med surg hesi
A client is admitted with a diagnosis of chronic obstructive pulmonary disease (COPD). What is the nurse's rationale for keeping the client's oxygen administration level at 3 L/min or less?
Chronic hypoxemia creates the urge to breathe in COPD.
A client is being discharged following radioactive seed implantation for prostate cancer. What is the most important information for the nurse to provide this client's family?
Follow exposure precautions.
What is the correct procedure for performing an ophthalmoscopic examination on a client's right eye?
From a distance of 8 to 12 inches and slightly to the side, shine the light into the client's pupil.
The nurse is counseling a healthy 30-year-old female client regarding osteoporosis prevention. Which activity would be most beneficial in achieving the client's goal of osteoporosis prevention?
cross country skiing
The nurse is preparing a teaching plan for healthy adults. Which individual is most likely to maintain optimum health?
A teacher whose blood glucose levels average 126 daily with oral antidiabetic drugs
Which instruction should the nurse teach a female client about the prevention of toxic shock syndrome?
"Change your tampon frequently."
An older female client with dementia is transferred from a long-term care unit to an acute care unit. The client's children express concern that their mother's confusion is worsening. How should the nurse respond?
"Confusion in an older person often follows relocation to new surroundings."
The nurse is completing an admission interview for a client with Parkinson disease. Which question will provide additional information about manifestations the client is likely to experience?
"Have you ever been 'frozen' in one spot, unable to move?
The nurse plans to help an 18-year-old developmentally disabled female client ambulate on the first postoperative day. When the nurse tells her it is time to get out of bed, the client becomes angry and yells at the nurse, "Get out of here! I'll get up when I'm ready." Which response should the nurse provide?
"I'll be back in 30 minutes to help you get out of bed and walk around the room."
The nurse is giving preoperative instructions to a 14-year-old female client scheduled for surgery to correct a spinal curvature. Which statement by the client best demonstrates learning has taken place?
"Let me show you the method of turning I will use after surgery."
What nursing action is necessary for the client with a flail chest?
. Encourage coughing and deep breathing.
Seconal 0.1 gram PRN at bedtime is prescribed for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer?
1 tablet
A nurse working in a community health setting is performing primary health screenings. Which individual is at highest risk for contracting an HIV infection?
A 17-year-old who is sexually active with numerous partners
Debilitating anginal pain can be decreased in some clients by the administration of beta-blocking agents such as nadolol (Corgard). Which client requires the nurse to use extreme caution when administering Corgard?
A 47-year-old kindergarten teacher diagnosed with asthma 40 years ago
During change of shift report, the charge nurse reviews the infusions being received by clients on the oncology unit. The client receiving which infusion should be assessed first?
A continuous epidural infusion of morphine
The nurse is performing hourly neurologic checks for a client with a head injury. Which new assessment finding warrants the most immediate intervention by the nurse?
A unilateral pupil that is dilated and nonreactive to light
Which content about self-care should the nurse include in the teaching plan of a client who has genital herpes? (Select all that apply.)
A. Encourage annual physical and Pap smear. B. Take antiviral medication as prescribed. C. Use condoms to avoid transmission to others. D. Warm sitz baths may relieve itching.
A client is placed on a mechanical ventilator following a cerebral hemorrhage, and vecuronium bromide (Norcuron) 0.04 mg/kg every 12 hours IV is prescribed. What is the priority nursing diagnosis for this client?
Impaired communication related to paralysis of skeletal muscles
The nurse witnesses a baseball player receive a blunt trauma to the back of the head with a softball. What assessment data should the nurse collect immediately?
Ability to spontaneously open the eyes before any tactile stimuli are given
A 74-year-old male client is admitted to the ICU with a diagnosis of respiratory failure secondary to pneumonia. Currently, he is ventilator-dependent with settings of tidal volume (VT) 750 ml and intermittent mandatory ventilation (IMV) rate of 10. ABG results are pH 7.48; PaCO2 30; PaO2 64; HCO3 25; and FiO2 0.80. Which intervention should the nurse implement first?
Add 5 cm positive end-expiratory pressure (PEEP).
A male client who has never smoked but has had COPD for the past 5 years is now being assessed for cancer of the lung. The nurse knows that he is most likely to develop which type of lung cancer?
Adenocarcinoma
A central venous catheter has been inserted via a jugular vein and a radiograph has confirmed placement of the catheter. A prescription has been received for a stat medication, but IV fluids have not yet been started. What action should the nurse take prior to administering the prescribed medication?
Administer a bolus of normal saline solution
A client with hypertension has been receiving ramipril (Altace) 5 mg PO daily for 2 weeks and is scheduled to receive a dose at 0900. At 0830 the client's blood pressure is 120/70. What action should the nurse take?
Administer the dose as prescribed.
A 58-year-old female client tells the nurse that she feels a sense of loss since she has stopped having menstrual periods. She then states, "At least I will no longer have to suffer through those horrible Pap smear tests every year." Which action should the nurse implement?
Advise the client that Pap smear tests should be continued.
In taking health histories of the following individuals, which client would have the greatest potential for development of head and neck cancer?
An alcoholic, tobacco-chewing auctioneer
The nurse is reviewing the routine medications taken by a client with chronic angle closure glaucoma. Which medication prescription should the nurse question?
An anticholinergic with a side effect of pupillary dilation
When assigning clients on a medical-surgical floor to a registered nurse (RN) and a practical nurse (PN), it is best for the charge nurse to assign which client to the PN?
An older adult client with pneumonia and viral meningitis
The nurse notes that a client who is scheduled for surgery the next morning has an elevated blood urea nitrogen (BUN) level. Which client condition is most likely to have contributed to this finding?
Anorexia and vomiting for the past 2 days
One day after a Billroth II surgery, a male client suddenly grabs his right chest and becomes pale and diaphoretic. Vital signs are assessed at blood pressure 100/80, pulse 110 beats/min, and respirations 36 breaths/min. What action is most important for the nurse to take?
Apply oxygen at 2 L per nasal cannula.
Twelve hours after chest tube insertion for hemothorax, the nurse notes that the client's drainage has decreased from 50 ml/hr to 5 ml/hr. What is the best initial action for the nurse to take?
Assess for kinks or dependent loops in the tubing.
The nurse is preparing a 45-year-old female client for discharge from a cancer center following ileostomy surgery for colon cancer. Which discharge goal should the nurse include in this client's discharge plan?
Attend an ostomy support group within 2 weeks.
An older male client comes to the geriatric screening clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg that is warm to the touch and the nurse suspects that the client may have thrombophlebitis. Which additional assessment is most important for the nurse to perform?
Auscultate the client's breath sounds.
Client census is often used to determine staffing needs. Which method of obtaining census determination for a particular unit provides the best formula for determining long-range staffing patterns?
Average daily census
The nurse is planning the care for a client who is admitted with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which interventions should the nurse include in this client's plan of care? (Select all that apply.)
B. Quiet environment C. Deep tendon reflex assessments D. Neurologic checks E. Daily weights
The nurse notes that the only ECG for a 55-year-old male client scheduled for surgery in 2 hours is dated 2 years ago. The client reports that he has a history of "heart trouble," but has no problems at present. Hospital protocol requires that those over 50 years of age have a recent ECG prior to surgery. What nursing action would be best for the nurse to implement?
Call for an ECG to be performed immediately.
A client with chronic asthma is admitted to postanesthesia complaining of pain at a level of 8 of 10, with a blood pressure of 124/78, pulse of 88 beats/min, and respirations of 20 breaths/min. The postanesthesia recovery prescription is, "Morphine 2 to 4 mg IV push while in recovery for pain level over 5." What intervention should the nurse implement?
Call the anesthesia provider for a different medication for pain.
The nurse initiates neuro checks for a client who is at risk for neurologic compromise. Which manifestation typically provides the first indication of altered neuro function?
Change in level of consciousness
A client is ready for discharge following creation of an ileostomy. Which instruction should the nurse include in discharge teaching?
Change the bag when the seal is broken.
An older client is admitted with a diagnosis of bacterial pneumonia. The nurse's assessment of the client will most likely reveal which sign/symptom?
Confusion and tachycardia
During the shift report, the charge nurse informs a nurse that she has been assigned to another unit for the day. The nurse begins to sigh deeply and tosses about her belongings as she prepares to leave, making it known that she is very unhappy about being "floated" to the other unit. What is the best immediate action for the charge nurse to take?
Continue with shift report and talk to the nurse about the incident at a later time.
Which change in lab values indicates to the nurse that a client with rheumatoid arthritis may be experiencing an adverse effect of methotrexate (Mexate) therapy?
Decrease in hemoglobin
The nurse is caring for a critically ill client with cirrhosis of the liver who has a nasogastric tube draining bright red blood. The nurse notes that the client's serum hemoglobin and hematocrit are decreased. What additional change in lab data should the nurse expect?
Decreased serum ammonia
The nurse is caring for a client with a fractured right elbow. Which assessment finding has the highest priority and requires immediate intervention?
Deep, unrelenting pain in the right arm
A 77-year-old female client is admitted to the hospital. She is confused and has had no appetite for several days. She has been nauseated and vomited several times prior to admission. She is currently complaining of a headache. Her pulse rate is 43 beats/min. The nurse is most concerned about the client's history related to what medication?
Digitalis (Lanoxin)
An adult resident in a long-term care facility is diagnosed with hepatitis B. Which intervention should the nurse implement with the staff caring for this client?
Discuss the importance of all employees starting the hepatitis B vaccine series.
The home health nurse is assessing a male client being treated for Parkinson disease with levodopa-carbidopa (Sinemet). The nurse observes that he does not demonstrate any apparent emotion when speaking and rarely blinks. Which intervention should the nurse implement?
Document the presence of these assessment findings.
A 55-year-old male client is admitted to the coronary care unit having suffered an acute myocardial infarction (MI). Within 24 hours of the occurrence, the nurse can expect to find which systemic sign?
Elevated CM-MB level
A client who is receiving an ACE inhibitor for hypertension calls the clinic and reports the recent onset of a cough to the nurse. What action should the nurse implement?
Encourage the client to keep taking the drug until seen by the healthcare provider.
The nurse is providing care for a client who has had a cervical cord injury. Following reduction of the cervical fracture, a halo vest is placed to maintain realignment of the spinal canal. What intervention is needed to ensure client safety while the halo vest is in place?
Ensure that a set of wrenches are kept in close proximity
Which assessment finding would confirm the specific location of an enteral feeding tube?
Examination of portable radiograph taken after the tube was inserted
Which assessment finding in a client with an acute small bowel obstruction requires the most immediate intervention by the nurse?
Fever of 102° F
In assessing a client for complications of total parenteral nutrition, it is most important for the nurse to monitor which lab value regularly?
Glucose
A male client with arterial peripheral vascular disease (PVD) complains of pain in his feet. Which instruction should the nurse give to the unlicensed assistive personnel (UAP) to quickly relieve the client's pain?
Help the client to dangle his legs.
An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that this client's tongue is somewhat cracked and his eyeballs appear sunken into his head. What nursing intervention is indicated?
Help the client to determine ways to increase his fluid intake.
The nurse is administering a nystatin suspension (Mycostatin) for stomatitis. Which instruction will the nurse provide to the client when administering this medication?
Hold the medication in the mouth for a few minutes before swallowing it.
A female client with diabetes mellitus type 2 has a plantar foot ulcer. When developing a teaching plan regarding foot care, what information should the nurse obtain first from this client?
How the client examines her feet
The nurse is receiving report from PACU about a client with a Penrose drain who is to be admitted to the surgical nursing unit. Before choosing a room for this client, which information is most important for the nurse to obtain?
If the client's wound is infected
A client with congestive heart failure and atrial fibrillation develops ventricular ectopy with a pattern of 8 ectopic beats/min. What action should the nurse take based on this observation?
Increase oxygen flow via nasal cannula.
The nurse is caring for a client who is 1 day post acute myocardial infarction. The client is receiving oxygen at 2 L/min via nasal cannula and has a peripheral saline lock. The nurse notes that the client is having eight PVCs per minute. Which intervention should the nurse implement first?
Increase the client's oxygen flow rate.
Which assessment finding indicates that the expected outcome of administering donepezil (Aricept) to a client with Alzheimer disease has been accomplished?
Increased ability to solve simple problems
The nurse is assessing a 75-year-old male client for symptoms of hyperglycemia. Which symptom of hyperglycemia is an older adult most likely to exhibit?
Infection
Which condition should the nurse anticipate as a potential problem in a female client with a neurogenic bladder?
Infection
An emaciated homeless client presents to the emergency department complaining of a productive cough with blood-tinged sputum and night sweats. What action is most important for the emergency department triage nurse to implement for this client?
Initiate airborne infection precautions.
A family member was taught to suction a client's tracheostomy prior to the client's discharge from the hospital. Which observation by the nurse indicates that the family member is capable of correctly performing the suctioning technique?
Inserts the catheter until resistance or coughing occurs
What is the correct location for placement of the hands for manual chest compressions during cardiopulmonary resuscitation (CPR) on the adult client?
Just above the xiphoid process on the lower third of the sternum
A 43-year-old homeless, malnourished female client with a history of alcoholism is transferred to the ICU. She is placed on telemetry, and the rhythm strip shown is obtained. The nurse palpates a heart rate of 160 beats/min, and the client's blood pressure is 90/54. Based on these findings, which IV medication should the nurse administer?
Magnesium sulfate
A client in the emergency department is bleeding profusely from a gunshot wound to the abdomen. In what position should the nurse immediately place the client to promote maintenance of the client's blood pressure above a systolic pressure of 90 mm Hg?
Maintain the client in a supine position to reduce diaphragmatic pressure and visualize the wound
An antacid (Maalox) is prescribed for a client with peptic ulcer disease. What is the therapeutic action of this medication which is effective in treating the client's ulcer?
Maintenance of a gastric pH of 3.5 or above
Which abnormal lab finding indicates that a client with diabetes needs further evaluation for diabetic nephropathy?
Microalbuminuria
Cushing syndrome results from a hypersecretion of glucocorticoids in the adrenal cortex. Based on the clinical manifestations of Cushing syndrome, which nursing intervention would be appropriate for a client who is newly diagnosed with Cushing syndrome?
Monitor blood glucose levels daily.
During report, the nurse learns that a client with tumor lysis syndrome is receiving an IV infusion containing insulin. Which assessment should the nurse complete first?
Monitor the client's serum potassium and blood glucose.
A severe thunderstorm has moved into a small community, and the tornado warning alarm has been activated at the local hospital. Which action should the charge nurse in the surgical department implement first?
Move clients and visitors into the hallways and close all doors to client rooms.
In assessing a client with an arteriovenous shunt who is scheduled for dialysis today, the nurse notes the absence of either a thrill or a bruit at the shunt site. What action should the nurse take?
Notify the healthcare provider of the findings.
In assessing an older client with dementia for sundowning syndrome, what assessment technique is best for the nurse to use?
Observe for tiredness at the end of the day
The nurse assesses a postoperative client. Oxygen is being administered at 2 L/min and a saline lock is in place. Assessment shows cool, pale, moist skin. The client is very restless and has scant urine in the urinary drainage bag. What intervention should the nurse implement first?
Obtain IV fluids for infusion per protocol.
A female client who received a nephrotoxic drug is admitted with acute renal failure and asks the nurse if she will need dialysis for the rest of her life. The nurse should explain which pathophysiologic consequence that supports the need for temporary dialysis until acute tubular necrosis subsides?
Oliguria
The nurse is observing an unlicensed assistive personnel (UAP) who is performing morning care for a bedfast client with Huntington disease. Which care measure is most important for the nurse to supervise?
Oral care
A 62-year-old woman who lives alone tripped on a rug in her home and fractured her hip. Which predisposing factor most likely contributed to the fracture in the proximal end of her femur?
Osteoporosis resulting from declining hormone levels
During a health fair, a male client with emphysema tells the nurse that he fatigues easily. Assessment reveals marked clubbing of the fingernails and an increased anteroposterior chest diameter. Which instruction is best to provide the client?
Pace your activities and schedule rest periods
A 63-year-old client with type 2 diabetes mellitus is admitted for treatment of an ulcer on the heel of the left foot that has not healed with conventional wound care. The nurse observes that the entire left foot is darker in color than the right foot. Which additional symptom should the nurse expect to find?
Pedal pulses will be weak or absent in the left foot.
A client with alcohol-related liver disease is admitted to the unit. Which prescription should the nurse question as possibly inappropriate for this client?
Pentobarbital (Nembutal sodium) 50 mg at bedtime for rest
A client who is being monitored with telemetry has a pattern of uncontrolled atrial fibrillation with a rapid ventricular response. Based on this finding, the nurse anticipates administering which treatment?
Perform synchronized cardioversion
A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which nursing intervention has the highest priority
Place the client on NPO status.
In assessing a client diagnosed with primary aldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance?
Potassium
During assessment of a client in the intensive care unit, the nurse notes that the client's breath sounds are clear upon auscultation, but jugular vein distention and muffled heart sounds are present. Which intervention should the nurse implement?
Prepare the client for a pericardial tap.
The nurse knows that clients taking diuretics must be assessed for the development of hypokalemia, and that hypokalemia will create changes in the client's normal ECG tracing. Which ECG change would be an expected finding in the client with hypokalemia?
Presence of a U wave
The nurse is planning care for a client with diabetes mellitus who has gangrene of the toes to the mid-foot. Which goal should be included in this client's plan of care?
Prevent infection
Which consideration is most important when the nurse is assigning a room for a client being admitted with progressive systemic sclerosis (scleroderma)?
Provide a room that can be kept warm.
A female practical nurse (PN) who is a valued employee tells the charge nurse in a long-term facility that she does not want to be assigned to one particular resident. She reports that the male client keeps insisting that she is his daughter and begs her to stay in his room. What is the best managerial decision?
Reassign the PN until the resident can be assessed more completely for reality orientation.
A client with non-insulin-dependent diabetes mellitus (NIDDM) takes metformin (Glucophage) daily. The client is scheduled for major surgery requiring general anesthesia the next day. The nurse anticipates the use of which approach to best manage the client's diabetes while the client is NPO during the perioperative period?
Regular insulin subcutaneously per sliding scale
A postoperative client receives a Schedule II opioid analgesic for pain. Which assessment finding requires the most immediate intervention by the nurse?
Respiratory rate of 12 per minute with O2 saturation of 85%
The nurse is interviewing a client who is taking interferon-alfa-2a (Roferon-A) and ribavirin (Virazole) combination therapy for hepatitis C. The client reports experiencing overwhelming feelings of depression. What action should the nurse implement first?
Review the medication actions and interactions.
Which statement reflects the highest priority nursing diagnosis for an older client recently admitted to the hospital for a new-onset cardiac dysrhythmia?
Risk for injury related to syncope and confusion
The nurse is assessing a client who presents with jaundice. Which assessment finding is the most significant indication that further follow-up is needed?
Serum amylase and lipase levels are twice their normal values
The nurse knows that normal lab values expected for an adult may vary in an older client. Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old man who is in good health overall?
Urinalysis reveals slight protein in the urine and bacteriuria with pyuria.
The nurse observes ventricular fibrillation on telemetry and upon entering the client's bathroom finds the client unconscious on the floor. What intervention should the nurse implement first?
Start cardiopulmonary resuscitation
Which description of symptoms is characteristic of a client diagnosed with trigeminal neuralgia (tic douloureux)?
Sudden, stabbing, severe pain over the lip and chin
A client diagnosed with angina pectoris complains of chest pain while ambulating in the hallway. Which action should the nurse implement first?
Support the client to a sitting position.
After attending a class on reducing cancer risk factors, a client selects bran flakes with 2% milk and orange slices from a breakfast menu. In evaluating the client's learning, the nurse affirms that the client has made good choices, and makes what additional recommendation?
Switch to skim milk.
When preparing a male client who has had a total laryngectomy for discharge, what instruction would be most important for the nurse to include in the discharge teaching?
Tell the client to carry a medic alert card that explains his condition.
A 55-year-old male client has been admitted to the hospital with a medical diagnosis of chronic obstructive pulmonary disease (COPD). Which risk factor is the most significant in the development of this client's COPD?
The client smokes 1 to 2 packs of cigarettes per day.
A 58-year-old client, who has no health problems, asks the nurse about taking the pneumococcal vaccine (Pneumovax). Which statement given by the nurse would offer the client accurate information about this vaccine?
The immunization is administered once to older adults or persons with a history of chronic illness."
A client with cirrhosis states that his disease was caused by a blood transfusion. What information should the nurse obtain first to provide effective client teaching?
The year the blood transfusion was received
A home health nurse knows that a 70-year-old male client who is convalescing at home following a hip replacement is at risk for developing decubitus ulcers. Which physical characteristic of aging contributes to such a risk?
Thinning of the skin with loss of elasticity
The nurse is caring for a client with a chest tube to water seal drainage that was inserted 10 days ago because of a ruptured bullae and pneumothorax. Which finding should the nurse report to the healthcare provider before the chest tube is removed?
Tidaling of water in water seal chamber
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He begins to cough and produces a moderate amount of white sputum. Which action should the nurse take first?
Turn off the continuous feeding pump.
In evaluating the effects of lactulose (Cephulac), which outcome would indicate that the drug is performing as intended?
Two or three soft stools per day
A nurse is assisting an 82-year-old client with ambulation and is concerned that the client may fall. What area contains the older person's center of gravity?
Upper torso
The nurse is assessing a male client with acute pancreatitis. Which finding requires the most immediate intervention by the nurse?
While the nurse is taking the client's blood pressure, he has a carpal spasm.
In caring for a client with acute diverticulitis, which assessment data warrant immediate nursing intervention? The client
has a rigid hard abdomen and elevated white blood cell count (WBC).
A client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly treated at a community hemodialysis facility. In assessing the client before his scheduled dialysis treatment, which electrolyte imbalance should the nurse anticipate?
hypocalcemia
A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff?
just prior to tube feeding
A client with Parkinson disease is taking carbidopa-levodopa (Sinemet). Which observation by the nurse would indicate that the desired outcome of the medication is being achieved?
lessing of tremors
A 25-year-old client was admitted yesterday after a motor vehicle collision. Neurodiagnostic studies showed a basal skull fracture in the middle fossa. Assessment on admission revealed both halo and Battle signs. Which new symptom indicates that the client is likely to be experiencing a common life-threatening complication associated with a basal skull fracture?
oral temp 102 F
A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last 2 hours. What action should the nurse take first?
reposition the patient on her side
A client with cirrhosis develops increasing pedal edema and ascites. What dietary modification is most important for the nurse to teach this client?
restrict salts and fluid intakes
The nurse receives the client's next scheduled bag of total parental nutrition (TPN) labeled with the additive NPH insulin. What action should the nurse implement?
return solution to pharmacy
he nurse includes frequent oral care in the plan of care for a client scheduled for an esophagogastrostomy for esophageal cancer. This intervention is included in the client's plan of care to address which nursing diagnosis?
risk for infection
A male client has undergone insertion of a permanent pacemaker. When developing a discharge teaching plan, the nurse writes a goal of, "The client will verbalize symptoms of pacemaker failure." Which behavior indicates that the goal has been met? The client
states that changes in the pulse and feelings of dizziness are significant changes.
What is the most important nursing priority for a client who has been admitted for a possible kidney stone?
straining all urine
