HESI Med Surg 2
Which statement indicates understanding after teaching a post-radiation therapy client about proper skin care to the treatment area? Select all that apply. - I will wear loose-fitting clothes over the area - I will avoid using adhesive bandages - I will avoid exposing the area to cold temperatures - I will avoid rinsing the area with a saline solution - I will use lotions to moisten the area when wearing makeup
- I will wear loose-fitting clothes over the area - I will avoid using adhesive bandages - I will avoid exposing the area to cold temperatures Rationale: Avoid all sources of excessive heat and cold temperature. A client who underwent radiation therapy should regularly rinse the radiation treatment area with saline solution to prevent infection.
Which instruction would the nurse provide an older client using ice and heat to treat pain from back strain? - Switch positions every 4 hours - Use a heating pad for the first 24 hours - Apply for 30-minute time intervals - Place the ice pack directly on the injury site
Apply for 30-minute time intervals Rationale: To prevent skin damage, ice and heat should only be applied for 20 to 30 minute intervals. Client should be instructed to shift positions every hour to prevent skin breakdown. Ice should be used for the first 24 to 48 hours followed by heat. Ice should never be directly applied to the skin as it can cause injury to the tissue.
The nurse is caring for a client admitted with peritonitis. Which finding in the medical record is most likely the cause? - Gastritis - Hiatal hernia - Diverticulosis - Bowel obstruction
Bowel obstruction Rationale: Causes of peritonitis include bowel obstruction, appendicitis, external penetrating wound, or peritoneal dialysis
Which instruction would the nurse include when teaching a client how to perform diaphragmatic breathing? - Take rapid, deep breaths - Breathe with hands on the hips - Expand the abdomen on inhalation - Lean forward from a sitting position
Expand the abdomen on inhalation Rationale: Expanding the abdomen on inhalation aids descent of the diaphragm so that more air can enter and fill the lungs. Diaphragmatic breathing techniques include slowing the respiratory rate
Which action would the nurse take to prevent complications when caring for a client with a chest tube to water seal drainage system for a pneumothorax? - Emptying the drainage system when full - Keeping the drainage system at heart level - Notifying the health care provider of drainage greater than 50ml/hr - Marking the time on the drainage unit every shift
Marking the time on the drainage unit every shift Rationale: The nurse would mark the drainage system every shift to determine the amount of drainage. The drainage system is a closed system, so the nurse would switch out the drainage system when it is full. Emptying the system would break the sterility. The drainage system should remain below chest level to prevent fluid from backing up into the lungs. The nurse would notify the health care provider if drainage is greater than 100ml/hr.
Which medication turns urine reddish-orange in color? - Amoxicillin - Ciprofloxacin - Nitrofurantoin - Phenazopyridine
Phenazopyridine Rationale: topical anesthetic that is used to treat pain or burning sensation associated with nutrition.
Which health problem history would increase an older adult's risk for experiencing a cerebrovascular accident (CVA)? - Glaucoma - Hypothyroidism - Continuous nervousness, stress - Transient ischemic attacks (TIAs)
Transient ischemic attacks (TIAs) Rationale: TIAs are temporary neurological deficits related to cerebral hypoxia; about one third of the people who have TIAs will have a CVA within 2 to 5 years.
Which medication reduces the risk for human innumodeficiency virus (HIV) infection in unaffected individuals? -Truvada - Abacavir - Cromolyn - Medthdilazine
Truvada Rationale: Is the first medication who are at a high risk for HIV infection.
