HESI Med-Surg
A client is receiving an IV infusion of regular insulin 60 units in 100mL of normal saline at 5 units/hour. How many mL/hr? Round to nearest whole number.
8 mL
On the third postoperative day, a client who has had hip replacement surgery becomes anxious and diaphoretic, and begins to experience auditory hallucinations. Th client denies having any pain. The clients vital signs are pulse rate is 125 beats/minute, respiratory rate is 36 breaths/minute, and blood pressure is 166/88 mmHg. Which nursing interventions should the nurse implement? (Select all that apply).
Present a calm, supportive demeanor administer a PRN dose of lorazepam
The nurse is assessing a client who has returned from surgery following a thoracotomy. Which finding indications the client is experiencing adequate gas exchange?
Pulse Ox 96%
The nurse identifies an electrolyte imbalance, an elevated blood pressure, and a dependent edema for a client with progressive heart disease. Which is the most important action for the nurse to take?
Review ABGs
While caring for a client with full thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting the finding to the healthcare provider, the nurse should evaluate which lab value?
Serum Albumin
The nurse is assessing a client whose child was sent home with pediculosis capitis. The client reports having...which finding should the nurse associate with pediculosis on further investigation?
Small red bumps on the scalp, neck, and shoulders
In assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedures were successful?
Stone fragments are collected when straining the client's urine
The nurse observes that a newly admitted client with Parkinson's disease exhibits a mask like facial appearance. Which additional nursing assessment takes priority in response to this finding?
Swallowing ability
A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?
Topical corticosteroids
The nurse is assessing a client who is one-day post parathyroidectomy and finds that the client is experiencing stridor. After notifying the healthcare provider, the nurse should prepare for?
Tracheostomy Placement
A client is admitted to the hospital for shortness of breath and chest pain after an episode of syncope. Which lab finding?
Troponin I
The nurse is obtaining the admission history for a client with suspected PUD. Which subjective data reported by the client supports the medical diagnosis?
Upper mid abdominal gnawling and burning
The nurse brings a scheduled dose of docusate calcium to a male who has cirrhosis of the liver. The client states that he never had bowel problems and does not need a stool softener. Which action should the nurse take?
Withhold the medication until consulting with the healthcare provider.
An adult male client is admitted for pneumocystis carinil pneumonia (PCP) secondary to aids. While hospitalize he receives IV pentamidine isethionate therapy. In preparing this client for discharge what important aspect regarding his medication therapy should the nurse explain? a) AZT therapy must be stopped when IV aerosol pentamine is being used. b) IV pentamine will be given until oral pentamine can be tolerated c) it will be necessary to continue prophylactic doses of IV or aerosol pentamine every month d) IV pentamine may offer protection to others aids related conditions such as kaposis sarcoma
c) it will be necessary to continue prophylactic doses of IV or aerosol pentamine every month
The nurse is assessing a client who is receiving enteral feedings. Which clinical data indicates the client may not be tolerating the tube feedings? Select all that appyl
n/v Abdominal cramping Absent Bowel Sounds
The healthcare provider prescribes streptomycin 300 mg IM q12 hours for a client with TB. The available vial is labels 1 g/2.5 mL. How many mL? Round to the nearest tenth.
0.8 mL
The nurse is teaching a client how to collect a sputum specimen. Which steps should the nurse....
Breathe deeply, followed by coughing up the sputum
To reduce the risk for pulmonary complication for a client with ALS, which interventions should the nurse implement? Select all that apply
Chest Physiotherapy Teach the client breathing exercises Encourage use of incentive spirometer
The nurse is admitting a client with possible TB. The client is placed in a private room with airborne precautions pending diagnostic test results. which diagnostic test should the nurse review to confirm the diagnosis?
Chest X Ray or CT
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?
Increase the daily intake of oral fluids to liquefy secretions.
A client who was involved in a MVA 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 the client's distal pulses are diminished in the left foot. Which interventions should the nurse implement? Select all that apply.
A) Verify pedal pulse using a doppler pulse device B) Evaluate the application of the splint to the left leg C) Monitor left leg for pain, pallor ,paresthesia, paralysis, pressure.
A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the health care provider? a) low back pain and hypotension b) rhinitis and nasal stuffiness c) delayed painful rash and urticarial d) arthritic joint changes and chronic pain
A) low back pain and hypotension
Which nursing problem should be included in the plan of care for a client with heart failure?
Activity intolerance related to oxygen deficit secondary to inefficient cardiac contractility
A client with a right ulnar fracture and cast placement reports an increase in arm pain. Which action should the nurse perform?
Administer PRN analgesic
A hospitalized client with chemotherapy-induced stomatitis complains of mouth pain. What is the best initial nursing action? a) cleanse the tongue and mouth with glycerin swabs b) admin a topical analgesic per PRN protocol c) obtain a soft diet for the patient d) encourage frequent mouth care
B) administer a topical analgesic per PRN protocol
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
Which admission assessment findings should the nurse document related to a client who has been diagnosed with Cushing's?
Central-type obesity, with thin extremities
A client with cholelithiasis is admitted with jaundice due to obstruction of the common bile duct. Which finding is most important for the nurse to report?
Clay-Colored Stool
A postoperative client esports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the post anesthesia unit. Before selecting which medication to administer, which action should the nurse implement?
Compare the client's pain scale rating with the prescribed dosing.
A client who had surgery yesterday is becoming increasingly anxious. The client's respiratory rate has increased to 38 breaths/min. The client has a nasogastric tube to low intermittent suction with 500 mL of yellow-green drainage over the last four hours. The client's ABGs indicate a decreased CO2 and an increased pH. Which serum lab value should the nurse monitor first?
Creatinine creatinine test measures the level of creatinine in your blood and provides an estimate of how well your kidneys filter
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 min 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
The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding? a) nuchal rigidity b) palpable cervical lymph nodes. c) jugular vein distention d) carotid bruit
D) carotid bruit
A client with cirrhosis is admitted to the ICU because of deteriorating hepatic function. Which assessment finding warrants immediate intervention by the nurse?
Dependent pedal edema
A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?
Describe the use of an elimination diet to find trigger foods
During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and high waist-hip ratio, with a BMI of 32 kg/m^2. Which actions should the nurse take in response to these findings?
Discuss the importance of a regular exercise program Measure the client's blood pressure in both arms Screen for a family history for diabetes melitus
A client is recovering from a transurethral prostatectomy. Which activity should be limited until after the first postoperative visit with his healthcare provider?
Driving a car
The nurse is evaluating a male client's understanding of diet teaching about DASH (dietary approaches to stop hypertension) eating plan. Which behavior indicates that the client is adhering to the eating plan
Enjoys fat free yogurt as an occasional snack food
When providing care for an unconscious client who has seizures, which nursing intervention is most essential? A) Keep the room at a comfortable temperature B) Ensure oral suction is available C) Maintain the client in a semi Fowler's position D) Provide frequent mouth care
Ensure oral suction is available
A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of the finding should the nurse...
Evidence of spread of the disease to the kidney
The nurse is assessing clients in an outpatient diabetic clinic. Which entry provides the best indication that the client is adhering to the prescribed diabetic regimen?
Hemoglobin A1C of 6.2% A normal A1C level is below 5.7%, a level of 5.7% to 6.4% indicates pre-diabetes, and a level of 6.5% or more indicates diabetes. Within the 5.7% to 6.4% pre-diabetes range, the higher your A1C, the greater your risk is for developing type 2 diabetes.
When preparing a teaching plan for a client newly diagnosed with diabetes mellitus, the nurse should describe which situation as requiring the most immediate action by the client or family?
Hypoglycemic Shock
A client who has developed acute kidney injury (AKI) due to an amino glycoside antibiotic has moved from the oliguric phase to the diuretic phase of AKI. Which parameters are most important for the nurse to plan to carefully monitor?
Hypovolemia and ECG changes Hypovolemia - low extracellular fluid
In assessing a client with ulcers on the lower extremity, which finding indicates that the ulcers are likely to be venous, rather than arterial?
Irregular ulcer shapes and severe edema
A client with a long history of migraine headaches asks the nurse if there are non-pharmacological ways to help obtain pain relief. Which intervention should the nurse offer?
Lie down in a dark, quiet room
An adult woman with Grave's disease is admitted with severe dehydration and malnutrition. She is currently restless and refusing to eat. What action is most important for the nurse to implement?
Maintain a patent IV site
The nurse is developing a plan of care for a client undergoing peritoneal dialysis. Which intervention has the highest priority?
Maintain accurate I/O
A female college student comes to the school's health clinic complaining of urinary frequency and burning with right lower back pain. Which intervention should the nurse implement?
Measure her temperature and pulse
A client is hospitalized for...
Muscle weakness is an early sign
In providing discharge teaching to a client with COPD, which instruction is most important for the nurse to emphasize?
Notify the healthcare provider of any change in sputum color.
During a preoperative assessment phone call, a client states taking several "pills" everyday. Which response should the office nurse provide?
Obtain a copy of your medications records from your healthcare provider
A male 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?
Obtain a specimen of urethral drainage for culture.
A male client is admitted to the ED while vomiting dark brown, foul-smeling emesis. He reports he had surgical repair of a recurrent inguinal hernia a week ago and complains of intense abdominal pain. After finding that his bowel sounds are hyperactive, which prescription should the nurse implement first?
a) Insert a NGT and attach a low intermittent suction
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
A client with stage IV bone cancer is admitted to the hospital for a 1 to 10 scale. Which intervention should the nurse implement
administer opioid and non-opioid medication simultaneously
What instruction should the nurse include in the discharge teaching plan a a client who had a cataract extraction today? a) sexual activities may be resumed upon return home b) light housekeeping is permitted but avoid heavy lifting c) use a metal eye shield on operative eye during the day d) administer eye ointment before applying eye drops
b) light housekeeping is permitted but avoid heavy lifting