Med-Surg HESI Practice

An ER nurse is completing an assessment on a patient that is alert but struggles to answer questions. When she attempts to talk, she slurs her speech and appears very frightened. What additional clinical manifestation does the nurse expect to find if Nancy's symptoms have been caused by a brain attack (stroke)? A. A carotid bruit B. A hypotensive blood pressure C. hyperreflexic deep tendon relexes. D. Decreased bowel sounds

A. A carotid bruit

During preoperative teaching for a male client schedule for repair of an inguinal hernia, the client tells the nurse that he has had several surgeries and understand the need to perform coughing and deep breathing exercise after surgery. How should the nurse respond? a. Ask for a demonstration of these exercises b. Explain that coughing should be avoided c. Review the client previous surgical history d. Document the clients understanding of teaching

a. Ask for a demonstration of these exercises

A client uses triamcinolone (Kenalog), a corticosteroid ointment, to manage pruritus caused by a chronic skin rash. The client calls the clinic nurse to report increased erythema with purulent exudate at the site. Which action should the nurse implement? a. Schedule an appointment or the client to see the healthcare provider b. Advise the client to apply plastic wrap over the ointment to promote healing c. Instruct the client to continue the ointment until all erythema is relieved d. Explain the client need to complete all prescribed dose of the medication

a. Schedule an appointment or the client to see the healthcare provider

A nurse is caring for a client with Diabetes Insipidus (DI). Which data warrants the most immediate intervention by the nurse? a. Serum sodium of 185 mEq/L b. Dry skin with inelastic turgor c. Apical rate of 110 beats/minute d. Polyuria and excessive thirst

a. Serum sodium of 185 mEq/L

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

a. Teach the client to elevate the head of the bed on blocks

A male client who reports feeling chronically fatigued has a Hgb of 11.0 grams/dl, hematocrit of 34%, and microcytic and hypochromic red blood cells. Based on these findings, which dinner selection should the nurse suggest to the client? a) cheese pasta and a lettuce and tomato salad b) beef steak with steamed broccoli and orange slices c) broiled white fish with a baked sweet potato d) grilled shrimp and seasoned rice with asparagus salad

b) beef steak with steamed broccoli and orange slices

When providing care for a client following a bronchoscopy, which assessment finding should the nurse immediately report to the HCP? a) slight blood-tinged sputum b) dyspnea and dysphagia c) sore throat and hoarseness d) no gag reflex after thirty minutes

b) dyspnea and dysphagia

A fair-skinned female client who is an avid runner is diagnosed with malignant melanoma, which is located on the lateral surface of the lower leg. After wide margin resection, the nurse provides discharge teaching. I t is most important for the nurse to emphasize the need to observe for changes in which characteristic? a. Elasticity of the skin b. Appearance of any moles c. Muscle aches and pains d. Pigmentation of the skin

b. Appearance of any moles

When planning care for a client with rheumatoid arthritis, which intervention is most important for the nurse to include in the plan of care? a. Provide assistive devices to empower client independence b. Implement measures to manage chronic pain c. Teach coping skills for living with a chronic illness d. Schedule rest periods between activates to minimize fatigue.

b. Implement measures to manage chronic pain

In assessing a client with ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin? a. Black ulcers and dependent rubor b. Irregular ulcer shapes and severe edema c. Absent pedal pulses and shiny skin d. Hairless lower extremities and cool feet

b. Irregular ulcer shapes and sever edema

Two days following abdominal surgery a client c/o of cramping abdominal pain, and the nurse's inspection of the abdomen indicates slight distention. Which action should the nurse implement first? a) encourage pt to ambulate b) offer ice chips or warm liquids c) auscultate abdomen d) assess temperature

c) Auscultate the client's abdomen

A client who is receiving chemotherapy is vomiting. Which nursing intervention should the nurse implement first? a. Teach the client about the importance of hydration b. Report the volume of emesis t the healthcare provider c. Administer ondansetron hydrochloride (Zofran) Encourage the client to limit the amount of move

c. Administer ondansetron hydrochloride (Zofran)

A male client with a history of asthma reports having episodes of bronchoconstriction and increased mucous production while exercising. Which action should the nurse implement? a. Teach client to use pursed lip breathing when episodes occur b. Assess client for signs and symptoms of upper airway infection c. Determine if the client is using an inhaler before exercising d. Review the client's routine asthma management prescriptions.

c. Determine if the client is using an inhaler before exercising

A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client plan of care? a. Continuous cardiac monitoring b. Perform passive range of motion c. Evaluate level of consciousness d. Assess lung sounds q4 hours.

c. Evaluate level of consciousness

An older adult with heart failure is hospitalized during an acute exacerbation. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care? a. Assist with ambulation in the hallway b. Encourage active range of motion exercises c. Provide a bedside commode for toileting d. Teach to sleep in a slide-laying position

c. Provide a bedside commode for toileting

An older client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement? a. Teach a family member to administer eye drops b. Encourage deep breathing and coughing exercises c. Provide an eye shield to be worn while sleeping d. Obtain vital signs every 2 hours during hospitalization

c. Provide an eye shield to be worn while sleeping

An adult female client is diagnosed with restless leg syndrome and is referred to the sleep clinic. The healthcare provider prescribes ferrous sulfate (Feosol) 325 mg PO daily. Which laboratory values should the nurse monitor? a. Serum electrolytes b. Neutrophils and eosinophils c. Serum iron and ferritin d. Platelet count and hematocrit

c. Serum iron and ferritin

A client with acute renal injury (AKI) who weighs 50 kg and has potassium level of 6.7 mEq/L (6.7 mmol/l) is admitted to the hospital. Which prescribed medication should the nurse administer first a. Sevelamer (RenaGel) one tablet PO. b. Epoetin alfa, recombinant (Epogen) 2, 500 units SUBQ c. Sodium polystyrene (Kayexalate) 15 grams PO d. Calcium acetate (Phos-Lo) one tablet PO

c. Sodium polystyrene (Kayexalate) 15 grams PO

A client with ulcerative colitis is admitted to the medical unit during an acute exacerbation. The nurse should instruct the unlicensed assistive personnel (UAP) to report which finding related to the client's bowel movements? a. Hard pellets of stool b. Clay-colored stool c. Stool with fatty streaks d. Blood in the stool

c. Stool with fatty streaks

A male client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about the dietary restriction he should follow. In discussing fluid intake, the nurse should include which type of fluid limitation a. Low-sodium soups. b. Over all fluid intake c. Tea and hot chocolate d. Citrus fruit juices

c. Tea and hot chocolate

To reduce the risk for pulmonary complication for a client with Amyotrophic Lateral Sclerosis (ALS), what interventions should the nurse implement? (Select all that apply) a. Initiate passive range of motion exercises b. Establish a regular bladder routine c. Teach the client breathing exercises d. Perform chest physiotherapy e. Encourage use of incentive spirometer

c. Teach the client breathing exercises e. Encourage use of incentive spirometer

1. A male client who had abdominal surgery 5 days ago, and hospitalized because of a surgical wound infection, tells the nurse that he feels like his insides just spilled out when he coughed. What action should the nurse take first? a. Notify the healthcare provider b. Assure the client that such feelings occur with wound infections c. Visualize the abdominal incision d. Obtain sterile towels soaked in saline

c. Visualize the abdominal incision

An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action? a. Auscultate for the presence of bowel sounds. b. Monitor hemoglobin and hematocrit c. Encourage turning and deep breathing d. Administer IV antibiotics as prescribed

d. Administer IV antibiotics as prescribed

An adult female with multiple sclerosis (MS) fells while walking to the bathroom. On transfer to the intensive care unit, she is confused and has had projectile vomiting twice. Which intervention should the nurse implement first? a. Determine clients last dose of corticosteroids b. Determine neurological baseline prior to the fall c. Administer a PRN IV antiemetic as prescribed d. Complete head to toe neurological assessment.

d. Complete head to toe neurological assessment.

When providing care for a client following bronchoscopy, which assessment finding should he nurse immediately report to the healthcare provider? a. Slight blood-tinged sputum b. Dyspnea and dysphagia c. Sore throat and hoarseness d. No gag reflex after thirty minutes

d. No gag reflex after thirty minutes

The nurse is collecting information from a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain? a. Eating patterns and dietary intake b. Level and amount of physical activity c. Color and consistency of feces d. Presence and activity of bowel sounds

a. Eating patterns and dietary intake

The nurse calculates the body mass index (BMI) for an obese adult. Which additional assessment finding places the client at high risk for cardiac disease? a. Large waist circumference with central fat b. High serum insulin level c. Hyperpigmentation on neck skin folds d. Poor muscle tone

a. Large waist circumference with central fat

An older female client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment. To determine if the client is experiencing any long-term complication of DM, which assessments should the nurse obtain? (select all that apply) a. Serum creatinine and blood urea nitrogen (BUN) b. Sensation in feet and legs c. Skin condition of lower extremities d. Visual acuity e. Signs of respiratory tract infection

A, B, C, D

The clinic nurse is reviewing strategies for blood glucose monitoring with a client who is newly diagnosed with diabetes mellitus. When helping the client select a blood glucose meter, which client assessments should the nurse complete? a. Manual dexterity and visual acuity b. Capillary refill time and radial pulse volume c. Deep tendon reflexes and skin color d. Skin elasticity and hand grip strength.

a. Manual dexterity and visual acuity

The nurse is evaluating a male client understanding of diet teaching about the DASH (Dietary Approaches to Stop Hypertension) eating plan. Which behavior indicates that the client is adhering to the eating plan? a. Uses only lactose-free dairy products. b. Enjoys fat free yogurt as an occasional snack food c. No longer includes grains in his daily diet d. Carefully cleans and peels all fresh fruit and vegetables

d. Carefully cleans and peels all fresh fruit and vegetables

An older woman who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and she only eats half of the food on her meal tray. Her family expresses concern about her nutritional status. How should the nurse respond to the family's concern? a. Encourage the family to offer to feed the client when she does not eat her entire meal. b. Suggest that the family bring foods from home that the client enjoys c. Explain that weight loss will be reversed after the acute phase of the stroke has ended. d. Demonstrate the use of visual scanning during meals to the client and family.

d. Demonstrate the use of visual scanning during meals to the client and family.

A client's telemetry monitor indicates ventricular fibrillation (VF). After delivering one counter shock, the nurse resumes chest compression. After another minute of compressions, the client's rhythm converts to supraventricular tachycardia (SVT) on the monitor. At this point, what is the priority intervention for the nurse? a. Prepare for transcutaneous pacing b. Deliver another defibrillator shock c. Administer IV Epinephrine per ACLS protocol d. Give IV dose of adenosine rapidly over 1-2 seconds.

d. Give IV dose of adenosine rapidly over 1-2 seconds.

An older adult man recently diagnosed with chronic obstructive pulmonary disease (COPD) is admitted with shortness of breath. The nurse observes the client sitting upright and leaning over the bedside table, using accessory muscles to assist in breathing. What action should the nurse take? a. Assist the lien tot a high Fowler's position in bed b. Observe the client for the presence of a barrel chest c. Prepare to transfer the client to a critical care unit d. Instruct the client to pursed lip breathing techniques

d. Instruct the client to pursed lip breathing techniques

An older male client with long-standing lung disease is admitted to the medical unit for treatment of pulmonary infection. In assessing for signs of increasing hypoxia, which action should the nurse include? (select all that apply) a. Monitor dryness of mucous membranes b. Check for changes in mentation c. Observe color of skin and nailbeds d. Note appearance of jugular veins e. Assess breathing patterns

B, C, E

To reduce the risk for pulmonary complication for a client with amyotrophic lateral sclerosis (ALS), what interventions should the nurse implement? a. initiate passive range of motion b. establish a regular routine c. teach the client breathing exercises d. perform chest physiotherapy e. encourage use of incentive spirometer

C, E

Which clinical manifestation further supports an assessment of a left-sided brain attack? A) Visual field deficit on the left side. B) Spatial-perceptual deficits. C) Paresthesia of the left side. D) Global aphasia.

D) Global aphasia.

Three days after a female client with multiple sclerosis (MS) is admitted to the hospital with a severe urinary tract infection, she reports experiencing double vision. Which intervention should the nurse implement? a. Patch one eye and then the other every few hours b. Encourage bedrest until the diplopia is resolved c. Instruct the client to limit intake of oral fluids d. Administer artificial tear drops to both eyes

a. Patch one eye and then the other every few hours

A male client who reports feeling chronically fatigued has a hemoglobin of 11.0 grams/dl (110mmol/L), hematocrit of 34%, and microcytic and hypochromic red blood cells (RBCs). Based on these findings, which dinner selection should the nurse suggest to the client? a. Cheese pasta and a lettuce and tomato salad b. Beef steak with steamed broccoli and orange slices c. Broiled white fish with a baked sweet potato d. Grilled shrimp and season rice with asparagus salad

b. Beef steak with steamed broccoli and orange slices

A nurse assists a male client with Parkinson's disease (PD) to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. He tells the nurse that he is pretending to step over a crack on the floor. How should the nurse respond? a. Re-orient the client to his present location and circumstances b. Confirm that this is an effective technique to help with ambulation c. Assist the client to a carpeted area where he can walk more easily. Plan to assess the client's cognition after returning to his room.

b. Confirm that this is an effective technique to help with ambulation

A client who had a biliopancreatic diversion procedure (BDP) 3 months ago is admitted with a severe dehydration. Which assessment finding warrants immediate intervention by the nurse. a. Strong foul-smelling flatus b. Gastroccult positive emesis c. Complaint of poor night vision d. Loose bowel movements

b. Gastroccult positive emesis

An adult male client is admitted for Pneumocystis carinal pneumonia (PCP) secondary to AIDSs. While hospitalized, he receives IV pentamidine isethionate therapy. In preparing this client for discharge, what important aspect regarding his medication therapy should the nurse explain? a. IV pentamidine may offer protection to other AIDS-related conditions, such as Kaposi's sarcoma b. It will be necessary to continue prophylactic doses of IV or aerosol pentamidine every month c. IV pentamidine will be given until oral pentamidine can be tolerated d. AZT (Azidothymidine) therapy must be stopped when IV or aerosol pentamidine is being used.

b. It will be necessary to continue prophylactic doses of IV or aerosol pentamidine every month

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. Glucose b. Platelet count c. White blood cell count d. Amylase

b. Platelet count

Two days following abdominal surgery a client begins to report camping abdominal pain, and the nurse's inspection the abdomen indicates slight distention. Which action should the nurse implement first? a. Encourage the client to ambulate b. Offer ice ships or warm liquids c. Auscultate the client's abdomen d. Assess the client's temperature

c. Auscultate the client's abdomen

1. A client who has a history of long-standing back pain treated with methadone (Dolophines), is admitted to the surgical unit following urological surgery. Which modifications in the plan of care should the nurse make for this client's pain management during the postoperative period? a. Consult with surgeon about increasing methadone in lieu of parenteral opioids. b. Use minimal parenteral opioids for surgical pain, in addition to oral methadone c. Maintain client's methadone, and medicate surgical pain based on pain rating d. Make no changes in the standard pain management for the surgery and hold methadone.

c. Maintain client's methadone, and medicate surgical pain based on pain rating

A male client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling he is experiencing worsens at night. What client teaching should the nurse provide? a. Elevate the hands on two pillows at night b. Notify the healthcare provider as soon as possible c. Wear braces as both wriSts during the night d. Apply cold compresses for 30 min before bedtime

c. Wear braces as both wriSts during the night

A client with a liver abscess undergoes surgical evacuation and drainage of the abscess. Which lab value is most important for the nurse to monitor following the procedure? a. Serum creatinine b. Blood urea nitrogen (BUN) c. White blood cell count d. Serum glucose

c. White blood cell count

A hospitalized client with chemotherapy-induced stomatitis complains of mouth pain. What is the best initial nursing action? a. Encourage frequent mouth care b. Cleanse the tongue and mouth with glycerin swabs c. Obtain a soft diet for the client d. Administer a topical analgesic per PRN protocol.

d. Administer a topical analgesic per PRN protocol.

Two days after a nephrectomy, the client reports abdominal pressure and nausea, which assessment should the nurse implement? a. Palpate the abdomen b. Measure hourly urine output c. Ambulate client in hallway d. Auscultate bowels sounds.

d. Auscultate bowels sounds.

An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI). Prescriptions for intravenous antibiotics and an insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse? a. Glucose of 350 mg/dl b. White blood cell count of 15, 000 mm3 c. Blood PH of 7.30 d. Potassium of 2.5 mEq/L

d. Potassium of 2.5 mEq/L

1. The nurse is preparing a client for discharge who recently diagnosed with Addison's disease. Which instruction is most important for the nurse to include in the client's discharge teaching plan? a. Use a walker when weakness occurs b. Avoid extreme environmental temperatures c. Increase daily intake of sodium in diet d. Take prescribed cortisone accurately

d. Take prescribed cortisone accurately

A client returns to the unit following a suprapubic prostatectomy. He has a three-way catheter in place with a continuous bladder irrigation infusing. Which assessment finding warrants immediate intervention by the nurse a. True urinary output of 50ml/hr b. Lower abdominal tenderness c. Blood urine output with clots d. Urine leaking around the meatus

d. Urine leaking around the meatus

A male client with chronic kidney disease (CKD) is beginning his first hemodialysis 3 times per week. Which short-term goal is most important for the nurse to include in the plan of care for this client as he begins the series? a. Reports subjective symptom's during hemodialysis b. Documents his oral intake during dialysis treatments c. Demonstrates self-care of the arteriovenous (AV) Shunt d. Verbalizes understanding of the reasoning for dialysis

d. Verbalizes understanding of the reasoning for dialysis