MEDSURG HESI

A client is receiving chemotherapy for treatment of metastatic carcinoma. When monitoring the client for systemic side effects, which assessment finding warrants intervention by the nurse? A. Leukopenia B. Polycythemia C. Ascites D. Nystagmus

A

A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehiscences and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next? A. Prepare the client to return to the operating room B. Obtain a sample of the drainage to send to the lab C. Auscultate the abdomen for bowel sound activity D. Bring additional sterile dressing supplies to the room

A

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. Pitting ankle edema C. Quarter size blood spot on dressing D. Purple marks on skin of the abdomen

A

A client with chronic cirrhosis has esophageal varies. It is most important for the nurse to monitor the client for the onset of which problem? A. Brown, foamy urine B. Anorexia C. Clay-colored stool D. Hematemesis

A

A client with chronic kidney disease is started on hemodialysis. During the first dialysis treatment, the client's blood pressure drops from 150/90 mmHg to 80/30 mmHg. Which action should the nurse take first? A. Lower the head of the chair and elevate feet B. Monitor blood pressure q45 minutes C. Administer 5% albumin IV D. Stop the dialysis treatment

A

A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the client's plan of care? A. Begin straining all urine B. Implement seizure precautions C. Administer a PRN dose of a laxative D. Initiate cardiac telemetry

A

A client's laboratory findings indicate elevations in thyroxine and triiodothyronine hormones. The nurse suspects that the client may have hyperthyroidism. Which assessment finding is most often associated with hyperthyroidism? A. Increased pulse rate B. Diarrhea stools C. Atrophied thyroid gland D. Periorbital edema

A

A female client who recently married returns to the clinic with recurrent cystitis and urethritis. The client presents with pain on urinating, urinary frequency, and urgency. Which additional information should the nurse obtain? A. Review a recent urinalysis for calcium oxalate B. Examine a client's history for any genetic renal disease C. Ask if she has recently has a streptococcus infection D. Inquire about hygiene practices after sexual intercourse

A

A female client who works as a data entry clerk is concerned as to how her recent diagnosis of Raynaud's syndrome is going to affect her job performance. Which instruction should the nurse provide this client? A. Use a space heater to keep the workplace warm B. Obtain a keyboard designed to limit wrist flexion C. Keep both hands elevated during work breaks D. Take a multivitamin that contains vitamin D daily

A

A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin test. The nurse's assessment of the test after 72 hours indicates 5mm of erythema without induration. What is the best initial nursing action? A. Review client's history for possible exposure to TB B. Instruct the client to return for a repeat test in 1 week C. Refer client to a healthcare provider for isoniazid (INH) therapy D. Document negative results in the client's medical record

A

An adult client comes to urgent care clinic 5 days after being diagnosed with influenza. The client is short of breath, febrile, and coughing green-colored sputum. Which intervention should the nurse implement first? A. Obtain a sputum sample for culture B. Check his oxygen saturation level C. Auscultate bilateral lung sounds D. Administer an oral antipyretic

A

The home health nurse is evaluating a male client who manages his asthma and measures his peak expiratory flow rate (PEFR). Today he is experiencing an acute exacerbation and tells the nurse his PEFR is 60% of his personal-best reading. He is experiencing expiratory and inspiratory wheezes and has a RR of 24 breaths/minute, and oxygen saturation rate of 94% on room air. Which PRN medication should the nurse instruct the client to use? A. Albuterol 2.5 to 5 mg per nebulization B. Epinephrine auto-injector 0.15 mg C. Salmeterol 2 puffs per measured-dose inhaled D. Oxygen at 6 liter/minute by nasal cannula

A

The nurse auscultates a client's heart sounds and hears a mid-systolic click associated with mitral valve prolapse. Which diagnostic test should the nurse prepare the client to expect the healthcare provider to prescribe? A. 12-lead electrocardiogram B. 2D-echocardiograhy C. Troponin and CK-MB levels D. . CT scan of the chest

A

The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition? A. Has everyone at home already had varicella? B. Have the anti fungal creams been effective? C. Do your family members share combs and brushes? D. Do you have any dry patches on your feet and hands?

A

The nurse is developing a plan of care for an adult client with cardiovascular disease who reports blurred-vision. Which outcome should the nurse include in the plan of care for this client? A. The client's daily blood pressure will be less than 140/80 mmHg this month B. The nurse will encourage the client to walk 30 minutes every day C. The client's blood pressure readings will be less than 160/90. mmHg D. The client will take up to 4 nitroglycerine tablets sublingually for chest pain

A

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. Red meats and eggs D. Green leafy vegetables

A

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 provide, the nurse should review which of the client's laboratory values? A. White blood cell count B. Blood pH level C. Platelet count D. Hematocrit

A

During the admission assessment, the nurse identifies multiple bruises at various stages of healing on a male client recently diagnosed with aplastic anemia. The nurse reviews his stat serum laboratory values which reveal platelets 50,000/mm^3, white blood cells 3,000/mm^3, and red blood cells 2.5 million/mm^3. Which actions should the nurse implement? (Select all that apply) A. Initiate sepsis protocol B. Provide a soft-bristle tooth brush C. Monitor for signs of bleeding D. Implement contact precautions E. Infuse blood products as prescribed

A, B, C, E

An older client who us agitated, dyspneic, orthopneic, and using accessory muscles to breathe is admitted for further treatment. Initial assessment includes a heart rate 128 beats/minute and irregular respirations 38 breaths/minute, blood pressure 168/100 mmHg, wheezes and crackles in all lung fields. An hour after the administration of furosemide 60 mg IV, which assessments should the nurse obtain to determine the client's response to the treatment? (Select all that apply) A. Oxygen saturation B. Skin elasticity C. Pain scale D. Lung Sounds E. Urinary output

A, D, E

A client has an absolute neutrophil count (ANC) of 500/mm^3 after completing chemotherapy. Which intervention is most important for the nurse to implement? A. Implement bleeding precautions B. Place the client in protective isolation C. Assess vital signs every 4 hours D. Review need for pneumococcal vaccine

B

A male client with acute abdominal pain, persistent nausea, and projectile vomiting is admitted to the hospital for observation. Acetaminophen is administered as prescribed for his oral temperature of 103 degrees F and an infusion of normal saline is initiated at 250 mL/hour. Which assessment finding should the nurse report to the healthcare provider immediately. A. Severe headache with photosensitivity B.Petechial hemorrhage under client's eyes C. Right lower abdomen rebound tenderness D. Dark green color emesis

B

After three days of persistent epigastric pain, a female client presents to the clinic. She has been taking oral antacids without relief. Her vital signs are heart rate 122 beats/min, respirations 16 breaths/minute, oxygen saturation 96%, and blood pressure 116/70mmHg. The nurse obtains a 12-lead electrocardiogram (ECG). Which assessment finding is most critical? A. Irregular pulse rate B. ST elevation in three leads C. Complaint of radiating jaw pain D. Bile colored emesis

B

Following a transurethral resection of the prostate (TURP), a client is discharged from the hospital with an indwelling urinary catheter. Which instruction is important for the nurse to include in the discharge teaching plan? A. Avoid driving a car for 2 weeks B. Drink 3 liters of water each day C. Eliminate all spicy foods from your diet D. Clamp the catheter when taking a shower

B

The nurse is assessing a client's arteriovenous (AV) fistula. Which finding provides evidence of its normal function? A. Ecchymotic area B. Enlarged vein C. Pulselessness D. Redness

B

The nurse provides dietary instructions about iron rich foods to a client with iron deficiency anemia. Which food selection made by the client indicates a need for additional instructions? A. Liver B. Oranges C. Leafy green vegetables D. Kidney beans

B

Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires the most immediate action by the nurse? A. Surgical consent form is not signed B. Preoperative serum potassium level is 2.8 mEq/L (2.8mmol/L) C.Preoperative chest x-ray report is not available D. Client's pulse oximeter reading is 96%

B

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

B

When providing care for a client following a bronchoscopy, which assessment finding should the nurse immediately report to the healthcare provider? A. Slight blood-tinged sputum B. Dyspnea and dysphagia C. No gag reflex after 30 minutes D. Sore throat and hoarseness

B

When teaching a client with Parkinson's disease, which rationale for the prescription of carbidopa-levodopa should the nurse include? A. Reduces the inflammatory process improving nerve transmission and function B Increases the amount of dopamine available for muscles to function correctly C. Slows the scarring in the myelin sheath improving muscle tone and strength D. Acts as an antiseizure medication reducing the tremors caused by the disease

B

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

B

The nurse is assessing a client who has a bowel obstruction. Which observations should the nurse expect to find? (Select all that apply) A. Peristaltic waves observed B. Abdominal distention C. High-pitch bowel sounds D. Dullness on percussion E. Abdomen soft on palpations

B, C, D

The nurse prepares a teaching plan for an adult client with metabolic syndrome. Which findings should the nurse address to help the client reduce the risk for diabetes mellitus and vascular disease? (Select all that apply) A. Hypothyroidism B. Increased triglyceride levels C. Hyperglycemia D. Blood pressure of 150/96 E. Elevated high density lipoproteins F. Abdominal obesity

B, C, D, F

A client is diagnosed with diverticulosis following a colonoscopy. The client denies any symptoms, and asks the nurse what to expect. Which is the best response by the nurse? A. Episodes of burning pain are commonly experienced B. Appetite loss, with resultant feelings of weakness, are common problems C. Symptoms may not occur unless sacs become inflamed D. As the sacs enlarge pain may be experienced in the lower abdomen

C

A client with eczema is applying 10% urea cream onto the affected skin areas. Which finding reflects the expected therapeutic response? A. Reduced pain in eczematous areas : B. Decreased weeping of ulcerations in affected areas C. Healing with a return to normal skin appearance D. Hydration of affected dry skin areas

C

One hour after major abdominal surgery, a client in the post anesthesia care unit (PACU) has a blood pressure (BP) of 136/80 mmHg. Fifteen minutes later it is 114/72 mmHg. Which action should the nurse take first? A. Increase frequency of BP assessments B. Review the client's baseline BP trends C. Check the abdominal surgical dressing D. Encourage the client to breathe deeply

C

The drainage in the chest tube of a client with emphysema has changed from viscous green to clear watery fluid. Which action is best for the nurse to take? A. Obtain a specimen of the drainage for culture B. "Milk" the tube to remove any clots C. Maintain the current IV antibiotic schedule D. Schedule a portable chest x-ray per PRN protocol

C

The nurse admits a client who has a medical diagnosis of bacterial meningitis to the unit. Which intervention has the highest priority in providing care for this client? A. Administer initial dose of broad-spectrum antibiotic B. Instruct the client to force fluids hourly C. Obtain results of culture and sensitivity of CSF D. Assess the client for symptoms of hyponatremia

C

The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a Thoracotomy two hours ago. The nurse observes the following vital signs: heart rate 140 beats/minute, respirations 26 breaths/minute, and blood pressure 140/90 mmHg. Which intervention is most important for the nurse to implement? A. Administer IV fluid bolus as prescribed by the healthcare provider B. Medicate for pain and monitor vital signs according to protocol C. Encourage the client to splint the incision with a pillow to cough and deep breathe D. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter

C

The nurse is developing plan of care 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? A. The nurse will encourage the client to walk 30 minutes every day B. The client's blood pressure readings will be less than 160/90 mmHg C. The client's hemoglobin A1c will be less than 7.0% in 3 months D. The nurse will demonstrate the procedure for accurate eye care

C

The nurse reviews the laboratory results of a client during an annual physical examination and identifies a positive guaiac test of stool. Which additional serum laboratory test result should the nurse review? A. Whit blood cell count B. Glucose C. Platelet count D. Amylase

C

Which instruction should the nurse include in the discharge teaching for a client who has gastroesophageal reflux? A. Encourage the client to lie down and rest after meals B. Remind the client to avoid high-fiber foods C. Teach the client to elevate the head of the bed on blocks D. Instruct the client to use antacids only as a last resort

C

Which laboratory test result is most important for the nurse to report to the surgeon prior to a client's scheduled abdominal surgery? A. Potassium level of 4 mEq/liter B. Blood glucose of 90 mg/dl C. Serum creatinine of 5 mg/dl D. Hemoglobin level of 13 grams

C

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

C

An older adult recently diagnosed with type 2 diabetes mellitus (DM) suddenly becomes confused and weak, with cool, clammy skin. The client is unable to remember what to do for such symptoms and is taken to a near-by urgent care facility by a neighbor. Which nursing interventions should the nurse implement? (select all that apply) A. Prepare to administer regular insulin B. Palpate for bladder for pain or distention C. Check a blood sample for glucose level D. Report any changes in blood pressure E. Observe respiratory rate and pattern

C, D, E

A client is admitted with a deep and productive cough, hemoptysis, and a low-grade fever. The client's Mantoux skin test has a 15mm induration. Which intervention should the nurse implement first? A. Administer the initial dose of rifampin and isoniazid B. Collect a sputum specimen for acid-fast bacillus C. Provide a mask for the client to wear in public areas D. Initiate airborne particulate isolation precautions

D

A client is being treated for acute kidney injury. On examination, the client has a weight gain of 4.4 lbs (2kg) in 24 hours and exhibits changes in mental status. Which intervention should the nurse implement? A. Monitor daily sodium intake B. Assess for dependent pitting edema C. Record usual eating patterns D. Obtain serum creatine levels daily

D

A client who fractured the right femur from a fall at home is placed in a skeletal traction while awaiting surgery. When the client tells the nurse the need to urinate, which intervention should the nurse implement? A. Insert an indwelling catheter preoperatively B.Release the traction so the client can use a bedpan C. Log roll the client and place adult disposable briefs beneath the client D. Maintain traction while the client uses a female urinal

D

A client with renal calculus is complaining of severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority? A. Risk for aspiration related to vomiting B. Nutritional deficit related to nausea C. Impaired renal function related to pain D. Acute pain related to real calculus

D

A male client with acquired immune deficiency syndrome (AIDS) and Pneumocystis carinii pneumonia has a CD4+ T cell count of 200 cells/microliter. The client asks the nurse why he keeps getting these massive infections. Which pathophysiologic mechanism should the nurse describe in response to the client's question? A. Bone marrow suppression of white blood cells causes insufficient cells to phagocytize organisms B. Exposure to multiple environmental infectious agents overburdens the immune system until it fails C. The humoral immune response lacks B cells that form antibodies and opportunistic infections result D. Inadequate numbers of T lymphocytes are available to initiate cellular immunity and macrophages

D

A young adult male client has a diagnosis of epididymitis and a positive culture for Escherichia coli. Which information should the nurse include in the teaching plan? A. Avoid penile contact with the rectal area B. Epididymitis is a pre-cancerous condition C. Obtain an annual prostate digital exam D. Surgical intervention is often indicated

D

After several days of coughing and taking acetaminophen to treat temperature of 101 F, a client with diabetes mellitus (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 intervention should the nurse implement first? A. Reassess vital signs B. Administer an antipyretic C. Obtain a sputum for culture D. Obtain a fingerstick glucose

D

An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI) Prescriptions for intravenous antibiotics and insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse? A. blood ph of 7.30 B. glucose of 350 mg /dl C. white blood cell count of 15000mm D. potassium of 2.5 meq/l

D

An adult client who received partial-thickness and full-thickness burns over 40% of the body in a house fire is admitted to the inpatient burn unit. Which fluid should the nurse prepare to administer during the acute phase of the client's burn recovery? A. 5% dextrose in water B. total parenteral nutrition C. 5% dextrose in 0.25 normal saline D. Lactate Ringers

D

Following a lumbar puncture, a client voices several concerns.Which concern indicates to the nurse that the client is experiencing a complication from the procedure? A. "My throat hurts badly when I swallow and when I talk" B. "I feel sick to my stomach and am going to throw up" C. "I am having pain in my lower back when I move my legs" D. "I have a headache that gets worse when I sit up"

D

The nurse is caring for a client on a rehabilitation unit who has right cerebrovascular accident and is struggling with independent self-care. The nurse places a large mirror in the client's room. Which instruction should the nurse provide the client? A. Mirrors reflect light to brighten the room so you can see better B. A hoe-like environment helps you relax and feel more confident C. Check your appearance before leaving the room D. Use the mirror to watch yourself while dressing

D

When planning care for a client with rheumatoid arthritis, which intervention is most important for the nurse to include? A. Schedule rest periods between activities to minimize fatigue B. Teach coping skill for living with a chronic illness C. Provide assistive devices to empower client independence D. Implement measures to manage chronic pain

D