HESI MED SURG
lean beef, mushrooms, cooked broccoli
The nurse prepares a list of recommended foods for a client with hypertension who is starting a 2-gram sodium diet. Which foods should the nurse include in the list? Select all that apply.
Continues after rest and nitroglycerin
The nurse provides discharge teaching to a client with a history of angina. The nurse instructs the client to call for emergency services immediately if the client's pain exhibits which characteristic?
"Red blood cells appear normal in size and color; however, there is a decreased amount produced."
The student nurse demonstrates correct understanding of anemia related to chronic disease with which statement?
"This is a noninvasive test to check your heart's response to physical activity."
A client who had several episodes of chest pain is scheduled for an exercise electrocardiogram (ECG). Which explanation should the nurse include when teaching the client about this procedure?
Practice relaxation techniques
A client who has always been active is diagnosed with atherosclerosis and hypertension. The client is interested in measures that will help promote and maintain health. Which recommendation by the nurse will help the client maintain blood vessel patency?
Describe the neurologic mechanisms in language that the client understands
A client who has an above-the-knee amputation (AKA) reports phantom limb sensations. What should the nurse do?
Straight-back armchair
A client who has passed the acute phase of rheumatoid arthritis is permitted to be out of bed as tolerated. After assisting the client out of bed, where should the nurse place the client?
urine may be discolored, i will loose weight on this med, the medication should be taken between meals, when im feeling better, i can stop taking med,
A client with chronic obstructive pulmonary disease will be taking long-term oral corticosteroid therapy. After the nurse conducts a teaching session, which statements by the client indicates that the nurse should follow up? Select all that apply.
Blood transfusions may be necessary
A client with multiple myeloma asks how the disease and therapy progresses. What would be appropriate to include in the client's teaching?
Before the surgery
A client is scheduled for a below-the-knee amputation. When should the nurse begin rehabilitation planning for the client?
fear
A client is to be transferred from the coronary care unit to a progressive care unit. The client asks the nurse, "Are you sure I'm ready for this move?" What should the nurse determine that the client most likely is experiencing based on this statement?
Increased restlessness
A client on a ventilator is exhibiting signs of poor oxygenation. The nurse is assessing the client for which signs?
Plantar fasciitis
A client reports burning sensation and sharp pain on the sole of a foot. Which condition does the nurse suspect in the client?
Urinary tract infections
A client has recently developed osteomyelitis. The client's laboratory reports show strains of Escherichia coli. What might be a possible reason for this condition?
Activation of regulators that control renal angiotensin II, Increase of left ventricular stroke volume to maintain blood volume, Enervation of the sympathetic nervous system to constrict arterioles
A client has serially decreasing blood pressures after surgery. Which mechanisms involved in the regulation of blood pressure should the nurse consider? Select all that apply.
Pain at the insertion site
A client is admitted to the hospital for an emergency cardiac catheterization. What adaptation is the client most likely to complain of after this procedure?
Conduct a complete nutritional assessment of the client
A 78-year-old client comes to the health clinic presenting with fatigue. The client's laboratory results indicate a hematocrit of 32.1% and a hemoglobin of 10.5 g/dL (105 mmol/L). Which is the most appropriate nursing intervention in response to these laboratory results?
Unilateral chest pain
A client develops a deep vein thrombosis after surgery. Which alteration in the client's condition may indicate that the client is experiencing a pulmonary embolus
Taking a hot tub bath or shower in the mornins
A client with rheumatoid arthritis asks the nurse about ways to decrease morning stiffness. What should the nurse suggest?
The client smokes four cigarettes per day
During a follow-up visit, a nurse finds that the client has a slow rate of healing after laryngeal cancer surgery. The nurse also finds that the client is at risk of developing lung cancer. What would be the reason behind the nurse's suspicion?
An expected effect of the dye used with the procedure
Following a client's cardiac catheterization, the nurse identifies that the client's urinary output is three times the client's intake amount. The client is stable otherwise. The nurse concludes that what is the cause of the increase in the client's urinary output?
joint crepitation, muscle atrophy, tenderness of spine
Identify abnormal assessment findings in the client's musculoskeletal system. Select all that apply.
Rises in the tube of the water-seal chamber during inspiration
Immediately after a thoracentesis, a client's right lung collapses. A chest tube is inserted and is attached to a three-chamber closed drainage system. What does the nurse assess about the fluid when the chest tube is functioning properly?
Dantrolene (Dantrium): reduces muscle one and metabolism and decreasing calcium
The nurse is reviewing the blood test reports of a child whose blood sample was tested after receiving a general anesthetic. The nurse finds that the client has increased intracellular calcium levels. What medication would be beneficial to the client?
troponin
Serum cardiac marker studies are prescribed for a client after a myocardial infarction. Which laboratory test is most important for the nurse to monitor?
Encourage coughing deeply
What nursing action will most help a client obtain maximum benefits after postural drainage?
Subcutaneous emphysema on the second postoperative day
The nurse is providing postoperative care to a client with cancer of the lung who had a lobectomy. The client has a chest tube attached to suction. Which assessment finding includes a complication?
Use a prescribed reliever drug therapy
The nurse instructed a client with asthma about the use of a peak flow meter at home. The client assesses the peak expiratory flow by using the peak flow meter. Which action performed by the client would be appropriate when the reading is in the yellow zone?
have you ever smoked elicit street drugs, what equipment helps you manage your respiratory problems
The nurse is collecting the health history of a client suspected to have a pulmonary disorder. Which questions should the nurse ask the client related to health perception and health management? Select all that apply.
Fruits and juices
The nurse is creating a teaching plan for a client who has been prescribed a 2-gram sodium diet. Which low-sodium foods should the nurse include in the plan?
Decreased PaO2, increased fat cells in urine, decreased hematocrit level
What are the diagnostic abnormalities present in a client with fat embolism syndrome? Select all that apply.
To flex, rotate, and extend the knees
What does the nurse instruct a client to do while performing McMurray's test?
Climbing a flight of stairs to the bedroom
When assessing a client with heart failure, the nurse asks what aggravates the problem. Which activity should the nurse expect will cause the client the greatest distress?
dependent rubor, ulcers on the toes, delayed capillary refill
When assessing the client with peripheral arterial disease, the nurse anticipates the presence of which clinical manifestations? Select all that apply.
Remove secretions by suctioning
When caring for an intubated client receiving mechanical ventilation, the nurse hears the high-pressure alarm. Which action is most appropriate?
1. tension pneumonthorax, compound fracture of femur, laceration of thigh muscle, severe wrist sprain, crushing head injury
When planning a citywide national homeland security disaster preparedness drill, a nurse is assigned to the triage committee. Place the following criteria in an order that reflects the most efficient triage plan for an actual mass casualty incident (MCI).
Check the dressing on the incision
A client had an open reduction and internal fixation of the head of the femur. In the postanesthesia care unit, the client's vital signs remained stable for 1 hour, with a blood pressure (BP) 130/78 mm Hg, pulse (P) 68, and respiration (R) 16. One hour after returning to the postsurgical unit, the client's vital signs are BP 100/60 mm Hg, P 74, and R 22, and the client is restless. What should the nurse do first?
Fresh orange wedge
A client is receiving a 2-gram sodium diet. The family members ask whether they can bring snacks from home. Which food item will the nurse suggest?
If both parents are carriers, the odds are one in four that an offspring will get the disease, and one in four that an offspring will be disease free.
A client is seen in the clinic with sickle cell anemia. The parents of the client ask how their child got sickle cell anemia. What is an accurate explanation?
Monitor for cardiovascular irregularities.
An 85-year-old client has a serum potassium level of 6.7 mEq/L (6.7 mmol/L). Which nursing action is the priority at this time?
Intravenous fluid infusion
An older client who was found unconscious at home was admitted to the hospital with a fractured hip, renal failure, and dehydration. In the 24 hours since admission, the client has received 3 L of intravenous fluid. The client has also developed hyponatremia. Which element would the nurse conclude is the most likely to have contributed to the client developing hyponatremia?
occasional cocaine use, african american heritage
An older client with hypertension is admitted to the hospital. Which data from the client's history and diagnostic workup represent risk factors for hypertension? Select all that apply.
Keep the client in the semi-Fowler position
A client has a bronchoscopy in the ambulatory surgery unit. Which action should the nurse take to prevent laryngeal edema?
"It decreases the swelling of the area
A client who had an above-the-knee amputation (AKA) has a pressure dressing on the end of the residual limb. The client asks, "Why do I have to have this tight dressing on my leg?" Which answer by the nurse is correct?
Palpate the area around the tubes for crepitus
A client who sustained trauma to the chest as a result of an injury has chest tubes inserted and is attached to a closed chest drainage system. When caring for this client, what should the nurse do?
Applying cold compresses and loosening client bandage
A client with a fracture is found to have compartment syndrome. Which interventions will be contraindicated? Select all that apply.
A positive attitude toward the eventual outcome
A nurse is caring for a client with severe rheumatoid arthritis. What is most important in the nurse's approach to help this client achieve self-reliance and independence?
chicken breast and broiled beef steak
A nurse is counseling a client who is at risk for developing osteoporosis. Which foods should the nurse recommend? Select all that apply.
72 mm Hg
A nurse is taking the blood pressure of a client with hypertension. The first sound is heard at 140 mm Hg; the second sound is a swishing sound heard at 130 mm Hg; a tapping sound is heard at 100 mm Hg; a muffled sound is heard at 90 mm Hg; the sound disappears at 72 mm Hg. When recording just the systolic and diastolic readings, what is the diastolic pressure?
Advance the cane simultaneously with the affected extremity.`
A nurse is teaching a client with hemiparesis how to ambulate with a cane. What should the nurse instruct the client to do?
Addressing the pain
After an amputation of a limb, a client begins to experience extreme discomfort in the area where the limb once was. What is the nurse's greatest concern at this time?
Prone
The nurse is providing care to a client with acute arthritis who is on bed rest. The client reports bilateral painful hip and swollen knee joints. What position will help prevent flexion deformities during the acute phase of this client's care?
Strength of contraction
When a client has a myocardial infarction, one of the major manifestations is a decrease in the conductive energy provided to the heart. When assessing this client, the nurse is aware that the existing action potential is in direct relationship to what?
Clear yellow halo ring structure on a filter paper
While caring for a client with a nasal injury, the nurse also suspects a skull fracture. Which manifestation might have led the nurse to conclude this?
Hypoventilation
Which condition can cause a client's partial pressure of end-tidal carbon dioxide (PETCO2) to be 50 mmHg?
insulin and growth hormone
Which hormones are involved in building and maintaining healthy bone tissue? Select all that apply.
midline trachea pink nasal mucosa nonlabored respiration of 14 breaths/min
Which physical assessment findings of a client suspected of having a respiratory disorder would be considered normal? Select all that apply.
Atelectasis
Which would the nurse consider to be a potential respiratory system-related complication of surgery?
temp: 102 erythema of the affected area tenderness of the affected area
While assessing a client, the nurse suspects that the client has acute osteomyelitis. Which symptoms in the client support the nurse's suspicion? Select all that apply.
"I'll report any instance of blue skin right away." "I'll report any feeling of air hunger immediately."
A registered nurse is educating a client who has just undergone thoracentesis on the manifestations of pneumothorax. Which statements made by the client indicate effective learning? Select all that apply.
A client with acute asthma and 85% oxygen saturation
A registered nurse is examining the medical reports of different clients. Which client may need immediate assessment?
Ventilatory exchange
A nurse is caring for a client who had a pneumonectomy. Which is the priority nursing assessment?
Examining the bedding under the client
A nurse is caring for a client who had a total hip replacement. Which is the priority assessment when monitoring the client for hemorrhage?
Hemolytic reaction
A prescribed blood transfusion of packed red blood cells was started five minutes ago. Now the client is complaining of chest pain, flank pain, difficulty breathing, and chills. The blood pressure has dropped from 140/88 to 110/60 mm Hg, temperature is 100.8° F (38.2° C), and the client seems less alert. What should the nurse suspect?
Pseudoephedrine
A primary healthcare provider prescribes an antihypertensive medication. Which over-the-counter medication should the nurse teach the client to avoid because it has the potential to counteract the effect of the antihypertensive?
Failure to stimulate the heart
A client has a synchronous pacemaker inserted. The nurse observes spikes on the monitor at a regular rate that are not followed by myocardial activity. What conclusion should the nurse make about the pacemaker based on this data?
Increased blood viscosity
A client is admitted with a higher than expected red blood cell (RBC) count. What physiologic alteration does the nurse expect will result from this clinical finding?
Distal pulses in the right leg
A client is brought to the emergency department triage by private car with an obvious compound fracture of the right lower leg. What is the initial assessment the triage nurse needs to perform?
Orthopneic position
A client is experiencing dyspnea. In which position should the nurse place the client?
Check for a pulse
A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first?
Plan for maximum periods of rest
A client is postoperative from open heart surgery. What should the nurse do to decrease or control the sensory and cognitive disturbances?
semi fowler postition
A client returns from surgery after a total laryngectomy with a laryngectomy tube in the permanent stoma. In which position should the nurse place this client to facilitate respirations and promote comfort?
Diminished breath sounds on the affected side
A client sustains fractured ribs as a result of a motor vehicle collision. Which clinical indicator identified by the nurse suggests the client may be experiencing a complication of fractured ribs?
Breathing exercises
A client who experienced smoke inhalation has a negative chest x-ray and arterial blood gases that demonstrate PaO2 of 75 mm Hg, PaCO2 of 45 mm Hg, and pH of 7.35. Which intervention should the nurse anticipate will be prescribed by the healthcare provider?
Raise the client to high-Fowler position
A client with a history of heart failure is experiencing dyspnea with a respiratory rate of 32. Crackles are noted bilaterally. The client is in Sims position, receiving oxygen at 2 L/min via nasal cannula. Which action should the nurse take first?
place them dependent to the torso
A client with peripheral arterial insufficiency is scheduled for surgery. On admission, the client complains of discomfort and aches in the legs and feet. How should the nurse position the client's feet and legs?
Assess the client's readiness to learn
A healthcare provider prescribes epoetin subcutaneously three times a week for an older adult with chronic lymphocytic leukemia (CLL) who lives alone. The nurse plans to teach the client about the medication. What should the nurse do first?
Promote pain relief
A nurse begins to develop a plan of care with a client who has left ventricular heart failure that resulted from a myocardial infarction (MI). Which goal is priority during the acute phase of recovery?
Client's systolic blood pressure drops from 130 to 90 mm Hg.
A nurse in the postanesthesia care unit is caring for a client who received a general anesthetic. Which finding should the nurse report to the primary healthcare provider?
Client's ability to plan a low-fat meal
After teaching a client about a low-fat diet, what is most important for the nurse to document?
Orthopneic
An 80-year-old client with a history of coronary artery disease is admitted to the hospital for observation after a fall. During the night the client has an episode of paroxysmal nocturnal dyspnea. In what position should the nurse place the client to best decrease preload?
The bone has broken into several fragments, and the skin is intact.
An x-ray film of a client's arm reveals a comminuted fracture of the radial bone. When determining an appropriate plan of care, the nurse considers that a comminuted fracture has what characteristics?
Pain control should include regularly scheduled analgesics and may necessitate use of as needed medications as well, Frequent neurovascular assessment should be done distal to the surgical site and compared with the unaffected side, When turning, the client should be log rolled to prevent the leg from falling forward or backward.
Considerations when caring for a client with a total hip replacement should include which interventions? Select all that apply.
Coughing and deep breathing every hour
The nurse is developing a plan of care for a client who had a chest tube removed. To promote respiratory exchange, what should the nurse add to the plan of care?
Instruct the client to avoid drinking coffee or tea 24 hours before the procedure
The nurse is preparing a care plan for a client who is to undergo an electromyography. Which nursing intervention should the nurse add to the care plan?
The remaining lung tissue will fill in the empty space. I will have chest tubes to help with drainage after surgery."
The nurse provides preoperative education to a client with extensive cancer of the upper right lobe of the lung who is scheduled for a lobectomy. The nurse concludes that the teaching was effective when the client makes which statement?
Thoracentesis; performed to obtain a specimen of pleural fluid for diagnosis
While preparing the client for a diagnostic procedure, the nurse positions the client upright with elbows on an overbed table and the feet supported. The nurse also instructs the client not to talk or cough during the procedure. Which diagnostic test is the client undergoing?
