injection sites.

The client is taking digoxin for congestive heart failure. The nurse would be correct in withholding a dose of digoxin based on which assessment?

serum potassium level is 3.

A client has taken steroids for 12 years to help manage chronic obstructive pulmonary disease (COPD). When making a home visit, which nursing assessment is of greatest importance to this client?

temperature.

A client who is HIV positive asks the nurse, "How will I know when I have AIDS?" Which response is best for the nurse to provide?

"AIDS is diagnosed when a specific opportunistic infection is found in an otherwise healthy individual."

Which milestone indicates to the nurse successful achievement of young adulthood?

Completes education and becomes self-supporting.

The nurse assesses a client with advanced cirrhosis of the liver for signs of hepatic encephalopathy. Which finding would the nurse consider an indication of progressive hepatic encephalopathy?

Difficulty in handwriting

A client with cirrhosis develops increasing pedal edema and ascites. Which dietary modification is most important for the nurse to teach this client?

Restrict salt and fluid intake.

Small bowel obstruction is a condition characterized by which finding?

Severe fluid and electrolyte imbalances.

Which information about mammograms is most important to provide a post-menopausal female client?

Yearly mammograms should be done regardless of previous normal x-rays.

In preparing to administer intravenous albumin to a client following surgery, which are the priority nursing interventions? (Select all that apply.)

-Set the infusion pump to infuse the albumin within four hours. -Administer through a large gauge catheter. -Monitor hemoglobin and hematocrit levels. -Assess for increased bleeding after administration.

The nurse is assisting a client out of bed for the first time after surgery. Which action should the nurse do first?

Allow the client to sit with the bed in a high Fowler's position

The nurse is performing an ophthalmoscopic examination on a hypertensive client. When assessing the client, which finding indicates the severity of hypertension?

Amount of retinal vessel damage that has occurred

During an interview with a client planning elective surgery, the client asks the nurse, "What is the advantage of having a preferred provider organization insurance plan?" Which response is best for the nurse to provide?

An individual may select healthcare providers from outside of the PPO network.

A 32-year-old female client complains of severe abdominal pain each month before her menstrual period, painful intercourse, and painful defecation. Which additional history should the nurse obtain that is consistent with the client's complaints?

Inability to get pregnant

A client has been hospitalized with a femur fracture and is being treated with traction. Which action by the nurse is the priority when caring for this client?

Assess neurovascular status

What types of medications should the nurse expect to administer to a client during an acute respiratory distress episode?

Bronchodilators and steroids.

A client who is fully awake after a gastroscopy asks the nurse for something to drink. After confirming that liquids are allowed, which assessment action should the nurse consider a priority?

Check the client's gag and swallow reflexes.

A 58-year-old client who has been post-menopausal for five years is concerned about the risk for osteoporosis because her mother has the condition. Which information should the nurse offer?

Calcium loss from bones can be slowed by increasing calcium intake and exercise.

The nurse notes that the only ECG for a 55-year-old male client scheduled for surgery in two hours is dated two years ago. The client reports that he has a history of "heart trouble," but has no problems at present. Hospital protocol requires that those over 50 years of age have a recent ECG prior to surgery. Which nursing action is best for the nurse to implement?

Call for an ECG to be performed immediately

The nurse is caring for a client with a continuous feeding through a percutaneous endoscopic gastrostomy (PEG) tube. Which intervention should the nurse include in the plan of care?

Check for tube placement and residual volume q4 hours.

An elderly client is admitted with a diagnosis of bacterial pneumonia. When observing the client for the first signs of decreasing oxygenation, the nurse should assess for which clinical cues?

Confusion and tachycardia.

The nurse is assessing a client with bacterial meningitis. Which assessment finding indicates the client may have developed septic emboli?

Cyanosis of the fingertips

The nurse is interviewing a male client with hypertension. Which additional medical diagnosis in the client's history presents the greatest risk for developing a cerebral vascular accident (CVA)?

Diabetes mellitus.

The nurse is caring for a client with a stroke resulting in right-sided paresis and aphasia. The client attempts to use the left hand for feeding and other self-care activities. The spouse becomes frustrated and insists on doing everything for the client. Based on this data, which nursing problem should the nurse document for this client?

Disabled family coping related to dissonant coping style of significant person.

A 49-year-old female client arrives at the clinic for an annual exam and asks the nurse why she becomes excessively diaphoretic and feels warm during nighttime. What is the nurse's best response?

Discuss perimenopause and related comfort measures.

A postmenopausal client asks the nurse why she is experiencing discomfort during intercourse. Which response is best for the nurse to provide?

Estrogen deficiency causes the vaginal tissues to become dry and thinner.

A male client receives a local anesthetic during surgery. During the post-operative assessment, the nurse notices the client is slurring his speech. Which action should the nurse take?

Evaluate his blood pressure, pulse, and respiratory status.

An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that his tongue is somewhat cracked and his eyeballs are sunken into his head. Which nursing intervention is indicated?

Help the client to determine ways to increase his fluid intake.

Which nail color alteration should the nurse expect to observe in a client with chronic kidney disease?

Horizontal white banding

Which statement made by a client with chronic pancreatitis indicates that further education is needed?

I will cut back on smoking cigarettes daily.

Which description of pain is consistent with a diagnosis of rheumatoid arthritis?

Joint pain is worse in the morning and involves symmetric joints.

A client receiving cholestyramine for hyperlipidemia should be evaluated for which vitamin deficiency?

K

The nurse is assessing a client who smokes cigarettes and has been diagnosed with emphysema. Which finding would the nurse expect this client to exhibit?

Normal skin coloring

An older adult male client comes to the geriatric screening clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg which is warm to the touch and suspects it might be thrombophlebitis. Which type of pain would further confirm this suspicion?

Pain in the calf upon exertion which is relieved by rest and elevating the extremity.

Which intervention should the nurse plan to implement when caring for a client who has just undergone a right above-the-knee amputation?

Place a large tourniquet at the client's bedside

A client who was in a motor vehicle collision was admitted to the hospital and the right knee was placed in skeletal traction. The nurse has documented this nursing diagnosis in the client's medical record: "Potential for impairment of skin integrity related to immobility from traction." Which nursing intervention is indicated based on this diagnosis statement?

Provide back and skin care while maintaining the traction.

A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client?

Raising the head of the bed on blocks.

After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 mL for the last 2 hours. Which priority nursing action should be implemented?

Report the findings to the surgeon.

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)?

Serum calcium of 5 mg/dL

A 46-year-old female client is admitted for acute renal failure secondary to diabetes and hypertension. Which test is the best indicator of adequate glomerular filtration?

Serum creatinine

The nurse working on a telemetry unit finds a client unconscious and in pulseless ventricular tachycardia (VT). The client has an implanted automatic defibrillator. Which action should the nurse implement?

Shock the client with 200 joules per hospital policy.

The nurse is assessing a client who has a history of Parkinson's disease for the past 5 years. Which symptoms would this client most likely exhibit?

Shuffling gait, masklike facial expression, and tremors of the head.

In preparing a discharge plan for a 22-year-old male client diagnosed with Buerger's disease (thromboangiitis obliterans), which referral is most important?

Smoking cessation program.

The nurse is caring for a client who has been diagnosed with primary hyperaldosteronism. Which laboratory test result should the nurse expect an increase in the serum level?

Sodium

The registered nurse (RN) is assessing a client who was discharged home after management of chronic hypertension. Which equipment should the RN instruct the client to use at home?

Sphygmomanometer.

Which description of symptoms is characteristic of a client diagnosed with trigeminal neuralgia (tic douloureux)?

Sudden, stabbing, severe pain over the lip and chin.

The nurse is preparing a teaching plan for a client who is newly diagnosed with Type 1 diabetes mellitus. Which clinical cues should the nurse describe when teaching the client about hypoglycemia?

Sweating, trembling, tachycardia.

A 77-year-old female client is admitted to the hospital. She is confused, has no appetite, is nauseated and vomiting, and is complaining of a headache. Her pulse rate is 43 beats per minute. It is most important for the nurse to assess for which finding?

Takes digitalis

The nurse formulates the nursing problem of urinary retention related to sensorimotor deficit for a client with multiple sclerosis. Which nursing intervention should the nurse implement?

Teach the client techniques of intermittent self-catheterization.

When preparing a client who has had a total laryngectomy for discharge, which instruction is most important for the nurse to include in the discharge teaching?

Tell the client to carry a medic alert card stating that he is a total neck breather.

A 58-year-old client, who has no health problems, asks the nurse about the Pneumovax vaccine. The nurse's response to the client should be based on which information?

The immunization is administered once to older adults or persons with a history of chronic illness.

Which discharge instruction is most important for a client after a kidney transplant?

Use daily reminders to take immunosuppressants.

The nurse is planning to initiate a socialization group for older residents of a long-term facility. Which information would be most useful to the nurse when planning activities for the group?

The usual activity patterns of each member of the group.

The registered nurse (RN) is assessing a male client who arrives at the clinic with severe abdominal cramping, pain, tenesmus, and dehydration. The RN discovers that the client has had 14 to 20 loose stools with rectal bleeding. When taking the client's medical history, which information is most for the nurse to obtain?

Ulcerative colitis.

A client who is sexually active with several partners requests an intrauterine device (IUD) as a contraceptive method. Which information should the nurse provide?

Using an IUD offers no protection against sexually transmitted diseases (STD), which increase the risk for pelvic inflammatory disease (PID).

The registered nurse (RN) assesses arterial blood gas results of a client that has emphysema. Which finding is consistent with respiratory acidosis?

pH 7.32, pCO 2 46 mmHg, HCO 3 24 MEq/L.

The nurse working in a postoperative surgical clinic is assessing a woman who had a left radical mastectomy for breast cancer. Which factor puts this client at greatest risk for developing lymphedema?

she sustained an insect bite to her left arm yesterday