Med-Surg Practice Quiz Hesi

A client with acute appendicitis is experiencing anxiety and loss of sleep about missing final examination week at college. Which outcome is most important for the nurse to include in the plan of care? Sleeping six to eight hours. Achieve a sense of control. Utilize problem solving skills. Increased focus of attention.

Achieve a sense of control.

A male client with chronic atrial fibrillation and a slow ventricular response is scheduled for surgical placement of a permanent pacemaker. The client asks the nurse how this device will help him. How should the nurse explain the action of a synchronous pacemaker? Ventricular irritability is prevented by the constant rate setting of pacemaker. Ectopic stimulus in the atria is suppressed by the device usurping depolarization. An impulse is fired every second to maintain a heart rate of 60 beats per minute. An electrical stimulus is discharged when no ventricular response is sensed.

An electrical stimulus is discharged when no ventricular response is sensed.

The nurse is caring for a client receiving tamoxifen (Nolvadex) for the treatment of breast cancer. Which action should the nurse include in the client's plan of care? Increase fluid intake. Monitor sodium chloride intake. Assist the client in coping with hot flashes. Encourage milk products to increase calcium intake.

Assist the client in coping with hot flashes.

A client who had abdominal surgery two days ago has prescriptions for intravenous morphine sulfate 4 mg every 2 hours and a clear liquid diet. The client complains of feeling distended and has sharp, cramping gas pains. What nursing intervention should be implemented? Obtain a prescription for a laxative. Withhold all oral fluid and food. Assist the client to ambulate in the hall. Administer the prescribed morphine sulfate.

Assist the client to ambulate in the hall.

Which finding should the nurse identify as an indication of carbon monoxide poisoning in a client who experienced a burn injury during a house fire? Pulse oximetry reading of 80%. Expiratory stridor and nasal flaring. Cherry red color to the mucous membranes. Presence of carbonaceous particles in sputum.

Cherry red color to the mucous membranes.

The nurse is caring for a male client who had an inguinal herniorrhaphy 3 hours ago. The nurse determines the client's lower abdomen is distended and assesses dullness to percussion. What is the priority nursing action? Assessment of the client's vital signs. Document the finding as the only action. Determine the time the client last voided. Insert a rectal tube for the passage of flatus.

Determine the time the client last voided.

A client with sickle cell anemia is admitted with severe abdominal pain and the diagnosis is sickle cell crisis. What is the most important nursing action to implement? Limit the client's intake of oral fluids and food. Evaluate the effectiveness of narcotic analgesics. Encourage the client to ambulate as tolerated. Teach the client about prevention of crises.

Evaluate the effectiveness of narcotic analgesics.

A client who is receiving the sixth unit of packed red blood cell transfusion is demonstrating signs and symptoms of a febrile, nonhemolytic reaction. What assessment finding is most important for the nurse to identify? Increased anxiety since the transfusion began. Drowsiness after receiving diphenhydramine (Benadryl). Complaints of feeling cold. Flushed skin and headache.

Flushed skin and headache.

A client with osteoarthritis receives a prescription for Naproxen (Naprosyn). Which potential side effect should the nurse provide to the client about this medication? Sensitivity to sunlight. Muscle fasciculations. Increased urinary frequency. Gastrointestinal disturbance.

Gastrointestinal disturbance

A client who returns to the unit after having a percutaneous transluminal coronary angioplasty (PTCA) complains of acute chest pain. What action should the nurse implement next? Inform the healthcare provider. Obtain a 12-lead electrocardiogram. Give a sublingual nitroglycerin tablet. Administer prescribed analgesic.

Give a sublingual nitroglycerin tablet.

A college student who is diagnosed with a vaginal infection and vulva irritation describes the vaginal discharge as having a "cottage-cheese" appearance. Which prescription should the nurse implement first? Cleanse perineum with warm soapy water 3 times per day. Instill the first dose of nystatin (Mycostatin) vaginally per applicator. Perform glucose measurement using a capillary blood sample. Obtain a blood specimen for sexually transmitted diseases (STDs).

Instill the first dose of nystatin (Mycostatin) vaginally per applicator.

The nurse is caring for a client scheduled to undergo insertion of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks the nurse to explain how a PEG tube differs from a gastrostomy tube (GT). Which explanation best describes how they are different? Method of insertion. Location of the tubes. Diameter of the tubes. Procedure for feedings.

Method of insertion.

The nurse is caring for a client who is two days postoperative. Which observation should alert the nurse to call the Rapid Response Team (RRT)? Fresh bleeding noted on abdominal surgical wound dressing. Pulse change from 85 to160 beats/minute lasting more than 10 minutes. Temperature of 103.1 F and white blood cell (WBC) count of 16,000 mm3. Weakness, diaphoresis, complaints of feeling faint. BP 100/56 mm Hg.

Pulse change from 85 to160 beats/minute lasting more than 10 minutes.

The nurse is preparing discharge instructions for a client who is going home with a surgical wound on the coccyx that is healing by secondary intention. What is the priority nursing diagnosis that should guide the discharge instruction plan? Acute pain. Risk for infection. Disturbed body image. Risk for deficient fluid volume.

Risk for infection.

A male client with a prostatic stent is preparing for discharge. What should the nurse ensure the client understands? Ongoing antibiotic therapy is needed for one year. The client should not undergo magnetic resonance imaging. Increased frequency of assessment for prostatic cancer is needed. The client should not be catheterized through the stent for at least three months.

The client should not be catheterized through the stent for at least three months.

A 48-year-old client with endometrial cancer is being discharged after a total hysterectomy and bilateral salpingo-oophorectomy. Which client statement indicates that further teaching is needed? "Well, I don't have to worry about getting pregnant anymore." "I can't wait to go on the cruise that I have planned for this summer." "I know I will miss having sexual intercourse with my husband." "I have asked my daughter to stay with me next week after I am discharged."

"I know I will miss having sexual intercourse with my husband."

The home health nurse is assessing a client with terminal lung cancer who is receiving hospice care. Which activity should be assigned to the hospice practical nurse (PN)? Administer medications for pain relief, shortness of breath, and nausea. Clarify family members' feelings about the meaning of client behaviors and symptoms. Develop a plan of care after assessing the needs of the client and family. Teach the family to recognize restlessness and grimacing as signs of client discomfort.

Administer medications for pain relief, shortness of breath, and nausea.

The PET (positron emission tomography) scan is commonly used with oncology clients to provide for which diagnostic information? A description of inflammation, infection, and tumors. Continuous visualization of intracranial neoplasms. Imaging of tumors without exposure to radiation. An image that describes metastatic sites of cancer.

An image that describes metastatic sites of cancer.

The nurse directs an unlicensed assistive personnel (UAP) to obtain the vital signs for a client who returns to the unit after having a mastectomy for cancer. What information should the nurse provide the UAP? Elevate the arm with an IV infusing on the operative side with a pillow. Apply the blood pressure cuff to the arm on the non-operative side. Position the arm on the operative side close to the body. Collect a fingerstick blood specimen from the arm on the operative side.

Apply the blood pressure cuff to the arm on the non-operative side.

The nurse is caring for a client after a transurethral resection of the prostate (TURP) and determines the client's urinary catheter is not draining. What should the nurse implement? Reposition the catheter drainage tubing. Encourage the client to drink oral fluids. Irrigate the catheter. Change drainage unit tubing.

Irrigate the catheter.

A client is admitted for complaints of chest pain and aching for the past 4 days. The results for serum creatine kinase-MB (CK-MB) and troponin levels are obtained. What rationale should the nurse use to evaluate the laboratory findings? Serum myoglobin levels are needed to confirm myocardial damage. The most reliable indicator of myocardial necrosis is serum CK-MB. Serum cardiac markers are inconclusive in determining myocardial injury after waiting several days. Myocardial damage that occurred several days earlier is best validated by serum troponin levels.

Myocardial damage that occurred several days earlier is best validated by serum troponin levels.

The nurse is preparing a client for orthopedic surgery on the left leg and completing a safety checklist before transport to the operating room. Which items should the nurse remove from the client? (Select all that apply.) Select all that apply Nail polish. Hearing aid. Wedding band. Left leg brace. Contact lenses. Partial dentures.

Nail polish. Hearing aid. Contact lenses. Partial dentures.

A male client with sickle cell anemia, who has been hospitalized for another health problem, tells the nurse he has had an erection for over 4 hours. What action should the nurse implement first? Notify the client's healthcare provider. Document the finding in the client record. Prepare a warm enema solution for rectal instillation. Obtain a large bore needle for aspiration of the corpora cavernosa.

Notify the client's healthcare provider.

Three weeks after discharge for an acute myocardial infarction (MI), a client returns to the cardiac center for follow-up. When the nurse asks about sleep patterns, the client tells the nurse that he sleeps fine but that his wife moved into the spare bedroom to sleep when he returned home. He states, "I guess we will never have sex again after this." Which response is best for the nurse to provide? Sexual intercourse can be strenuous on your heart, but closeness and intimacy, such as holding and cuddling, can be maintained with your wife. Sexual activity can be resumed whenever you and your wife feel like it because the sexual response is more emotional rather than physical. You should discuss your questions about your sexual activity with your healthcare provider because sexual activity may be limited by your heart damage. Sexual activity is similar in cardiac workload and energy expenditure as climbing two flights of stairs and may be resumed like other activities.

Sexual activity is similar in cardiac workload and energy expenditure as climbing two flights of stairs and may be resumed like other activities.

What is the priority nursing action while caring for a client on a ventilator when an electrical fire occurs in the intensive care unit? Tell another staff member to bring extinguishing equipment to the bedside. Close the doors to the client's area when attempting to extinguish the fire. Use a bag-valve-mask resuscitator while removing the client from the area. Implement an emergency protocol to remove the client from the ventilator.

Use a bag-valve-mask resuscitator while removing the client from the area.