HESI medsurg incorrect practice
Which characteristic does the nurse associate with a punch biopsy? It is usually indicated for superficial or raised lesions. It is more uncomfortable than other biopsies while healing. It is performed using a circular cutting instrument 2 to 6 mm in diameter. It removes only the portion of the skin that rises above the surrounding tissue.
Rationale Punch biopsy is a common technique that involves the use of a small circular cutting instrument with a diameter of 2 to 6 mm. Shave biopsies are usually recommended for superficial or raised lesions. Excisional biopsies are comparatively more uncomfortable than punch or shave biopsies. Shave biopsies remove the skin portion that rises above surrounding tissues.
A client who develops heart failure has a serum potassium level of 2.3 mEq/L (2.3 mmol/L). Digoxin and potassium chloride are prescribed. What action should the nurse take? Double the dose of potassium chloride and administer it with the prescribed digoxin. Hold the dose of digoxin, administer the potassium chloride, and call the primary healthcare provider immediately. Give the digoxin and potassium chloride as prescribed and report the laboratory results to the primary healthcare provider. Administer the prescribed digoxin and potassium chloride with a glass of orange juice and continue to monitor the client.
Rationale A low potassium level with the administration of digoxin can cause digitalis toxicity, resulting in life-threatening dysrhythmias. Doubling the dose of potassium chloride and administering it with the prescribed digoxin has the potential of causing digitalis toxicity. In addition, changing the dose of a medication is not within the legal role of the nurse and requires a primary healthcare provider's prescription. Giving the digoxin and potassium chloride as prescribed and reporting the laboratory results to the primary healthcare provider has the potential of causing digitalis toxicity, especially when the potassium level is less than 3 mEq/L (3 mmol/L). Administering the prescribed digoxin and potassium chloride with a glass of orange juice and continuing to monitor the client has the potential of causing digitalis toxicity. One glass of orange juice and one dose of potassium chloride will not change the potassium level significantly.
The nurse is reviewing the laboratory reports of four clients. Which client is in the third stage of human immune virus (HIV) disease? Client A Client B Client C Client D
Rationale According to HIV disease classification, a client with HIV disease is in the third stage of the disease if the CD4+ T-cell count is less than 200 cells/mm 3. Therefore, client A is in third stage of HIV disease. A client is in second stage of HIV disease if the CD4+ T-cell count is between 200 and 499 cells/mm 3. Therefore, client B and client C are in the second stage of HIV disease. A client is in the first stage of HIV disease if the CD4+ T-cell count is greater than 500 cells/mm 3. Therefore, client D is in first stage of HIV disease. Test-Taking Tip: Chart/exhibit items present a situation and ask a question. A variety of objective and subjective information is presented about the client in formats such as the medical record (e.g., laboratory test results, results of diagnostic procedures, progress notes, healthcare provider orders, medication administration record, health history), physical assessment data, and assistant/client interactions. After analyzing the information presented, the test taker answers the question. These questions usually reflect the analyzing level of cognitive thinking.
According to the common scale for grading muscle strength, what rating will be given to a client who can complete range of motion with some resistance? 1 2 3 4
Rationale According to the common scale for grading muscle strength, a client who can complete range of motion with some resistance is given the rating 4. Rating 1 is given to a client with no joint motion and slight evidence of muscle contractility. Rating 2 is given to a client who can complete range of motion with gravity eliminated. Rating 3 is given to a client who can complete range of motion against gravity. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.
Which type of allergic skin condition in a client is associated with immunological irregularity, asthma, and allergic rhinitis? Urticaria Psoriasis Acne vulgaris Atopic dermatitis
Rationale Atopic dermatitis is an allergic skin condition that is a genetically influenced, chronic, relapsing disease. It is associated with immunologic irregularity involving inflammatory mediators associated with allergic rhinitis and asthma. Urticaria is an allergic skin condition that results in a local increase in permeability of capillaries, causing erythema and edema in the upper dermis. Psoriasis is an autoimmune chronic dermatitis but not an allergic skin condition. Acne vulgaris is an inflammatory disorder of sebaceous glands.
Which leukocyte is responsible for the allergic response? Basophils Monocytes Eosinophils Macrophages
Rationale Basophils stimulate the inflammation of allergy and hypersensitivity reactions. Monocytes are responsible for the destruction of bacteria and cellular debris before maturing into macrophages. Eosinophils act against parasitic infestations and limit inflammatory reactions. The main function of the macrophages is phagocytosis.
A client with hepatic cirrhosis begins to develop slurred speech, confusion, drowsiness, and a flapping tremor. Which diet can the nurse expect will be prescribed for this client based upon the assessment? No protein Moderate protein High protein Strict protein restriction
Rationale Because the liver is unable to detoxify ammonia to urea and the client is experiencing impending hepatic encephalopathy coma, protein intake should be moderate. Strict protein and no protein restrictions are not required because clients need protein for healing. High protein is contraindicated in hepatic encephalopathy. Test-Taking Tip: After choosing an answer, go back and reread the question stem along with your chosen answer. Does it fit correctly? The choice that grammatically fits the stem and contains the correct information is the best choice.
Which skin color alteration may be observed in a client diagnosed with methemoglobinemia? Red Blue White Yellow-orange
Rationale Blue discoloration of the skin may indicate an increase in deoxygenated blood, which is associated with methemoglobinemia. Red (erythema) may be associated with generalized inflammation. White (pallor) may indicate a decreased level of hemoglobin. It may signify a risk of anemia and shock. A yellow-orange skin discoloration may indicate jaundice and is associated with liver disorders.
What is a clinical manifestation of hypernatremia in burns? Fatigue Seizures Paresthesias Cardiac dysrhythmias
Rationale Seizures are the clinical manifestation of hypernatremia in burns. Fatigue, paresthesias, and cardiac dysrhythmias are clinical manifestations of hyperkalemia.
A nurse educates the client about the relationship between the kidneys and blood pressure. Which term should the nurse use to describe the part of the kidney that senses changes in blood pressure? Calices Glomerulus Macula densa Juxtaglomerular cells
Rationale The macula densa, a part of the distal convoluted tubule, consists of cells that sense changes in the volume and pressure of blood. Calices are cup-like structures, present at the end of each papilla that collect urine. The glomerulus is the initial part of the nephron, which filters blood to make urine. Juxtaglomerular cells secrete renin. Renin is produced when sensing cells in the macula densa sense changes in blood volume and pressure.
A young man who sustained a spinal cord injury at the cervical level expresses concern about sexual functioning. What should the nurse do when counseling this client? Consider that the client most likely will be able to have reflex penile erections. Arrange for the client to see the healthcare provider because sexual performance is unlikely. Discourage the client from forming sexual relationships because little pleasure will be possible. Reassure the client that he will be able to have sexual relationships with the ability to reproduce.
Rationale The reflex arc for sexual activity is intact; control of ejaculation is not. The ability to perform sexually is determined on an individual basis. There are many ways to fulfill sexual needs. Reassuring the client that he will be able to have sexual relationships with the ability to reproduce may provide false reassurance. The ability to function is determined on an individual basis.
Which clinical finding occurs due to thinning of the subcutaneous layer? Decreased tone and elasticity Decreased sensory perception Increased risk for hypothermia Increased susceptibility to dry skin
Rationale Thinning of the subcutaneous layer results in increased risk for hypothermia. Degeneration of elastic fibers in the dermis results in decreased tone and elasticity. In the dermis, reduced number and function of nerve endings leads to decreased sensory perception. A decrease in dermal blood flow results in increased susceptibility to dry skin.
Which statement does the nurse know is true regarding a grade 2 goiter? A goiter mass is impalpable. A goiter is usually asymmetrical. A goiter mass moves up while swallowing. A goiter is invisible with the neck in normal position.
Rationale In a grade 2 goiter, the mass is usually asymmetrical and is easily palpable. The goiter is invisible or impalpable in grade 0. The goiter mass moves up while swallowing and is palpable in grade 1. The goiter mass is invisible in grade 1 while the neck is in a normal position.
Which drug is a newer treatment option for treating metastatic melanoma? Lomustin Ipilimumab Carmustine Temozolomide
Rationale Ipilimumab is a type of immunotherapy and is monoclonal antibody. It is a newer option of drug therapy used in the treatment of metastatic melanoma. Lomustin, carmustine, and temozolomide are established chemotherapy drugs in use for many years for the treatment of metastatic melanoma.
A nurse is caring for a client with a hiatal hernia. Which risk factor should the nurse assess for in this client? Obesity Alcoholism Chronic bronchitis Esophageal varices
Rationale Obesity causes stress on the diaphragmatic musculature, which weakens and allows the stomach to protrude into the thoracic cavity. Alcoholism may cause gastritis, an enlarged liver, or pancreatitis, but not a hiatal hernia. Inflammation of the bronchi will not weaken the diaphragm. Esophageal varices result from increased portal pressure; they do not cause a hiatal hernia.
Which description is associated with fissures? Deep erosions that extend beneath the epidermis Thinning of the skin surface with a loss of skin markings Linear cracks in the epidermis that extend into the dermis Thickened areas of epidermis with accentuated skin markings
Rationale Fissures are linear cracks in the epidermis that extend into the dermis. Ulcers may be described as deep erosions extending beneath the epidermis. Atrophy is the thinning of the surface of the skin with a loss of skin markings. Lichenifications are characterized by thick areas of epidermis with accentuated skin markings.
Which clinical manifestation is associated with cellulitis? Lymphadenopathy Occasional papules Vesicles that evolve into pustules Isolated erythematous pustules
Rationale Cellulitis is accompanied by lymphadenopathy. Occasional papules are present in folliculitis. Herpes simplex viral infections evolve the vesicles into pustules. Isolated erythematous pustules occur in folliculitis bacterial infections.
Which hormone is released from the posterior pituitary gland? Oxytocin Prolactin Growth hormone Luteinizing hormone
Rationale Oxytocin is released from the posterior pituitary gland, which acts on the uterus and mammary glands. Prolactin, growth hormone, and luteinizing hormone are produced by the anterior pituitary gland.
The nurse is caring for a client with a hiatal hernia. The client states that favorite beverages include ginger ale, apple juice, orange juice, and cola beverages. Of the four the client listed, which is the only beverage that should remain in the client's diet? Ginger ale Apple juice Orange juice Cola beverages
Rationale Apple juice is not irritating to the gastric mucosa. Carbonated beverages like ginger ale distend the stomach and promote regurgitation. The acidity of orange juice aggravates the disorder. Most colas should be avoided because they contain caffeine, which causes increased acidity and aggravates the disorder; also they are carbonated, which distends the stomach and promotes regurgitation. STUDY TIP: Rest is essential to the body and brain for good performance; think of it as recharging the battery. A run-down battery provides only substandard performance. For most students, it is better to spend 7 hours sleeping and 3 hours studying than to cut sleep to 6 hours and study 4 hours. The improvement in the rested mind's efficiency will balance out the difference in the time spent studying. Knowing your natural body rhythms is necessary when it comes to determining the amount of sleep needed for personal learning efficiency.
Which information indicates the nurse has a good understanding about the mechanism of action for maraviroc? Inhibits the insertion of viral DNA into the host cell's human DNA Prevents protease enzyme from cutting human immunodeficiency virus (HIV) into the proper length Blocks the C-C chemokine receptor type 5 (CCR5) receptor on CD4+ T cells Binds directly to the HIV-1 enzyme reverse transcriptase
Rationale Entry inhibitors such as maraviroc act by blocking the CCR5 receptor on CD4+ T cells. Integrase inhibitors inhibit the insertion of viral DNA into the host cell's human DNA by inhibiting the HIV enzyme integrase. Protease inhibitors prevent the protease enzyme from cutting HIV proteins into the proper lengths. Non-nucleoside reverse transcriptase inhibitors act by binding directly to the HIV-1 enzyme reverse transcriptase.
A client has a kidney transplant. The nurse should monitor for which assessment findings associated with rejection of the transplant? Select all that apply. Select all that apply Some correct answers were not selected Fever Oliguria Jaundice Polydipsia Weight gain
Rationale Fever is a characteristic of the systemic inflammatory response to the antigen (transplanted kidney). Oliguria or anuria occurs when the transplanted kidney is rejected and fails to function. Weight gain can occur from fluid retention when the transplanted kidney fails to function or as a result of steroid therapy; this response must be assessed further. Jaundice is unrelated to rejection. Polydipsia is associated with diabetes mellitus; it is not a clinical manifestation of rejection.
Which hormone is released from the pancreas? Oxytocin Prolactin Calcitonin Somatostatin
Rationale Somatostatin is a hormone produced by the pancreas that inhibits the release of insulin and glucagon. Oxytocin is a hormone produced by the posterior pituitary gland that acts on the uterus and mammary glands. Prolactin is a hormone produced by the anterior pituitary gland that targets the ovaries and mammary glands in women and testes in men. Calcitonin is a hormone produced by the thyroid gland that interacts with bone tissue.
Which organ has only beta 1-receptors? Liver Heart Bladder Pancreas
Rationale The heart has only beta 1 receptors, which increase heart rate and contractility. The liver has only alpha receptors. The bladder and pancreas have both alpha and beta receptors.
Which causative organism colonization signifies purulent exudates of greenish-blue pus with a fruity odor? Proteus Bacteroides Pseudomonas Staphylococcus
Rationale The purulent exudates of greenish-blue pus with a fruity odor signifies the colonization of Pseudomonas. Proteus colonization causes pus with a fishy odor. The colonization of Bacteroides causes brownish pus with a fecal odor. Staphylococcus colonization results in purulent exudate of creamy yellow pus.
Which hormone increases the rate of protein synthesis in a client? Estrogen Thyroxine Parathormone Vitamin D
Rationale Thyroxine increases the rate of protein synthesis in all the body tissues. Estrogen stimulates bone-building, which is known as osteoblastic activity. Parathormone promotes osteoclastic activity in a state of hypocalcemia. Vitamin D and its metabolites are produced in the body and transported in the blood to promote the absorption of calcium and phosphorus from the small intestine.
