Medical-Surgical HESI Practice Exams
a hospitalized client with peripiheral arterial disease (PAD) is instrcuted regarding leg and foot care. Which statement by the client indicates the nurse that learning has occured/ "whenever I am sitting in a chair. i will keep my legs up to reduce swelling" "i can use a mirror to check the bottoms of my feet for any signs of breakdown" "I will try to keep moving if leg pain occurs to help promote good coruclation" "I will use my swimming pools early in the day while the water is still very cool"
"i can use a mirror to check the bottoms of my feet for any signs of breakdown"
a 70 year old male client with type 2 diabetes mellitus (DM) is hospliazed with an infected ulcer on this right great toe. Which instructions should the nurse emphasize during dischare teaching? a. open toed shoes allow air to ciruclate and help prevent toenail gunfus growth b. Check the insides and linings of all enclosed shoes before putting the shoes on c. be sure you only walk barefoot on soft surfacesm such as fully carpeted rooms. d. Nylon socks provide warmth wouthout trapping excess mositure around your feet
. Check the insides and linings of all enclosed shoes before putting the shoes on
the healthcare provider prescribes pencillin 200,000 units intramuscularly for a client with pneumonia. the avlaible vial is labeled, "pencillin 500,000 units/ml" how many mL should the nurse admisnter to the client?
0.4
A client receives a prescreiption for 1 liter of lactated ringers intravenosuly to be insfused 6 hours. How many mL/hr should the nurse progra, the infusion pump to deliver. round to the nearest whole number
167
A cliuent with hyperparathyroid reports a sudden onset of severe flank pain. Which itnervention should the nurse include in the clients plan of care?
Begin straining all urine
When planning care for a client newly diagnosed with open angle glaucoma, the nurse identifies a priority nursing problem of visual perceptual alterations, this problem is based on which etiology?
Blurred Distance Vision
The nurse is teaching a client how to collect a sputum specimen. Which step should the nurse isntruct the client to follow when collecting sputum a. avoid mouth care prior to collecting the sputum b. Breathe deeply, followed by coughing up the sputum c. Obtain the specimen before bedtime restrict fluid before expecting the sputum specimen d. restrict fluids before expecting the sputum specimen
Breathe deeply, followed by coughing up the sputum
While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the cleint's fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse task? a. assess the client's radial pulses and capillary refill time b. Discuss approaches to the chronic pain control with the client c. Notify the healthcare prpivder of the fidning with the client d. review the client's dietary intake of high protein foods
Discuss approaches to the chronic pain control with the client
A client is recovering from a transurethral prostatectomy. Which activity should be limited until after the first post operative visit with this HCP? a. Driving a car b. eating high fiber foods c. kegel exercise d. walking around the house
Driving a car
Which dietary instruction is most important for the nurse to explain to a client who has had gastric bypass surgery? a. reduce intake of fatty foiods b. Eat small frequent meals c. sip fluids with each meal d. chew slowly and throughly
Eat small frequent meals
The nurse is assessing a client's arteriovenous fistula. Which finding provides evidence of its normal function? a. Ecchymotic Area b. Redness c. Pulselessness d. Enlarged Vein
Enlarged Vein
Which food is most important for the nurse to encourage a client with osteomalacia to include in a daily diet? a. Fortified Milk and Cereals b. Citrus Fruits and Juices c. Green Leafy Vegetables d. Red Meats and Eggs
Fortified Milk and Cereals
When planning care for a client with rheumatoid arthritis, which intervention is most important for the nurse to include?
Implement measures to manage chronic pain
The nurse observes an increased number of blood clots in the drainage tubing of a client with continous bladder irrigation following a transurethral resection of the prostate (TURP). What is the best intial nursing action? a. Provide additional oral fluid intake b. Measure the clients intake and output c. Increase the flow of the bladder irrigation d. admisnter a PRN dose of an antispamodic agent
Increase the flow of the bladder irrigation
A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by that nurse? a. Pitting Ankle Edema b. Purple Marks on Skin of the Abdomen c. Irregular Apical Pulse d. Quarter size blood spot on dressing
Irregular Apical Pulse
A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse? a. Purple Marks on Skin of the abdomen b. Irregular Apical Pulse c. Quarter Size Blood Spot on Dressing d. Pitting Ankle Edema
Irregular Apical Pulse
While planning care for a client with carpal tunnel syndrome, the nurse identifies a collaborative problem of pain. What is the etiology of this problem?
Irritation of the nerves endings
The drainage in the chest tube of a client with emphysema has changed from viscous green to clear water fluid/ Which action is best for the nurse to take? a. Obtain a specimen of the drainage for culture b. Maintain the current IV antibiotic schedule c. Milk the tube to remove any clots d. Schedule a portable Chest X-Ray per PRN protocol
Maintain the current IV antibiotic schedule
When providing care a client following a bronchoscope, which assessment finding should the nurse immediately report to the healthcare provider?
No gag reflex after thirty minutes
While assisting a female client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor, The nurses call for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?
Oberseve for prolonged periods of apnea
An adult client comes to the urgent care clinic 5 days after being diagnosed with influenza. The client is short of breathe, febrile, and coughing green-colored sputum. Which interventions should the nurse implement first? a. Check his oxygen saturation level b. Obtain a sputum sample for culture c. Auscultate bilateral lung sounds d. Administer an oral antipyretic
Obtain a sputum sample for culture
A client with Herpes Zosters (shingles) on the thorax tells the nurse of having difficulty sleeping. Which is the probable etiology of this problem? a. Frequent Cough b. Pain c. Nocturia d. Dypnea
Pain
a client has ana bsolute count of 500/mm, after completling chemotherapy. Which intervention is most important for the nurse to implement?
Place the cliuent in protective isolation
The nurse reviews the laboratory results of a client during an annual physical examination and identifies a positives guar test of stool. Which additional serum laboratory test results should the nurse review? a. Glucose b. Platelet Count c. White blood cell count d. Amylase
Platelet Count
The nurse is caring for a client who is postoperative for a femoral fracture repair. Which itnervention(s) should the nurse plan to administer for deep vein thrombosis prophylaxis? (SATA) a. Pneumatic Compression Devices b. Incentive Spriometery c. Assisted Ambulation d. Patient-controlled anaglesia d. Calf-Pump Exercises e. prescribed anticoagulant therapy
Pneumatic Compression Devices d. Calf-Pump Exercises e. prescribed anticoagulant therapy
On third postoperattive day, a client who has had a hip replacement surgery becomes anxious and diaphoretic and begins to experience auditory hallucinations. The client denies having any pain. The cleints vital signs are pulse rate 125 bpm, repsiratory rate is 36 b/pm and blood pressure is 166/88. Whcih nursing interventions should the nurse implement (SATA) a. Present a calm, supportive demeanor b. apply soft wrist restraints bilaterly c. adminster a PRN dose of lorasepam d. reorient to day and time frequently e. turn the television on for distraction
Present a calm, supportive demeanor adminster a PRN dose of lorasepam
A male client with acute abdominal pain persistent nausea, and projectile vomitting is admitted to the hospital for observation, acetaminophen is administered as prescription for his oral temperature of 103F and an infusion of normal saline is initiated at 250ml/hr. Which assessment finding should the nurse report to the healthcare provider immediately
Right Lower
After three days of persistent epigastric pain, a female client presents to the clinic. She ha sbeen taking oral antacids without relief. Her vital signs are: heart rate 122 bpm, respiration 16 breaths per min, oxygen sat 96%, and bp is 116/70. the nurse obtains a 12 lead ECG. What assessment finding is most critical? a. irewgular pulse rate b. bile colored emesis ST elevared in three leads cmpliant of raditing jaw pain
ST elevared in three leads
A young adult male client has a diagnosis of epididmyitis and a postive cultre for C Coli. Which information should the nurse include in the teaching plan?
Surgical Intervention is foten indicated
The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomy under general anesthesia. Which finding warrants notification of the healthcare provdier prior to proceeding with the scheduled procedure a. The client vomits 20mL of clear yellowish fluid b. the iV Insertion site is red, swollen, and leaking IV fluid c. light yellow coloring of the cleint's skin and eyes d. The clients blood pressure is 184/88 mm hg
The clients blood pressure is 184/88 mm hg
Which client has the hghest risk for developing skin cancer? a 70 year old fair skinned client who works as a secretary a 65 year old fair skinned client who is a construction worker a 16 year old dark skinned client who tans in tanning beds once a week a 25 year old fark skinned client whose mother had skin cancer
a 65 year old fair skinned client who is a construction worker
the family suspects that acquired defiency syndrome (AIDS) dementia is occuring in their son who is human immunodeficeny virus (HIV) positive. Which symptoms confirms their suspcisons? he has begun to sleep 18 out of 24 hours a change has recently occured in his handwriting he refuses to see any of his friends or to reutrn their phone calls he echibits angry outburst when the subject of dying is approached
a change has recently occured in his handwriting
a client arrives to the medical surgical unit 4 hours after a transurethral reserction of the prostate. A triple lumen cathter to continous bladder irrigation with normal saline is infusing and the nurs eobserves dark, pink tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take? a. monitoring catjerter drainage b. decreasing the flow rate c. imaging the catheter manually d. discontinuing infusing solution
a. monitoring catjerter drainage
A client recieves prescirptions for a multidrug reigmen for the treatment of tuberculosis. Whcih information should the nurse priortize? a. adherence to the regimen is imperative b. medications should be taken with food c. serum liver panels are collected regularly d. enhanced sun protection measures will be needed
adherence to the regimen is imperative
A client with a history of peptic ulcers disease (PUD) is admitted after vomitting bright red blood several times over the course of 2 hours. In reviewing the laborartory results, the nurse finds the clients hemoglobin is 12 g/dl and the hematocrit is 35%. Which action should the nurse prepare to take? continue to monitor for blood loss admisnter 1000ml normal saline transfuse 2 units of platetls Prepre the client for emergency surgery
admisnter 1000ml normal saline
A client with lung cancer who wears a subcutaenous morphine sulfate patch for pain is short of breathe and is difficult to arouse. When performing a head to toe assessment, the nurse discovers four anagelsic patches on the clients body. Which interventions sould the nurse implement first? a. Remove all of the morphine patches b. admisnter a narcotic antagonist c. apply oxygen per face mask d. measure the clients blood pressure
admisnter a narcotic antagonist
Four days following an abdominal aortic aneurysm repair, the client is exhibting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first? a. Elevate extremties on pillows evaluate edema for pitting assess pusles with a vasdcular doppler Wrap the feet with warmed blankets
assess pusles with a vasdcular doppler
an older adult client with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of brearthe of breathe and persistent cough The client is anxious and is complaining of a dry mouth. which intervention should the nurse implement? assust cluebt ti ab upright positiion admisnter a prescribed sedative apply a high dlow venting mask encourage client to drink water
assust cluebt ti ab upright positiion
The nurse is developing a plan of care for an adult with cardiovasuclar disease who reports blurred vision. Which outcome should the nurse include in the plan of care for this client? a. the clients blod pressure readings will be less than 160.90 b. the nurse will encourage the client to walk thirty mionutes every day c. thye cleints dailt blood pressure will be less than 140.80 this month d. the cleints family will state signs and symptoms about the diease
b. the nurse will encourage the client to walk thirty mionutes every day
A male client who reports feeling chronically fatiqued has a hemoglobin of 11.0 grams/dL, hematocrit of 34% and microcytic and hypochromic red blood cells. Base on these findings, which dinner selection the nurse suggests to the client? a. beef steak with steamed broccoli and orange silices b. cheese pasta and a lettuce and tomato sald. c. broiled white fish with a baked sweet potato d. griled shrimp and seasoned rice with asparagus salad
beef steak with steamed broccoli and orange silices
A client with phenochromocytoma reports the onset of a sevetre headache . the nurse observes that the client is very diaphrotetic. Which assessment data should the nurse obtain next? a. capillary glucose b. blood pressure c. oxygen saturation d. body temperature
blood pressure
A postoperative client reports incisional pain. The client has two prescirptions for PRN analgesia that accompanied the client from the postanesthetic unit. Before selecting which medication to adminster, which action should the nurse implemenet? a. determine which prescription will have the quickest onset of action b. compare the clients pain scale rating with the presvribed dosing c. document the clients report of pain in the electronic medical record d. ask the client to choose which medication is needed for the pain
compare the clients pain scale rating with the presvribed dosing
while completing a health assessment for a client with migrane headaches, the nurse assesses bilateral weakness in the cleints hand grips. The cleint reports joint pain and trouble twisting a door knob due to weakness. WEHich action should the nurse take in respoinse to these findings? Esplaint he relief of the migrane pain will reduce related symptoms gather additional assessments data about the pain and weakness implement fall precautions to reduce the cleints risk for injury consult with the occupational therpaist for a functional assessment
consult with the occupational therpaist for a functional assessment
The nurse is teaching a cient with allergic rhinitis about avoidance of allergens. Whcih is an important point that should be included in the traching plan? a. Removing petrs from interior of home brings immediate relief b. focus on increasing the humidity level in cleints home c. ensure air conditioning vents in bedroom remain open d. common triggers include dust mites and cockroaches
d. common triggers include dust mites and cockroaches
Ten hours following thrombolysis for an ST elevation myocardial infarction (STEMI) a client is recieving a lidocaine infusion for isolate runs of ventircular tachycardia (VT). Which fidning should the nurse document in the electornic medical record as a therapeutic response to the lidocaine infusion? a. Stablization of blod pressure ranges b. cessation of chest pain c. reduce heart rate d. decreased freqwuency of episode of VT
decreased freqwuency of episode of VT
a client with cholethithiasis is admitted with jaundice due to obnstruction of the common bile duct. Which finding is most important for the nurse to report to the healthcare provider? distended, hard and rigid abdomen clay colored stool radiating, sharp pain in right shoulder bile strained emesis
distended, hard and rigid abdomen
an adult client is admitted with flank plan and is diagnosed with acute pyelnoephritis. What is the priority nursing action? monitor hemoglobin and hematocrite encourage turning and deep brrathing dmisnter iv antibiotics as prescribed ausuclate for presence of bowel sounds
dmisnter iv antibiotics as prescribed
When conductin dischare traching for a client diagnosed with diverticulosis, which diet instruction should the nurse include? have small frequent meals and sit up for at least two hours after meals eat a bland diet and avoid spicy foods eat a high-fiber diet and increase fluid intake eat a soft diet with increased intake of milk and milk products
eat a high-fiber diet and increase fluid intake
the nurse is obtaining a health history from a new client who has a history of kidney stones. Which statement by the client indicates an increased risk for renal calculi? a. eat a vegetarian diet with cheese to 2 to 3 times a day experience additional stress since adopting a child jogs more freuqently than usual daily toutines drinks several bottles of carbonated water daily
eat a vegetarian diet with cheese to 2 to 3 times a day
the nurse is collecting information from a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse obtain? presence and activity of bowel sounds color and consistency of feces eating patterns and dietary intake level and amount of physical acitvity
eating patterns and dietary intake
A client admitted to a surgical unit is being evaluated for an intestinal obstruction. The healthcare provider prescribe NGT to be inserted and placed to intermittent low wall sucxtion. Which intervention should the nursr implement to facilitate proper tube placement? a. Apply suction while inserting tube b. soak nasogastric tube in warm water c. elevate head of bed 60 to 90 degrees d. insert tube with clients head titled back
elevate head of bed 60 to 90 degrees
The nurse is planning care for an older client who experienced a cerebrovascular accident several weeks ago. The client has expressive aphasia and often becomes frustrates with the nursing staff. Which intervention should the nurse implenment? a. Teac the client use of basic sign language b. speak slowly to the client c. encourage client use of picture charts d. ask the clients simple questions
encourage client use of picture charts
A client sickle cell anemia develops a fever during the last hour of adminstration of a unit of packed red blood cell. When notifying the healthcare provider what information should the nurse provide first using the SBAR communication process? a. explain specific reason for urgent notification b. communicate the pre-transfusion temperature c. preface the report by stating the clients name and admittin diagnosis d. obtain PRN prescirption for acetaminophen for fever over 101
explain specific reason for urgent notification
the nurse is providing teraching to a client with type 2 DM and peripheral neurppathy. Which information should the nurse provider? family members can help with regular boot exams heating pads are useful if onthe lowest setting aching feet may be soaked in lukewarm water for one hour or more shoes hsould be worn outside the house, but it is fine to be barefoot inside
family members can help with regular boot exams
An obese client with empsyema who smokes at least a pack of cigrarettes daily is admitted after experiencing a sodium increase in dyspnea and activity intolerance. Oxygen therapy is intitated an it is determined that the client will be dischzrged with oxygfen. Which informationto most im portant for the nurse to e,phaizse in the disahcre plan> a. methfofs to weight loss guidelines for oxufen use approaches to conserve enrgy stragiethies for smoking cessation
guidelines for oxufen use
a client with a history of type 1 diabetes melitius (DM) and asthma is readitted to the unit for the third time in two months with a current fasting blood sugar (FBS) is a 325 mg.dl. The client describes to the nurse of not understanding why the blood glucose levels continues to be out of control. Which interventions should the nurse implement ? SATA have the client describes a typical day at work, home and social activites determine if the client is using a new insulin needle each adminstration evaluate the clients asthma medication thart can elevate the client blood glucose ask the client if they want a different manufacutre's glucose mopnitoring device have the client demonstrate techqiue used to mmonitor blood glucose levels
have the client demonstrate techqiue used to mmonitor blood glucose levels have the client describes a typical day at work, home and social activites
the nurse assess a client with cirrohis and finds 4+ pitting edema of the feet and legs, and massice ascities. Which mechanism controbutes to edema and ascities in clients with cirrohisis hyperaldosteronism causing an increased sodium reabosrption in renal tubules. decreased portacaval pressure with greater collateral xirxulation decreased renin - angiotensin rsponse related to an increase in renal blood flow hypoalbumin that results in a decreased collodial oncotic pressure
hypoalbumin that results in a decreased collodial oncotic pressure
a client with a hsitory of asthma and bronchtiitis arrives at the clinic with shoirtness of breathe , productive cough with thickened, tendacious muscous, and the inability to walk up a flight of stairs without experiencing breathelessness. Whcih action is most important for the nurse to isntruct the client about self care? call the clinic if undesirable side effects of medication occur avoid crowded enclosed areas to reduce pathogen exposure increase the daily intak if oral fluids to liquefify secretions teach anxiety reduction medthods for feelings of suffocation
increase the daily intak if oral fluids to liquefify secretions
the nurse observes an increased number of blood clots in the drianage tubing of a client with continious bladder irrigation following a trans-urethral resection of the pprostate (TURP_ what is the best intital fluid intake a. admisnter a PRN dose of an antispasmodic agent b. Provide additional oral fluid intake c. increase the flow of the bladder irrigation d. measure the clients intake and output
increase the flow of the bladder irrigation
During spring break a young pressure to the urgent care clinic and reports a stiff neck , a fe ver for the past 6 hours and a headache. Which interventions is most important for the nurse ti implement first? intiate isolation precuation adminster an antipyretic draw blood culture prepare for a lumbar punture
intiate isolation precuation
During spring break, a young adult presents to the urgent care unit and reports a stiff neck, a fever for the past 6 hours and a headache. Which intervention is most important for the nurse to implemement first? a. draw blood cultures b. prepare for a lumbar puncture c. intitate isolatyion precaustions d. Admisnter an antipyretic
intitate isolatyion precaustions
An adult who was recently diagnosed with gluacoma tells the nurse "it feels like I am driving through a tunnel" the client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client? maintain prescribed eye drop regimen avoid frequent eye pressure measurement wear prescription glasses eat a diet high in carotene
maintain prescribed eye drop regimen
The nurse is caring for a client in the post anesthenia care unit (PACU) who underwent a thoractomy two hours ago. the nurse observes the dollow signs: heart rate 140 bpm, repsiraqtion 26 breaths per min and blood pressure 140/90 mmhg. Which intervention is most important for the nurse to implement? medicate for pain and monitor vital signs according to protocot admisnter intravenous fluid bolus are prescribed by the healthcare provider apply oxygen at 10L via non rebreather mask and monitor pulse oxiumeter encourage the client to splint the incision with a pillow to cough and deep breathe
medicate for pain and monitor vital signs according to protocot
In providing discharge teaching to a client with chronic obstructive pulmonary disease (COPD), which isntruction is most important for the nurse to empahsize? a. avoid going outdoors whenever the pollen count is high b. keep a food dietary for one week and bring to next appointment c. stay in the house if the outdoor tremperatur is hot and humid d. notify the healthcare provider of any change in sputum color
notify the healthcare provider of any change in sputum color
the nurse is preparing a client for surgery who was admitted to the emergency center following a motor vechile collisions. The client has an open fracture of the femur and is bleeding moderately from the bone protusion site. During the preoperative assessment, the nurse nurse determines that the client currently recieves heparin sodium 5,000 units subcutaneously daily. What is the priority nrusing clients? a. notofdy the healthcare provider of the client's medication hsitory b. observe the heparin injections sites for signs of brusing c. have the cleint sign the surgical and transfusion permits d. ensure the potential for leeding is explained to the cleint
notofdy the healthcare provider of the client's medication hsitory
a client tells the clinic nurse about experiencing burning on urination, and assessment reveals the cleint had sexual intercourse four days ago with a person who was casually met. which action shoiuld the nurse implement observe the perineal area for a chancroid like lesion obtain a specimen of urethral drainage for culture assess for perineal itching, erthyema and exocritation identify all sexual partners in the last four days
obtain a specimen of urethral drainage for culture
a client who had c-5 spinal cord injury 2 years ago is admitted to the emergency department with the diagnosis of automnomic drysflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit? compliant of chestp pain and shortness of breathe hypotensionand venous pooling in the extremities profuse diaphrosesis and severe, pounding headache pain and burning sesnation ipon urination and hematuria
pain and burning sesnation ipon urination and hematuria
The nurse assess a client who is newly diagnosis with hyperthyriodism and observes that the clients eyeballs are protuberant, causing a wide eyed appearance and eye discomfort. Based on this finding, which action should the nurse include in this cleints plan of care? a. assess for signs of icnreased intracranial pressure prepare the admisnter intravenous levothryoxxine review the clients sreum electrolyte values pbtain a prescription for artficail tear drops
pbtain a prescription for artficail tear drops
to reduce the risk for pulmonary complication for a client with ALS, which intervention should the nurse implememnt> SATA perform chest physiotherapy trach the client breathing exercises initate passive range of motion exercises establish a regular bladder routine encourage use of incentive spirometer
perform chest physiotherapy trach the client breathing exercises encourage use of incentive spirometer
a client is hosplitalized with heart failure. which itnervention should the nurse implement to improve ventilation and reduce venous return? a. perform passive range of motion exercises place the client in high fowler position admisnter oxygen per nasal cannula in crease the clients activity level
place the client in high fowler position
the nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which labortory results results should the nurse review? a. red blood cell count b. platelet count hemoglobin levels white blood cells count
platelet count
a client is the operatinf room recieved syccinycholine. The client is experiencing muscle ridgitiy and has a extremly high temperature. Which action should the nurs eimplement? hold a prescription for dantrolene until fever is reduced prepare ice packets for palcemenrt in the client's axillary area call thr PACU nurse tio prepare for prolonfed ventilatory support determine if prescribed antibioptics were admisntered preoperativitley
prepare ice packets for palcemenrt in the client's axillary area
the nurse is caring for a client who is recieving teletherapy radition for a malignant tumor. Which instruction regarding skin care of the portal site should the nurs eprovide? protect the skin of the raditian portal site from sunlight exopsure apply moisutre lotions daily to the radition portal site avoid washing the skin inside the radition portal site remove the ink marks of the portal after each radition treatment
protect the skin of the raditian portal site from sunlight exopsure
the nurse is providing discharge instructions to a client who is recieving predinsoone 5mg daily to a rash due to contact with posion ivu. Which symptom should the nurse tell the client to report to the healthcare provider? rapid weight gain abdominal striae moon faces gastric irritation
rapid weight gain
After several days of coughing and taking acetaminophen to treat temperautre of 101 F, a client with DM is admitted to the hospital with an upper respiratory infection. Several hours after admission, the client reports having a severe headache and feeling dizzy. Which itnervention should the nurse implement first? a. reasses bital signs b. admisnter an antipyretic c. obtain sputum for culture d. obtain a fingerstick glucose
reasses bital signs
An adult client who recieve paretial thickness and full thcikness burns over 40% of the body un a house fire is admitted to the inpatient unit. Whcih fluid should the nurse prepare to admisnter during the acute phase of the clients burn recovery?
ringer lactate
an older client with long term type 2 diabetes mellitues (DM) is seen in the clinic for a routine health assessments. Which assessment would the nurse complete to determine if a patient with type 2 DM is experiencing long term complications (SATA) signs of respiratory tract infection sensations in feet and legs skin conditions of lower extremities serum creatintine and blood urea nitrogen (BUN) visual acuity
sensations in feet and legs skin conditions of lower extremities visual acuity
An adult client is diagnosed with restless leg syndrome and is referred to the sleep clinic. The healthcare provider prescribes ferrous sulfaste 325 mg PO Daily. Whch lab values shoul the nurse monitor? a. serum electorlytes b. neutrophils and eosinophils c. serum iron and ferritin d. platelet count hematocrit
serum iron and ferritin
an adult client is diagnosed with restlesness leg syndrome and is referred to the sleep clinic. The healthcare provider prescribes ferrous sulfate 325 mg PO daily. which labvalues should the nurse monitor? platelet count and hematocrit serum electrolyte serum iron and ferritin neutrophils and eosinophils
serum iron and ferritin
a nurse is caring for a client with diabetes insipidus (DI). Which data warrants the most immediate intervention by the nurse? serum sodium of 185 mEq Dry skin with inelastic turgor aprical rate of 110 beats per minute polyuria and excessive thirst
serum sodium of 185 mEq
The nurse assess a client being treated for herpes zoster (shngles) Which assessment should the nurse include when evaluating the effectiveness of treatment? (SATA) a. heart sounds b. skin intergirty functional ability d. bowel sounds e. pain scale
skin intergirty functional ability pain scale
A client with acute renal injury weighs 50kg and has postassuum level of 6.7 is admitted to the hospital, Which prescribed medication should the nurse adminster first? a. calcium acetate one tablet by mouth sodium polystyrne sulfonate 15 grams by mouth epoetein alfa, recombinant 2500 units subcutaneoulsy sevetamer one tablet by miytgh
sodium polystyrne sulfonate 15 grams by mouth
The nurse is providing dietary instruction for a client who is being discharged after passing a calcium oxalate renal stone. Which food should the nurse instruct the client to avoid? a. fish b. sweet potatoes c. spinach salad d. banannas
spinach salad
the healthcare provider prescribes diagnostic tests for a client whose chest xray indicates pneomnia. Which daignsotic test should the nurse review for implementation in the most theraputic treatment of the pneumonia? a. sputum culutre and sensitivity blood culture arterial blood gases (ABG) computerized tomography (CT) of the chest
sputum culutre and sensitivity
a client with chronic kidney disease in started on hemodiaylsis. During the first diaylsis treatment, the client blood pressure drops from 150/90 to 80/30 mmHg. Which action should the nurse take first? stop the diaylsis treatment admisnter 5% albumin IV monitor blood pressure q45 minutes lower the head of the chair and elebvate feet
stop the diaylsis treatment
The nurse is developing a plan of who reports blurred visions and who is newly diagnosed with cardiovasular disease. Whuch outcome should the nurse include in the plan of care for the client? the nurse will encourge the client to walk thirty minutes everyday the client family will state signs and symptoms about the disease the cleint daily blood pressure will be less than 145/80 mmHg this month the clients blood pressure readings will be less than 150/90 mmhg
the cleint daily blood pressure will be less than 145/80 mmHg this month
When teaching a client with parksons diease, whcih rationale for the prescreiption of carbidopa-levodopa should the nurse include?
the client is at increased risk for falls due to dizziness and orthostatic hypotension
The nurse is developing a plan of cvare for a client who reports blurred vision and who is newly diagnosed with type 2 diabetes. Which outcome should the nurse include in the plan of care for this client?
the clients hemoglobin A1C will be less than 7.0% in 3 months
a client with orthopnea expresses concern about the ability to "get enough sitr" during a scheduled thoracentsis/ On which information should the nurses repsonses to based? A thoracentesis is a bried procedure that has minimal discomfort orthopnea is freuqently caused by a cleint's uncontrolled anxiety the procudre is performed with the client in an upright positions extra pillows can be sued if needed to elebvater the cleints head
the procudre is performed with the client in an upright positions
The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this medical diagonosis? a. Freuwent use of chewable and liquid antacids for indgestion severe abdonminal craps and diarrhea after eating spicy food upper mid-abdominal pain described as gnawing and burning marked loss of wight and appetiote over the last 3 or 4 motnhs
upper mid-abdominal pain described as gnawing and burning
a client who was involved in a motor vechile collision is admitted with a fractured left femur which is immoblized using a fracture traction in a splint in preperation for an open reduction internal fixation (ORIF). the nurse determines that the clients distal pulses are diminshed in the left foot. Wehich interventions should the nurse implement ? SATA verify pedal pulses using a droppler pulse device evaulate the application of the splint to the left leg offfer ice chips and oral clear liquids monitor left leg for pain, pallor, parethesia, paralysis and pressure admisnter oral antispasmodics and narcotic anaglesics
verify pedal pulses using a droppler pulse device evaulate the application of the splint to the left leg monitor left leg for pain, pallor, parethesia, paralysis and pressure
The nurse is teaching a client with cancer about skin care for the portal site recieving external beam radition. Which client action about skin care indicates a need for further teaching? a. dries the area with patting motions after taking a shower b. washes the radiation site with antibacterial soap and water c. wear clotheing to xcover the radition site d. applies prescirbed lotions to the radition site
wear clotheing to xcover the radition site
while caring for a client with a full thickness burn covering 40% of the body, the. nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the clients laboratory values? white blood cell (WBC) count platelet count blood pH level hematocrit
white blood cell (WBC) count
