med surg HESI

A client is admitted after blunt abdominal injury. Which assessment finding requires immediate action by the nurse? o Radiating abdominal pain with left lower quadrant palpation. o Grimacing after palpation of the right hypochondriac region. o Rebound tenderness with abdominal palpation. o Bluish periumbilical skin discoloration.

Bluish periumbilical skin discoloration. Immediate action is indicated for intraperitoneal hemorrhage which causes periumbilical discoloration (D) and indicates the presence of a splenic rupture, a life-threatening complication of blunt abdominal injury. (A, B, and C) indicate inflammation of the appendix or gallbladder but do not represent an acute finding as a result of blunt abdominal trauma.

Which preexisting diagnosis places a client at greatest risk of developing superior vena cava syndrome? o Carotid stenosis. o Steatosis hepatitis. o Metastatic cancer. Correct o Clavicular fracture.

Metastatic cancer. Superior vena cava syndrome occurs when the superior vena cava (SVC) is compressed by outside structures, such as a growing tumor that impedes the return blood flow to the heart. Superior vena cava syndrome is likely to occur with metastatic cancer (C) from a primary tumor in the upper lobe of the right lung that compresses the superior vena cava. (A, B, and D) do not result in SVC syndrome.

A client asks the nurse about the purpose of beginning chemotherapy (CT) because the tumor is still very small. Which information supports the explanation that the nurse should provide? o Side effects are less likely if therapy is started early. o Collateral circulation increases as the tumor grows. o Sensitivity of cancer cells to CT is based on cell cycle rate. o The cell count of the tumor reduces by half with each dose.

The cell count of the tumor reduces by half with each dose. Iniating chemotherapy while the tumor is small provides a better chance of eradicating all cancer cells because 50% of cancer cells or tumor cells are killed with each dose. (A, B, and C) vary based on the type of cancer.

When caring for a client with a percutaneous endoscopic gastrostomy (PEG) tube, what protocols should the nurse implement for intermittent feedings? (Select all that apply.) o Assessing residual amounts once a day. o Keeping the head of the bed elevated 30 degrees. o Changing the enteral-feeding bag every 24 hours. o Checking the placement of the tube by means of gastric aspiration. o Flushing the tube with 50 ml of normal saline solution after each feeding.

eeping the head of the bed elevated 30 degrees. Correct o Changing the enteral-feeding bag every 24 hours. Correct o Checking the placement of the tube by means of gastric aspiration. Correct o Flushing the tube with 50 ml of normal saline solution after each feeding. (B, C, D, and E) are correct. Keeping the head of the bed elevated 30 degrees (B), changing the enteral-feeding bag every 24 hours (C), checking the placement of the tube by means of gastric aspiration (D), and flushing the tube with 50 ml of normal saline solution after each feeding (E) are interventions used to provide care of the client with a PEG tube. Residual amounts should be assessed prior to each feeding, not once daily (A).

A client with type II diabetes arrives at the clinic with a blood glucose of 50 mg/dL. The nurse provides the client with 6 ounces of orange juice. In 15 minutes the client's capillary glucose is 74 mg/dL. What action should the nurse take? o Obtain a specimen for serum glucose level. o Administer insulin per sliding scale. o Provide cheese and bread to eat. o Collect a glycosylated hemoglobin specimen.

o Provide cheese and bread to eat. Once blood glucose is greater than 70 mg/dl, the client should eat a regularly scheduled meal or a snack to prevent hypoglycemia from recurring (C). Blood glucose has just been checked and a serum level is not indicated at this time (A). The blood glucose does not indicate a need for insulin (B) which may further exacerbate a hypoglycemic response. A glycosylated hemoglobin (hemoglobin A1C) level is not indicated at this time (D).

Which findings are within expected parameters of a normal urinalysis for an older adult? (Select all that apply.) o pH 6. o Nitrate small. o Protein small. o Sugar negative. o Bilirubin negative. o Specific gravity 1.015.

pH 6 Protein small. Sugar negative. Bilirubin negative. Specific gravity 1.015. Correct selections are (A, D, E, and F). (A) is within the normal pH range for urine. Glucosuria and bilirubinuria are abnormal and should be negative upon urinalysis (D and E). Normal changes associated with aging include decreased creatinine clearance and decreased concentrating and diluting abilities which influence the normal range of urine specific gravity, 1.001 to 1.035. Although common health problems associated with aging include renal insufficiency, urinary incontinence, urinary tract infection (B and C), and enlarged prostate, these are indicative of pathology which should be treated.

A young adult female reports that she is experiencing a lack of appetite, hypersomnia, stress incontinence, and heart palpitations. Which symptom is characteristic of premenstrual syndrome? A) Heart palpitations. B) Anorexia. C) Hypersomnia. D) Stress incontinence.

A) Heart palpitations. Characteristic features of premenstrual syndrome include heart palpitations (A), sleeplessness, increased appetite and food cravings, and oliguria or enuresis. (B, C, and D) are not consistent with symptoms of premenstrual syndrome.

The nurse should explain to a client with lung cancer that pleurodesis is performed to achieve which expected outcome? A) Prevent the formation of effusion fluid. B) Remove fluid from the intrapleural space. C) Debulk tumor to maintain patency of air passages. D) Relieve empyema after pneumonectomy.

A) Prevent the formation of effusion fluid. Instillation of a sclerosing agent to create pleurodesis (adherence of the parietal and visceral pleura) is aimed at preventing the formation of pleural effusion fluid (A). (B) refers to thoracentesis. (C) is achieved by surgical resection. (D) is treated by closed-chest drainage.

Which nursing intervention should the nurse implement that best confirms the placement of an endotracheal tube? A) Use an end-tital CO2 detector. B) Ascultate for bilateral breath sounds. C) Obtain pulse oximeter reading. D) Check symmetrical chest movement.

A) Use an end-tital CO2 detector The end-tital CO2 detector indicates the presence of CO2 by a color change or a number (A), which is evidence that the ET is in the trachea, not the esophagus. Other assessments, such as breathe sounds (B), pulse oximetry (C) and chest movement (D), are methods to evaluate the effectiveness of ventilation and oxygenation, but do not measure CO2 in expired air from the ET.

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 devise will help him. How should the nurse explain the action of a synchronous pacemaker? o Ventricular irritability is prevented by the constant rate setting of pacemaker. o Ectopic stimulus in the atria is suppressed by the device usurping depolarization. o An impulse is fired every second to maintain a heart rate of 60 beats per minute. o An electrical stimulus is discharged when no ventricular response is sensed.

An electrical stimulus is discharged when no ventricular response is sensed. Correct The artificial cardiac pacemaker is an electronic device used to pace the heart when the normal conduction pathway is damaged or diseased, such as a symptomatic dysrhythmias like atrial fibrillation with a slow ventricular response. Pacing modes that are synchronous (impulse generated on demand or as needed according to the patient's intrinsic rhythm) send an electrical signal from the pacemaker to the wall of the myocardium stimulating it to contract when no ventricular depolarization is sensed (D). (A, B, and C) do not provide accurate information.

An older female client is admitted with atrophic vaginitis and perineal cutaneous candidiasis. What is the priority nursing diagnosis for this client? A) Risk for injury. B) Impaired comfort. C) Disturbed body image. D) Ineffective health maintenance.

B) Impaired comfort. In menopausal women, the vaginal mucous membrane responds to low estrogen levels causing the vaginal walls to become thinner, drier, and susceptible to infection which leads to atrophic vaginitis. Perineal cutaneous candidiasis contributes to other manifestations of vaginal infections, such as vaginal irritation, burning, pruritus, increased leukorrhea, bleeding, and dyspareunia, and support the primary nursing diagnosis, Impaired comfort (B). Risk for injury (A), body image (C), and ineffective health maintenance (D) are secondary and linked to impaired comfort.

A man who smokes two packs of cigarettes a day wants to know if smoking is contributing to the difficulty that he and his wife are having getting pregnant. What information is best for the nurse to provide? (Select all that apply.) A) Only marijuana cigarettes affect sperm count. B) Smoking can decrease the quantity and quality of sperm. C) The first semen analysis should be repeated to confirm sperm counts. D) Cessation of smoking improves general health and fertility. E) Sperm specimens should be collected in 2 subsequent days. Correct Answer(s): B, C, D

B) Smoking can decrease the quantity and quality of sperm. C) The first semen analysis should be repeated to confirm sperm counts. D) Cessation of smoking improves general health and fertility. Correct selections are (B, C, and D). Use of tobacco, alcohol, and marijuana may affect sperm counts (B). Sperm counts vary from day to day and are dependent on emotional and physical status and sexual activity, so a single analysis may be inconclusive (C). A minimum of two analyses should be performed several weeks apart to assess male fertility, not (E). (A and D) contain inaccurate information.

The nurse is caring for a client who returns to the unit following a colonoscopy. Which finding should the nurse report to the healthcare provider immediately? A) Large amounts of expelled flatus with mucus. B) Tympanic abdomen and hyperactive bowel sounds. C) Increased abdominal pain with rebound tenderness. D) Complaint of feeling weak with watery diarrheal stools.

C) Increased abdominal pain with rebound tenderness. Positive rebound tenderness (C) may be an indication of peritonitis or perforation and needs follow-up immediately. Clients typically experience a large amount of flatus (A) and may have mucus from bowel irritation from the procedure. A tympanic abdomen on percussion and hyperactive bowel sounds are typical post procedure findings (B). Weakness and watery stools are a result from the preparation and are common symptoms experienced after a colonoscopy (D).

The nurse is assessing a client who is bedfast and refuses to turn or move from a supine position. How should the nurse assess the client for possible dependent edema? o Compress the flank and upper buttocks. Correct o Measure the client's abdominal girth. o Gently palpate the lower abdomen. o Apply light pressure over the shins.

Compress the flank and upper buttocks. Dependent edema collects in dependent areas, such as the flank and upper buttocks (A) of the client who is persistently flat in bed. (B) provides data about ascites (fluid collection in the abdomen), rather than dependent edema, and (C) provides data about abdominal distention. (D) provides data about the collection of dependent edema for a client whose lower extremities are often in a dependent position, such as when sitting in a chair.

A client is admitted to the emergency department after being lost for four days while hiking in a national forest. Upon review of the laboratory results, the nurse determines the client's serum level for thyroid-stimulating hormone (TSH) is elevated. Which additional assessment should the nurse make? o Body mass index. o Skin elasticity and turgor. o Thought processes and speech. o Exposure to cold environmental temperatures.

Exposure to cold environmental temperatures. Correct

The nurse is caring for a client with end stage liver disease who is being assessed for the presence of asterixis. To assess the client for asterixis, what position should the nurse ask the client to demonstrate? o Extend the left arm laterally with the left palm upward. o Extend the arm, dorsiflex the wrist, and extend the fingers. o Extend the arms and hold this position for 30 seconds. o Extend arms with both legs adducted to shoulder width.

Extend the arms and hold this position for 30 seconds. asterixis (flapping tremor, liver flap) is a hand-flapping tremor that is often seen frequently in hepatic encephalopathy. The tremor is induced by extending the arm and dorsiflexing the wrist causing rapid, non-rhythmic extension and flexion of the wrist while attempting to hold position (B). (A, C, and D) do not illicit axterixis.

The nurse is caring for a client with a small bowel obstruction. The client is vomiting foul smelling fecal-like material. What action should the nurse implement? o Administer antiemetics every 2 to 3 hours. o Position on the left side with knees drawn up. o Encourage ice chips sparingly. o Give IV fluids with electrolytes.

Give IV fluids with electrolytes. When the bowel is obstructed, electrolytes and fluids are not absorbed, so parenteral fluids with sodium chloride, bicarbonate, and potassium should be administered (D). (A and C) are contraindicated. (B) may or may not be a position of comfort for the client. The nurse should implement (D).

The nurse is giving discharge instructions to a client with chronic prostatitis. What instruction should the nurse provide the client to reduce the risk of spreading the infection to other areas of the client's urinary tract? o Wear a condom when having sexual intercourse. o Avoid consuming alcohol and caffeinated beverages. o Empty the bladder completely with each voiding. o Have intercourse or masturbate at least twice a week.

Have intercourse or masturbate at least twice a week. The prostate is not easily penetrated by antibiotics and can serve as a reservoir for microorganisms, which can infect other areas of the genitourinary tract. Draining the prostate regularly through intercourse or masturbation (D) decreases the number of microorganisms present and reduces the risk for further infection from stored contaminated fluids. (A, B, and C) do not reduce the risk of spreading the infection internally.

The nurse is assessing a client with a cuffed tracheostomy tube in place who is breathing spontaneously. To evaluate if the client can tolerate cuff deflation to promote speaking and swallowing, what action should the nurse implement? Ask the client to try to speak. Assess for respiratory distress. Auscultate for pulmonary crackles after the client drinks a small amount of clear water. Observe the client for coughing colored sputum after drinking a small amount of colored water.

Observe the client for coughing colored sputum after drinking a small amount of colored water.

A client is admitted to the hospital with a traumatic brain injury after his head violently struck a brick wall during a gang fight. Which finding is most important for the nurse to assess further? o A scalp laceration oozing blood. o Serosanguineous nasal drainage. o Headache rated 10 on a 0-10 scale. o Dizziness, nausea and transient confusion.

Serosanguineous nasal drainage. Any nasal discharge should be evaluated (B) to determine the presence of cerebral spinal fluid which indicates a tear in the dura making the client susceptible to meningitis. The scalp is highly vascular and results in blood oozing from wounds (A). Pain is expected and can be treated after further assessment of the presence of nasal discharge (C). Dizziness, nausea, and transient confusion (D) are expected manifestations following a traumatic brain injury and need ongoing monitoring, but (B) is most important.

The nurse is assessing a client admitted from the emergency room with gastrointestinal bleeding related to peptic ulcer disease (PUD). Which physiological factors can produce ulceration? (Select all that apply.) o Vagal stimulation. o An increased level of stress. o Decreased duodenal inhibition. o Hypersecretion of hydrochloric acid. o An increased number of parietal cells.

Vagal stimulation. Decreased duodenal inhibition. Hypersecretion of hydrochloric acid. An increased number of parietal cells. Correct selections are (A, C, D, and E). Hypersecretion of gastric juices (D) and an increased number of parietal cells (E) that stimulate secretion are most often the causes of ulceration. Vagal stimulation (A) and decreased duodenal inhibition (C) also increase the secretion of caustic fluids. An increased stress level is not physiologic and is not a direct cause of ulceration (B).