HESI medsurg

Key features of left sided heart failure

Oliguria, pallor, and cool extremities

A client with burns is prescribed polymixin by the primary healthcare provider. Which action should the nurse take?

Apply the drug every 2-8 hours

The nurse provides teaching to a client who will begin to receive tube feedings after a total laryngectomy. The nurse concludes that the teaching was understood when the client makes which statement about tube feedings?

"I will need tube feedings until healing of the incision is complete.

A nurse is teaching a client with pruritus about personal care interventions. Which statement made by the client indicates the nurse needs to intervene?

"I will not file the edges of fingernails."

A client is admitted for hypertension, and serum electrolyte studies have yielded abnormal results. The scheduled workup includes a scan for an aldosteronoma. What gland is affected in aldosteronoma?

An aldosteronoma is an aldosterone-secreting adenoma of the adrenal cortex.

The nurse is caring for a client who underwent intestinal surgery 3 days ago and notices brownish pus with a fecal odor draining from the incision. What should the nurse infer from this finding?

Colonization with aerobic coliform and Bacteroides

A client is admitted to the hospital with a tentative diagnosis of a brain tumor. Which diagnostic test result will the nurse check for confirmation of this diagnosis?

Computed tomography

Kernig's sign

an inability to completely extend the legs, is the classic sign of meningeal irritation

mediastinoscopy

endoscopic examination of mediastinal lymph nodes through a small suprasternal incision

Homans sign

indicates the presence of thrombophlebitis; pain is experienced when the foot is dorsiflexed because of vascular irritability.

Rhonchi indicate

partial airway obstruction because of bronchiolar alterations associated with COPD

A client with a suspected kidney disorder reports flank pain. Which nursing interventions should be conducted while performing flank assessment? Select all that apply.

Asking the client to assume a sitting position Placing one hand flat on costovertebral angle (CVA)

A nurse is caring for a client with severe dyspnea who is receiving oxygen via a Venturi mask. What should the nurse do when caring for this client?

Monitor oxygen saturation levels when eating.

Which laboratory value may indicate hyperfunction of the adrenal gland in a client?

Potassium: 2.9 mEq/L

A client is admitted to the hospital with suspected liver disease, and a needle biopsy of the liver is performed. After the procedure, the nurse should maintain the client in what position?

Right side-lying

During a seizure, a client had sudden loss of muscle tone that lasted for a few seconds followed by confusion. Which statement about this type of seizures is true? Select all that apply.

These seizures increase the risk of injuries due to fall. These seizures are most resistant to drug therapy.

A client with chronic obstructive pulmonary disease (COPD) reports chest congestion, especially upon awakening in the morning. What should the nurse suggest to the client?

Use a humidifier in the bedroom

After reviewing the client's laboratory reports, the physician concludes that the client has primary hypofunction of the adrenal gland. Which clinical manifestation is likely to be observed in that client?

Vitiligo is manifested by the presence of large patchy areas of pigment loss.

The nurse is preparing to insert an intravenous (IV) catheter in a client who is being admitted for uncontrolled diabetes. Upon assessment of the client's forearm for a potential insertion site, the nurse notes that the client has an excessive amount of hair. What should the nurse do to properly prepare the site for insertion?

Excessive hair should be clipped. Skin should never be shaved before venipuncture.

A client reports intolerance to music played at sound levels that do not bother other people. On assessing, the nurse observes impaired hearing in one ear. What could be the possible condition of the client?

Hyperacusis

A client has experienced an episode of myasthenic crisis. Upon review of the client history by the nurse, which finding will most likely be a precipitating factor of the myasthenic crisis

Myasthenic crisis often is caused by undermedication and responds to the administration of cholinergic medications, such as neostigmine and pyridostigmine

A nurse identifies a moderate amount of bright red blood in a client's gastric drainage four hours after a subtotal gastrectomy. What should the nurse do first?

Some bright red blood at this point is an expected finding that should be monitored; large amounts of blood or bleeding should be reported immediately. Clamping the nasogastric tube is contraindicated; secretions will accumulate and cause pressure on the suture line. Also, clamping the tube prevents observation of gastric drainage. If the tube is draining, there is no need to irrigate; also, irrigations are traumatic. Reducing suction pressure allows secretions to accumulate and causes pressure on the suture line.

A client who is taking an oral hypoglycemic daily for type 2 diabetes develops the flu and is concerned about the need for special care at home. What should the nurse instruct the client to do?

Take the oral hypoglycemic pill, drink warm fluids, and check blood sugar before meals and at bedtime

The nurse is caring for a client 4 days after the client had a cystectomy and formation of an ileal conduit. After observing mucous threads in the client's urine, what should the nurse do?

Recognize that this is an expected response

Which child is at the highest risk for blunt trauma associated with the indirect entry (hematogenous stage) of microorganisms?

The indirect entry of microorganisms, which is the hematogenous stage of osteomyelitis, most frequently affects the growing bones of boys younger than 12 years of age. Therefore an 8-year-old boy would be at the highest risk for blunt trauma.

A client is admitted to the hospital with a diagnosis of emphysema and dyspnea. The nurse should encourage the client to assume what position?

The orthopneic position lowers the diaphragm and provides for maximum thoracic expansion.

What are the primary causes of adrenal insufficiency?

The primary causes of adrenal insufficiency are hemorrhage, tuberculosis, and acquired immune deficiency syndrome.