HESI MEDSURG1 2020-06

49. The nurse is preparing to administer enoxaparin (Lovenox) 135 mg subcutaneously. The medication is available in a cartridge labeled 150 mg/ml. How many ml should the nurse administer? (enter numeric value only. If rounding is required, round to the nearest tenth.)

0.9 ml

2. A client is brought to the ED by ambulance in cardiac arrest with cardiopulmonary resuscitation (CPR) in progress. The client is intubated and is receiving 100% oxygen per self-inflating (ambu) bag. The nurse determines that the client is cyanotic, cold, and diaphoretic. Which assessment is most important for the nurse to obtain? A. Breath sounds over bilateral lung fields. B. Carotid pulsation during compressions C. Deep tendon reflexes D. Core body temperature

A. Breath sounds over bilateral lung fields.

18. An overweight, young adult made who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions should the nurse implement? (Select all that apply.) A. Check his fingerstick glucose level B. Assess his skin temperature and moisture C. Measure his pulse and blood pressure D. Document anxiety on the surgical checklist E. Administer a PRN dose of regular insulin

A. Check his fingerstick glucose level B. Assess his skin temperature and moisture C. Measure his pulse and blood pressure

50. The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take? A. Collect the blood sample B. Assess radial pulse volume C. Apply pressure to the site D. Select another finger

A. Collect the blood sample

26. When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain? A. Daily weight B. Vital signs C. Level of consciousness D. Bowel sounds

A. Daily weight

31. A client with cancer is receiving chemotherapy with a known vesicant. The client's IV has been in place for 72 hours. The nurse determines that a new IV site cannot be obtained, and leaves the present IV in place. What is the greatest clinical risk related to this situation? A. Impaired skin integrity B. Fluid volume excess C. Acute pain and anxiety D. Peripheral neurovascular dysfunction

A. Impaired skin integrity

6. A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened tenacious mucous, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care? A. Increase the daily intake of oral fluids to liquefy secretions B. Avoid crowded enclosed areas to reduce pathogen exposure C. Call the clinic if undesirable side effects of mediations occur D. Teach anxiety reduction methods for feelings of suffocation

A. Increase the daily intake of oral fluids to liquefy secretions 关键词 thickened tenacious

53. The wife of a client with Parkinson's disease expresses concern because her husband has lost so much weight. Which teaching is best for the nurse to provide? A. Invite friends over regularly to share in meal times B. Encourage the client to drink clear liquids between meals C. Coach the client to make an intentional effort to swallow D. Talk to the healthcare provider about prescribing an appetite stimulant

A. Invite friends over regularly to share in meal times

19. A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse? A. Irregular apical pulse B. Purple marks on the skin of the abdomen C. Quarter size blood spot on dressing D. Pitting ankle edema

A. Irregular apical pulse

28. A male client with Herpes zoster (shingles) on his thorax tells the nurse that he is having difficulty sleeping. What is the probable etiology of this problem? A. Pain B. Nocturia C. Dyspnea D. Frequent cough

A. Pain

37. The nurse assesses a client being treated for Herpes Zoster (shingles). Which assessments should the nurse include when evaluating the effectiveness of treatment? (Select all that apply) A. Skin integrity B. Functional ability C. Heart sounds D. Pain scale E. Bowel sounds

A. Skin integrity B. Functional ability D. Pain scale

25. Which client has the highest risk for developing skin cancer? A. A 16-year old dark-skinned female who tans in tanning beds once a week B. A 65 year-old fair-skinned male who is a construction worker C. A 25 year-old dark-skinned male whose mother had skin cancer D. A 70 year-old fair-skinned female who works as a secretary

B. A 65 year-old fair-skinned male who is a construction worker

48. The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding? A. Nuchal rigidity B. Carotid bruit C. Jugular vein distention D. Palpable cervical lymph node

B. Carotid bruit

29. When planning care for a client newly diagnosed with open angle glaucoma, the nurse identifies a priority nursing diagnosis of, "visual sensory/perceptual alterations." This diagnosis is based on which etiology? A. Limited eye movement B. Decreased peripheral vision C. Blurred distance vision D. Photosensitivity

B. Decreased peripheral vision

39. A client with Addison's disease started taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor which serum laboratory value? A. Osmolarity B. Glucose C. Albumin D. Platlets

B. Glucose

4. A male client with heart failure (HF) calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain? A. What time did he take his last medications? B. Has his weight changed in the last several days? C. Is he still able to tighten his belt buckle? D. How many hours did he sleep last night?

B. Has his weight changed in the last several days?

38. A male client tells the clinic nurse that he is experiencing burning on urination, and assessment reveals that he had sexual intercourse four days ago with a woman he casually met. Which action should the nurse implement? A. Observe the perineal area for a chancroid-like lesion B. Obtain a specimen of urethral drainage for culture C. Assess for perineal itching, erythema and excoriation D. Identify all sexual partners in the last four days

B. Obtain a specimen of urethral drainage for culture

30. A client who is newly diagnosed with emphysema is being prepared for discharge. Which instruction is best for the nurse to provide the client to assist them with dyspnea self-management? A. Allow additional time to complete physical activities to reduce oxygen demand B. Practice inhaling through the nose and exhaling slowly through pursed lips C. Use a humidifier to increase home air quality humidity between 30-50% D. Strengthen abdominal muscles by alternating leg raises during exhalation

B. Practice inhaling through the nose and exhaling slowly

17. The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendations should the nurse encourage the client to follow? A. Increase intake of high-fiber foods, such as bran cereal B. Restrict protein intake by limiting meats and other high-protein foods C. Limit oral fluid intake to 500 ml per day D. Increase intake of potassium-rich foods such as bananas or cantaloupe

B. Restrict protein intake by limiting meats and other high-protein foods

16. A female client enters the clinic and insists on being seen. She is weak, nervous, and reports a racing heart beat and recent weight loss of 15 pounds. After ruling out substance withdrawal, the healthcare provider suspects hyperthyroidism and admits her for further testing. Which action should the nurse implement? A. Begin preparing client for thyroidectomy procedure B. Space the client's care to provide periods of rest C. Assess the client for hyperactive bowel sounds D. Provide warm blankets to prevent heat loss

B. Space the client's care to provide periods of rest

22. 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 provider prior to proceeding with the scheduled procedure? A. Light yellow coloring of the client's skin and eyes B. The client's blood pressure reading is 184/88 mm Hg. C. The client vomits 20 ml of clear yellowish fluid D. The IV insertion site is red, swollen, and leaking IV fluid

B. The client's blood pressure reading is 184/88 mm Hg

13. The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client? A. Grafting increases the risk for bacterial infections B. The xenograft is taken from nonhuman sources C. Grafts are later removed by a debriding procedure D. As the burn heals, the graft permanently attaches

B. The xenograft is taken from nonhuman sources

27. A female client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions should the nurse implement? (Select all that apply.) A. Offer ice chips and oral clear liquids B. Verify pedal pulses using a doppler pulse device C. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure D. Evaluate the application of the splint to the left leg E. Administer oral antispasmodics and narcotic analgesics

B. Verify pedal pulses using a doppler pulse device C. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure D. Evaluate the application of the splint to the left leg

35. During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms? A. An old friend with eczema came for a visit B. Recently received an influenza immunization C. A grandson and his new dog recently visited D. Corticosteroid cream was applied to eczema

C. A grandson and his new dog recently visited

32. A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the postanasthesia unit. Before selecting which medication to administer, which action should the nurse implement? A. Document the client's report of pain in the electronic medical record B. Determine which prescription will have the quickest onset of action C. Compare the client's pain scale rating with the prescribed dosing D. Ask the client to choose which mediation is needed for pain

C. Compare the client's pain scale rating with the prescribed dosing

43. During a paracentesis, two liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed, and 50 ml of clear, straw-colored fluid drains within the first hour. What action should the nurse implement? A. Palpate for abdominal distention B. Send fluid to the lab for analysis C. Continue to monitor the fluid output D. Clamp the drainage tube for 5 minutes

C. Continue to monitor the fluid output

44. 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. Notify the healthcare provider of the finding immediately C. Discuss approaches to the chronic pain control with the client D. Assess the client's radial pulses and capillary refill time

C. Discuss approaches to the chronic pain control with the client

15. A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117 mEq/L. Which nursing problem should the nurse include in this client's plan of care? A. Altered urinary elimination B. Impaired gas exchange C. Fluid volume excess D. Decreased cardiac output

C. Fluid volume excess

24. Following surgical repair of the bladder, a female client is being discharged from the hospital to home with an indwelling urinary catheter. Which instruction is most important for the nurse to provide to this client? A. Avoid coiling the tubing and keep if free of kinks B. Cleanse the perineal area with soap and water twice daily C. Keep the drainage bag lower than the level of the bladder D. Drink 1,000 ml of fluids daily to irrigate catheter

C. Keep the drainage bag lower than the level of the bladder

9. What information should the nurse include in the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD)? A. Sleep without pillows at night to maintain neck alignment. B. Adjust food intake to three full meals per day and no snacks. C. Minimize symptoms by wearing loose, comfortable clothing D. Avoid participation in any aerobic exercise programs

C. Minimize symptoms by wearing loose, comfortable clothing

33. While assisting a female client to the toilet, the client begins to have a seizure and the nurse eases her to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first? A. Document details of the seizure activity B. Observe for lacerations to the tongue C. Observe for prolonged periods of apnea D. Evaluate for evidence of incontinence

C. Observe for prolonged periods of apnea

41. An older male client tells the nurse that he is losing sleep because he has to get up several times at night to go to the bathroom, that he has trouble starting his urinary stream, and that he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement? A. Collect a urine specimen for culture analysis B. Review the client's fluid intake prior to bedtime C. Palpate the bladder above the symphysis pubis D. Obtain a fingerstick blood glucose level

C. Palpate the bladder above the symphysis pubis

47. After a computer tomography (CT) scan with intravenous contrast medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement? A. Call respiratory therapy to give a breathing treatment B. Send another nurse for an emergency tracheotomy set C. Prepare a dose of epinephrine (Adrenalin) D. Review the client's complete list of allergies

C. Prepare a dose of epinephrine (Adrenalin)

52. A young female client with seven children is having frequent morning headaches, dizziness, and blurred vision. Her blood pressure (BP) is 168/104 mmHg. The client reports that her husband recently lost his job and she is not sleeping well. After administering a STAT dose of an antihypertensive IV medication, which intervention is most important for the nurse to implement? A. Measure urine output hourly to assess for rental perfusion B. Request a prescription for pain medication C. Use an automated BP machine to monitor for hypotension D. Provide a quiet environment with low lighting

C. Use an automated BP machine to monitor for hypotension

12. While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse? A. Inappropriate laughter B. Increasing anxiety C. Weakened cough effort D. Asymmetrical weakness

C. Weakened cough effort

21. A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 101F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to implement first? A. Obtain oxygen saturation level B. Encourage incentive spirometry C. Assess lower extremity circulation D. Administer PRN oral antipyretic

D. Administer PRN oral antipyretic

5. An older adult woman with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. She is anxious and is complaining of a dry mouth. Which intervention should the nurse implement? A. Administer a prescribed sedative B. Encourage client to drink water C. Apply a high-flow venturi mask D. Assist her to an upright position

D. Assist her to an upright position 缺氧 心肺关系

36. 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? A. Irritation of nerve endings B. Diminished blood flow C. Ischemic tissue changes D. Compression of a nerve

D. Compression of a nerve

20. An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red and the client reports a burning sensation. What action should the nurse take? A. Apply a cool compress to the affected fingers for 20 minutes B. Secure a pulse oximeter to monitor the client's oxygen saturation C. Report the finding to the healthcare provider as soon as possible D. Continue to monitor the fingers until color returns to normal

D. Continue to monitor the fingers until color returns to normal

46. Ten hours following thrombolysis for an ST elevation myocardial infarction (STEMI), a client is receiving a lidocaine infusion for isolated runs of ventricular tachycardia (VT). Which finding should the nurse document in the electronic medical record as a therapeutic response to the lidocaine infusion? A. Stabilization of blood pressure ranges B. Cessation of chest pain C. Reduce heart rate D. Decreased frequency of episodes of VT

D. Decreased frequency of episodes of VT

51. A client admitted to a surgical unit is being evaluated for an intestinal obstruction. The healthcare provider prescribes a nasogastric tube (NGT) to be inserted and placed to intermittent low wall suction. Which intervention should the nurse implement to facilitate proper tube placement? A. Soak nasogastric tube in warm water B. Insert tube with client's head tilted back C. Apply suction while inserting tube D. Elevate head of bed 60 to 90 degrees

D. Elevate head of bed 60 to 90 degrees

23. A client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse? A. Facial puffiness and periorbital edema B. Hematocrit of 30% C. Cold and dry skin D. Further decline in level of consciousness

D. Further decline in level of consciousness

45. A client who took a camping vacation two weeks ago in a county with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse report to the healthcare provider? A. Weakness and fatigue B. Intestinal cramping C. Weight loss D. Jaundiced sclera

D. Jaundiced sclera

55. A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions? A. Report when hematuria becomes pink tinged B. Use incentive spirometer C. Restrict physical activities D. Monitor urinary stream for decrease in output

D. Monitor urinary stream for decrease in output

40. A client with acquired immunodeficiency syndrome (AIDS) has impaired gas exchange from a respiratory infection. Which assessment finding warrants immediate intervention by the nurse? A. Elevated temperature B. Generalized weakness C. Diminished lung sounds D. Pain when swallowing

D. Pain when swallowing

54. A client who was discharged 8 months ago with cirrhosis and ascites is admitted with anorexia and recent hemoptysis. The client is drowsy but responds to verbal stimuli. The nurse programs a blood pressure monitor to take readings every 15 minutes,. Which assessment should the nurse implement first? A. Evaluate distal capillary refill for delayed perfusion B. Check the extremities for bruising and petechiae C. Examine the pretibial regions for pitting edema D. Palpate the abdomen for tenderness and rigidity

D. Palpate the abdomen for tenderness and rigidity ...

34. A male client with diabetes mellitus (DM) is transferred from the hospital to a rehabilitation facility following treatment for a stroke with resulting right hemiplegia. He tells the nurse that his feet are always uncomfortably cool at night, preventing him from falling asleep. Which action should the nurse implement. A. Provide a warming pad (Aqua-pad or K-pad) to feet B. Medicate the client with a prescribed sedative C. Use a bed cradle to hold the covers off the feet D. Place warm blankets next to the client's feet

D. Place warm blankets next to the client's feet

42. Fluids are restricted to 1,500 ml daily for a male client with acute kidney injury (AKI). He is frustrated and complaining of constant thirst, and the nurse discovers that the family is providing the client with additional fluids. Which intervention should the nurse implement? A. Remove all sources of liquids from the client's room B. Allow family to give client a measured amount of ice chips C. Restrict family visiting until the client's condition is stable D. Provide the client with oral swabs to moisten his mouth

D. Provide the client with oral swabs to moisten his mouth