HESI MED/SURG

the nurse is admitting a client with possible TB. The client is placed in a private room with airborne precautions pending diagnostic test results. which diagnostic test should the nurse review to confirm the diagnosis of TB? A. sputum culture positive for mycobacterium TB b. chest xray or CT c. positive PPD skin test D. hemoccult test on sputum collected from hemoptysis.

A. sputum culture positive for mycobacterium TB

The family suspects that AIDS dementia is occurring in their son who is HIV positive. Which symptom confirms their suspicions? a. a change has recently occurred in his handwriting b. he exhibits angry outbursts when the subject of dying is approached. c. he has begun to sleep 18-24 hours d. he refuses to see any of his friends or to return their phone calls.

a. a change has recently occurred in his handwriting

a client with a right ulnar fracture and cast placement reports an increase in arm pain. which action should the nurse take next? a. administer a PRN analgesic b. assess right radial pulse volume c. implement distraction techniques d. measure the bp

a. administer a PRN analgesic

a client with chronic myelogenous leukemia who has been on long-term corticosteroid therapy develops oral candidiasis. the client tells the nurse that the pain makes it difficult to chew or swallow. which action should the nurse implement first? a. administer a topical analgesic b. obtain a soft diet for the client c. cleanse the mouth with swabs d. encourage frequent mouth care.

a. administer a topical analgesic

during the preoperative assessment, the nurse learns that a client has a history of venous thromboembolism (VTE). to reduce the risk of this problem developing again in the postoperative period, which instruction should the nurse emphasize when teaching the client? a. early ambulation b. deep breathing c. diet progression d. wound care.

a. early ambulation

the nurse is providing discharge teaching to an elderly client hospitalized for treatment of venous leg ulcers. which instructions should the nurse include in the teaching plan? select all that apply a. eat a diet that is high in protein and vit. A and C b. maintain bed rest as much as possible c. apply intermittent cold compresses four times daily. d. keep legs elevated when sitting or lying down e. inspect ankles daily for areas of darkening skin.

a. eat a diet that is high in protein and vit. A and C d. keep legs elevated when sitting or lying down e. inspect ankles daily for areas of darkening skin.

a client who has developed acute kidney injury due to an aminoglycoside antibiotic has moved from the oliguric phase to the diuretic phase of AKI. which parameters are most important for the nurse to plan to carefully monitor? a. hypovolemia and electrocardiographic changes b. side effects of total parental nutrition and intralipids c. uremic irritation of mucous membranes and skin surfaces d. elevated creatinine and BUN

a. hypovolemia and electrocardiographic changes

which information should the nurse include in the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD) a. minimize symptoms by wearing loose, comfortable clothing b. avoid participation in any aerobic exercise programs c. adjust food intake to three full meals per day and no snacks. d. sleep without pillows at night to maintain neck alignment.

a. minimize symptoms by wearing loose, comfortable clothing

a client with benign prostatic hyperplasia is preparing for discharge following a transurethral needle ablation (TUNA). which information should the nurse include in the discharge instructions? a. monitor urinary stream for decrease in output. b. use incentive spirometer c. restrict physical activities. d. report when hematuria becomes pink-tinged.

a. monitor urinary stream for decrease in output.

during an annual well-woman exam, a postmenopausal client who expresses concern about her risk for heart disease describes herself as a moderate drinker. when the nurse asks the woman to quantify her statement, the client reports that she drinks 4 glasses of wine daily. which information should the nurse provide this client? a. reducing intake of wine to one glass daily can help lower the risk of cardiac disease b. alcoholic bev. should be avoided altogether by postmenopausal women. c. red wine is more advantageous to cardiac health than other types of alcohol. d. those who avoid alcohol throughout their lifetime have the lowest risk for cardiac disease.

a. reducing intake of wine to one glass daily can help lower the risk of cardiac disease

during a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and high waist-hip ratio, with a body mass index of 32. which action should the nurse take in response to these findings? a. screen for family history for diabetes mellitus. b. advise the client to restrict fluids and keep feet elevated c. discuss the importance of a regular exercise program d. measure the client's blood pressure in both arms e. arrange for immediate transportation to a medical facility.

a. screen for family history for diabetes mellitus. c. discuss the importance of a regular exercise program d. measure the client's blood pressure in both arms

a client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling experienced worsen at night. which client teaching should the nurse provide? a. wear braces on both wrists during the night b. apply cold compresses for 30 minutes before bedtime c. notify the health care provider as soon as possible. d. elevate the hands-on two pillows at night.

a. wear braces on both wrists during the night

a postoperative client reports incisional pain. the client has two prescriptions for prn analgesia that accompanied the client from the postanesthetic unit. before selecting which medication to administer, which action should the nurse implement? a. ask the client to choose which medication is needed for pain b. compare the client pain scale rating with the prescribed dosing c. determine which prescription will have the quickest onset of action d. document the client's report of pain in the electronic medical record.

b. compare the client pain scale rating with the prescribed dosing

an older client who experienced a cerebrovascular accident has difficulty with visual perception and eats only half of the food on the meal tray. the client's family expresses concern about the client's nutritional status. how should the nurse respond to the family's concern? a. explain that weight loss will be reversed after the acute phase of the stroke has ended. b. demonstrate the use of visual scanning during meals to the client and family c. encourage the family to offer to feed the client when she does not eat her entire meal. d. suggest that the family bring foods from home that the client enjoys eating.

b. demonstrate the use of visual scanning during meals to the client and family

while assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the client's fingers that are reddened. the client reports that the nodes are painful. which action should the nurse take? a. review the client's dietary intake of high-protein foods. b. discuss approaches to chronic pain control with the client c. notify the health care provider of the finding immediately d. assess the clients radial pulses and capillary refill time.

b. discuss approaches to chronic pain control with the client

a client with diabetes Mellitus is admitted with an upper respiratory infection. which changes in blood glucose management should the nurse tell the client to expect? a. fewer fingerstick glucose checks b. high doses of insulin c. restriction of caloric intake d. increased oral fluid intake

b. high doses of insulin

the nurse reviews the results of an abdominal CT scan for a client with severe colicky abdominal pain and vomiting. the results indicate a strangulated hernia of the small intestines and surgery is planned. after placing the client on nothing-by-mouth precautions and obtaining vital signs, which prescription should the nurse implement next? a. give a prescribed analgesic for temperature above 101 degrees F b. insert a NGT and attach to low intermittent suction c. send the client to xray for a flat plate of the abdomen d. place an indwelling urinary catheter and attach a bedside drainage unit.

b. insert a NGT and attach to low intermittent suction

a client experiences an ABO incompatibility reaction after multiple blood transfusions. which finding should the nurse report immediately to the health care provider? a. arthritic joint changes and chronic pain b. lower back pain and hypotension c. acute rhinitis and nasal stuffiness d. delayed painful rash with urticaria

b. lower back pain and hypotension

an adult woman with graves disease is admitted with severe dehydration and malnutrition. she is currently restless and refusing to eat. which action is most important for the nurse to implement? a. teach the client relaxation techniques b. maintain a patent intravenous site c. keep room temperature cool d. determine the clients food preferences

b. maintain a patent intravenous site

the nurse is developing a plan of care for a client undergoing peritoneal dialysis. which nursing intervention has the highest priority? a. assess peripheral pulses in lower extremities. b. maintain accurate intake and output record. c. turn and position the client at least every 2 hours d. encourage a high fiber, low protein diet.

b. maintain accurate intake and output record.

following an ileal conduit urinary diversion, a client voices several concerns. which finding indicates to the nurse that the client is experiencing a complication? a. a small amount of bleeding at the stoma site b. a bright red, moist ostomy site c. a dark purplish colored stoma d. amber colored urine coming out of the stoma.

c. a dark purplish colored stoma

a client with newly diagnosed crohns disease asks the nurse about dietary restrictions. how should the nurse respond? a. explain that the need to restrict fluids is the primary limitation b. advise the client to limit foods that are high in calcium and iron c. describe the use of an elimination diet to find trigger foods d. instruct the client to avoid foods with gluten, such as wheat bread.

c. describe the use of an elimination diet to find trigger foods

an older client with cirrhosis of the liver and hepatic failure is placed on a low-sodium diet and is receiving periodic albumin infusions. which assessment finding indicates progress toward the desired effect of this treatment plan? a. decreased abdominal girth b. prothrombin time within normal limits c. improved level of consciousness d. clear, dark amber-colored urine

c. improved level of consciousness

a client tells the clinic nurse about experiencing burning on urination, and assessment reveals that the client had sexual intercourse four days ago with a person who was casually met. which action should the nurse implement? a. observe the perineal area for a chancroid-like lesion b. identify all sexual partners in the last four days. c. obtain a specimen of urethral drainage for culture d. assess for perineal itching, erythema, and excoriation.

c. obtain a specimen of urethral drainage for culture

a client is recovering from an episode of urinary tract calculi. during discharge teaching, the client asks about dietary restrictions. in discussing fluid intake, the nurse should include which type of fluid limitation? a. over all fluid intake b. citrus fruit juices c. tea and hot chocolate d. low sodium soups

c. tea and hot chocolate

a client with a history of asthma reports having episodes of bronchoconstriction and increased mucous production while exercising. which action should the nurse implement? a. review the client's routine asthma management prescriptions b. determine if the client is using an inhaler before exercising. c. teach client to use pursed lip breathing when episodes occur. d. assess client for signs and symptoms of upper airway infection.

c. teach client to use pursed lip breathing when episodes occur.

a client with stage IV bone cancer is admitted to the hospital for pain control. the client verbalizes continuous, severe pain of 8 out of 1-10. which intervention should the nurse implement? a. give max dosage when the score reaches 10 b. alternate IV and IM analgesic medications c. educate the client on signs and symptoms of narcotic dependency. d. administer opioid and non-opioid medication simultaneously.

d. administer opioid and non-opioid medication simultaneously.

the nurse is teaching a client how to collect a sputum specimen. which step should the nurse instruct the client to follow when collecting sputum? a. avoid mouth care prior to collecting the sputum b. obtain the specimen before bedtime c. restrict fluids before expectorating the sputum specimen d. breathe deeply, followed by coughing up the sputum.

d. breathe deeply, followed by coughing up the sputum.

Which admission assessment findings should the nurse document related to a client who has been diagnosed with Cushing's? a. warm, soft, moist, salmon-colored skin b. visible swelling of the neck, with no pain c. husky voice and complaints of hoarseness d. central-type obesity, with thin extremities

d. central-type obesity, with thin extremities

when preparing a client for an abdominal paracentesis, which action should the nurse implement before the procedure is initiated? a. place the client in a side laying position b. measure the client abdominal girth c. maintain the client's npo for 8 hours d. encourage the client to empty the bladder

d. encourage the client to empty the bladder

while caring for a client with full-thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. before reporting this finding to the health care provider, the nurse should evaluate which lab value? a. blood pH level b. serium albumin c. platelet count d. neutrophil count

d. neutrophil count

in providing discharge teaching to a client with chronic pulmonary disease, which instruction is most important for the nurse to emphasize? a. avoid going outdoors whenever the pollen count is high b. stay in the house if the outdoor temperature is hot and humid. c. keep a food diary for one week and bring to next apt d. notify the healthcare provider of any change in sputum color.

d. notify the healthcare provider of any change in sputum color.