Medical Surgical HESI review
The nurse teaches a client about cortisone therapy. Which statements made by the client indicate the need for further teaching? Select all that apply. "I should take three tablets at a time." "I should take the tablet with water." "I should take the tablet twice a week." "I should take the tablet on an empty stomach." "I should take the tablet with a meal."
"I should take three tablets at a time." "I should take the tablet twice a week." "I should take the tablet on an empty stomach." Rationale The client should take the medication as prescribed. Therefore, the client should not take three tablets at a time because this action may lead to drug toxicity. Cortisone therapy involves the administration of 25 to 50 mg of cortisone on a daily basis. Cortisone should be taken with a meal or a snack; taking the medication on an empty stomach would cause gastric irritation. Tablets can be taken with any fluid such as water or fruit juice.
The nurse is teaching a nursing student how to care for a client who underwent stereotactic radiosurgery for a pituitary adenoma. Which statement made by the student indicates effective learning? "I will assess for bleeding." "I will monitor cardiac output." "I will monitor serum osmolarity." "I will assess for glucose levels in nasal discharge."
"I will monitor serum osmolarity." Rationale A client who underwent stereotactic radiosurgery for a pituitary adenoma may experience transient diabetes insipidus. Thus serum and urine osmolarity should be closely monitored. Bleeding is a complication caused by hypophysectomy. Cardiac output should be monitored in clients who underwent thyroid surgery because they may experience hypothyroidism post-surgery. High glucose levels in nasal discharge may indicate meningitis in a client who underwent a hypophysectomy for pituitary adenoma.
A client has a persistent productive cough that becomes blood tinged. A needle biopsy is scheduled. The client tells the nurse, "During the procedure, a needle will be inserted into my back to collapse my lung." Which is the most appropriate response by the nurse? "I will ask the primary healthcare provider to clarify the diagnostic procedure." "Tell me more about the conversation you had with your healthcare provider." "The procedure will be fast so that you will experience minimal discomfort." "Your perception of the diagnostic test is incorrect."
"Tell me more about the conversation you had with your healthcare provider." Rationale The response "Tell me more about the conversation you had with your healthcare provider" is the best response. Exploration and collection of data are important parts of the therapeutic process; anxiety, fear, and depression can influence understanding of the procedure. Instructing the client to ask the healthcare provider to clarify the procedure is not the priority; at this point, the nurse should collect more data and then may have to refer. The response "The procedure will be fast so that you will experience minimal discomfort" is false reassurance. The response "Your perception of the diagnostic test is incorrect" will put the client on the defensive.
A client is diagnosed with Parkinson disease and asks the nurse what causes the disease. On which underlying pathology does the nurse base a response? Disintegration of the myelin sheath Breakdown of upper and lower neurons Reduced acetylcholine receptors at synapses Degeneration of the neurons of the basal ganglia
Degeneration of the neurons of the basal ganglia Rationale Parkinson disease involves destruction of the neurons of the substantia nigra, reducing dopamine. The cause of this destruction is unknown. Disintegration of the myelin sheath is associated with multiple sclerosis. Breakdown of upper and lower motor neurons is associated with Lou Gehrig disease or amyotrophic lateral sclerosis. Reduced acetylcholine receptors at synapses are associated with myasthenia gravis.
A client is admitted for a rhinoplasty. To monitor for hemorrhage after the surgery, the nurse should assess specifically for the presence of which response? Facial edema Excessive swallowing Pressure around the eyes Serosanguineous drainage on the dressing
Excessive swallowing Rationale Internal bleeding after nasal surgery may flow by gravity to the posterior oropharynx, where it is swallowed. Facial edema is expected after the trauma of surgery. The edema that results from the trauma of surgery may be perceived as pressure around the eye; although it is expected, it is not a priority. Pink-tinged drainage on the nasal packing and nasal drip dressing is expected for 24 to 48 hours after surgery.
Which cranial nerves assist with both sensory and motor functioning in a client? Select all that apply. Optic Facial Trochlear Accessory Trigeminal
Facial Trigeminal Rationale The facial nerve (cranial nerve VII) assists with sensory perceptions such as pain and temperature from the ear area, deep sensations from the face, and taste from the anterior two-thirds of the tongue. Motor functions of this nerve include movements of muscles of the face and scalp. The trigeminal nerve (cranial nerve V) assists with sensory perception from the skin of the face and scalp and mucous membranes of the mouth and nose. The motor functions of this nerve include mastication (chewing). The optic nerve (cranial nerve II) assists with sensory functions of the eye. The trochlear (cranial nerve IV) assists with the motor functions such as eye movements via superior oblique muscles. The accessory nerve (cranial nerve XI) assists with the motor functions of skeletal muscles of the pharynx and larynx and sternocleidomastoid and trapezius muscles.
The nurse is assessing a client with a "moon-shaped" face and thinner arms and legs. Which other assessment findings would the nurse suspect to be present in this client? Select all that apply. Weight loss Gastric ulcer Pain in bones Poor appetite Muscle weakness
Gastric ulcer Pain in bones Muscle weakness Rationale The presence of such symptoms as "moon" face and thinner arms and legs indicates Cushing's syndrome. In Cushing's syndrome, the cortisol level rises resulting in gastric ulcer formation caused by increased hydrochloric acid secretion and decreased production of protective gastric mucus. Osteoporosis is common in Cushing's syndrome; therefore, bone pain is common. Clients may also feel muscle weakness. Clients with Cushing's syndrome experience increased appetite and weight gain, therefore, they display truncal obesity and a "buffalo hump."
A client develops increased respiratory secretions because of radiation therapy to the lung, and the healthcare provider prescribes postural drainage. What client assessment leads the nurse to determine that the postural drainage is effective? Is free of crackles Has a productive cough Is able to expectorate saliva Can breathe deeply through the nose
Has a productive cough Rationale A productive cough indicates that mucus is being raised from the lungs, which is an expected outcome. Crackles are unaffected by postural drainage or coughing. Saliva comes from the mouth; it does not indicate that the lungs are clear. Depth of respirations may not be altered by postural drainage.
When preparing a client for a liver biopsy, the nurse explains that during the test the client will be placed in what position? In the supine position, with the right arm raised behind the head On the right side, with the left arm stretched up and over the head On the left side, with the right arm extended out in front across the bed In the prone position, with both elbows flexed and the hands resting on the pillow
In the supine position, with the right arm raised behind the head Rationale The supine position with the right arm raised behind the head exposes the right intercostal space, making the large right lobe of the liver accessible. The right side with the left arm stretched up and over the head will not provide accessibility to the liver; the small left lobe is not anatomically near the left chest wall. On the left side with the right arm extended out in front across the bed, the liver will fall away from the chest wall and be less accessible. The prone position with both elbows flexed and the hands resting on the pillow will not provide accessibility to the liver.
A nurse prepares a client for insertion of a pulmonary artery catheter. What information can be obtained from monitoring the pulmonary artery pressure? Stroke volume Venous pressure Coronary artery patency Left ventricular functioning
Left ventricular functioning Rationale The catheter is placed in the pulmonary artery. Information regarding left ventricular function is obtained when the catheter balloon is inflated. Information on stroke volume, the amount of blood ejected by the left ventricle with each contraction, is not provided by a pulmonary catheter. Although a central venous pressure reading can be obtained with the pulmonary catheter, it is not as specific as a pulmonary wedge pressure, which reflects pressure in the left side of the heart. The patency of the coronary arteries usually is evaluated by cardiac catheterization.
A client is admitted to the hospital with a head injury sustained while playing soccer. For which early sign of increased intracranial pressure should the nurse monitor this client? Nausea Lethargy Sunset eyes Hyperthermia
Lethargy Rationale Lethargy is an early sign of a changing level of consciousness; changing level of consciousness is one of the first signs of increased intracranial pressure. Nausea is a subjective symptom, not a sign, that may be present with increased intracranial pressure. Sunset eyes are a late sign of increased intracranial pressure that occur in children with hydrocephalus. Hyperthermia is a late sign of increased intracranial pressure that occurs as compression of the brainstem increases.
A client is admitted to the hospital with a diagnosis of a fractured hip after a fall. What clinical finding does the nurse expect to identify when assessing the client? Bruising over the affected hip Pain when moving the affected leg Shortening of the affected extremity Presence of crepitus when the affected leg is moved
Shortening of the affected extremity Rationale Shortening of the affected leg occurs because of the overriding of bone fragments. Crepitus with a fracture indicates grating of bones or entry of air in an open fracture. Although bruising may be present with a fracture because of soft tissue damage sustained during the fall, it is not necessarily present with all fractures of the hip. Pain can be expected because of trauma to bone and soft tissue; however, the affected leg should not be moved because it can cause further damage to nerves and blood vessels. The affected leg should not be moved to elicit crepitus, because it can cause further damage to nerves and blood vessels.
A client with acquired immunodeficiency syndrome (AIDS) and Cryptococcal pneumonia frequently is incontinent of feces and urine and produces copious sputum. When giving this client a bath, which protective equipment should the nursemake it a priority to use? Select all that apply. Goggles Surgical mask Shoe covers Gown Gloves N95 hepa mask
Surgical mask Gown Gloves Rationale A gown, mask, and gloves when bathing the client prevent contact with feces, sputum, or other body fluids during intimate body care. Goggles would only be important if the client was on mechanical ventilation to avoid contact with sputum. An N95 hepa mask would be necessary if the client had tuberculosis, but not for Cryptococcal pneumonia alone. Shoe covers are designed for protecting a sterile environment such as a surgery suite and are not necessary for giving patient care at the bedside.
The client's laboratory report shows localized vasodilation and transudation of fluid. The nurse interprets these findings as erythema and a wheal. Which condition may be present in the client? Urticaria Angioedema Allergic rhinitis Contact dermatitis
Urticaria Rationale Urticaria is a cutaneous reaction to systemic allergens that occurs in atopic people. Histamine causes localized vasodilation (erythema), transudation of fluid (wheal), and flaring. Angioedema is a localized cutaneous lesion similar to urticaria. Dilation and engorgement of the capillaries resulting from the release of histamine cause diffuse swelling. Allergic rhinitis is the most common type I hypersensitivity reaction. Symptoms include nasal discharge, sneezing, lacrimation, and pruritus. Contact dermatitis manifests as erythematous and edematous skin lesions covered in papules, vesicles, and bullae.
A lithotripsy to break up renal calculi is unsuccessful, and a nephrolithotomy is performed. Which postoperative clinical indicator should the nurse report to the primary healthcare provider? Passage of pink-tinged urine Pink drainage on the dressing Intake of 1750 mL in 24 hours Urine output of 20 mL/hr
Urine output of 20 mL/hr Rationale Output should be at least 30 mL/hr or more; a decreased output may indicate obstruction or impaired kidney function. Blood, tinting the urine pink, is expected. Drainage on the dressing may be pink; bright red drainage should be reported. The intake of 1750 mL in 24 hours is adequate; however, a higher intake usually is preferred (e.g., 2000 to 3000 mL).
A client is admitted to the emergency department with joint pain and swelling. Upon assessment the nurse suspects rheumatoid arthritis. Which findings support the nurse's conclusion? Select all that apply. Obesity Antinuclear antibodies Inflammatory disease pattern Disease in the bilateral symmetric joints Disease in the distal intrapharyngeal joints Disease in the weight-bearing joints and hands
Antinuclear antibodies Inflammatory disease pattern Disease in the bilateral symmetric joints Rationale Rheumatoid arthritis is an autoimmune disorder identified by the presence of antinuclear antibodies. Disease in the bilateral symmetric joints is generally seen in rheumatoid arthritis. Rheumatoid arthritis involves inflammation of the joints. Osteoarthritis involves degeneration of the joints. Obesity is a risk factor for osteoarthritis. Osteoarthritis affects weight-bearing joints and the hands.
Which physical changes are associated with the condition of a client's cherry hemangiomas? Decreased dermal blood flow Degeneration of elastic fibers Benign proliferation of capillaries Reduced number and function of nerve endings
Benign proliferation of capillaries Rationale The client presents with cherry hemangiomas, which are benign. They are caused by benign proliferation of capillaries. A decrease in dermal blood flow results in increased susceptibility to dry skin. The degeneration of elastic fibers causes decreased skin tone and elasticity. Reduced number and function of nerve endings results in reduced sensory perception.
A client had a pneumonectomy. For which postoperative complication specific to this type of surgery should the nurse assess this client? Brain attack Renal failure Internal bleeding Cardiac overload
Cardiac overload Rationale Cardiac overload can be caused by the loss of the large vascular lung or a mediastinal shift. A brain attack is not unique to a pneumonectomy. Renal failure is not unique to a pneumonectomy. Internal bleeding is not unique to a pneumonectomy.
The registered nurse is caring for a client hospitalized with syndrome of inappropriate antidiuretic hormone. Which action performed by the nurse may result in a positive outcome of the treatment? Obtaining the client's weight weekly Elevating the head of the bed to 20 degrees Changing the position of the client frequently Restricting the client's total fluid intake to 500 mL/day
Changing the position of the client frequently Rationale Changing the position of the client frequently helps in maintaining skin integrity and joint mobility. The head of the bed should not be elevated more than 10 degrees to enhance venous return to the heart. The client's weight should be obtained daily to help assess fluid retention. In acute care settings, the client's fluid intake should be no more than 800 to 1000 mL/day. Fluid intake is restricted to 500 mL/day in severe hyponatremia cases.
A client has a surgical creation of a colostomy for cancer of the rectum. The client asks, "What's the difference between irrigating a colostomy and having an enema?" Which information should the nurse share with the client? Colostomy irrigation instillation uses a cone-shaped tip catheter. Colostomy irrigation lubricates the catheter tip with a water-soluble jelly. Colostomy irrigation clears the tubing of air before insertion of the solution. Colostomy irrigation instillation will not cause cramping in the client's abdomen.
Colostomy irrigation instillation uses a cone-shaped tip catheter. Rationale A cone-shaped tip controls the depth of insertion of the catheter, which prevents perforation of the bowel and limits leakage of water from the stoma during fluid insertion. In both procedures the catheter tip should be lubricated with a water-soluble jelly, which limits trauma to the intestinal mucosa. In both procedures the tubing should be clear of air to facilitate the tolerance of a larger volume of irrigating solution. In both procedures cramping can occur.
A nurse is a preceptor for a new graduate nurse. The new graduate is providing care for a client who requests pain medication. The new graduate discovers that the prescribed dose is higher than the safe range listed in the hospital formulary and informs the preceptor of this discovery. The preceptor instructs the new graduate to go ahead and give the prescribed dose. Which action is best for the new graduate to take? Contact the primary healthcare provider to discuss the dose. Contact a hospital pharmacist to verify the dose prescribed. Give the medication as prescribed to decrease the client's pain. Check the dose with another nurse on the unit to see if it is correct.
Contact the primary healthcare provider to discuss the dose. Rationale The new nurse should discuss the dose with the primary healthcare provider who prescribed the medication. Although talking to the pharmacist may elicit additional information, this is not the best action since the new nurse will have to notify the prescribing primary healthcare provider. Giving the medication as prescribed may place the client at risk. Although checking the dose with another nurse may elicit additional information, this is not the best course of action.
Two portable drainage catheters with hemovacs attached were placed during a client's hemiglossectomy and right radical neck dissection. Six hours after the catheters were placed, the nurse empties 180 mL of serosanguineous drainage from one of the drainage catheters. What is the priority nursing intervention? Turn the client onto the right side Notify the healthcare provider immediately Document the output as an expected finding Irrigate the drainage catheter to ensure patency
Notify the healthcare provider immediately Rationale Serosanguineous drainage of 80 to 120 mL is expected during the first 24 hours; more than this amount of drainage should be reported. Placing the client in the side-lying position will have no effect on the portable wound drainage system; it functions via negative pressure, not gravity. Drainage of 180 mL in six hours is excessive and should be reported. It is unusual for drainage catheters to need irrigation to remain patent. It is evident that the catheter is not obstructed.
A client is found to have groups of isolated erythematous pustules on the scalp. Which statement made by the client is associated with the skin infection present in the client? "I have had a fever." "I have no discomfort." "I have a lot of itching, stinging, and pain." "I have cracks at the corner of my mouth."
"I have no discomfort." Rationale The presence of isolated erythematous pustules in groups on the scalp indicates folliculitis. A client with folliculitis may not feel any discomfort. A client with cellulitis has a fever. A client with herpes simplex infection feels itching, stinging, or pain. A client with candidiasis may have cracks at the corner of the mouth.
A nurse is providing counseling to a client with the diagnosis of systemic lupus erythematosus (SLE). Which recommendations are essential for the nurse to include? Select all that apply. "Wear a large-brimmed hat." "Take your temperature daily." "Balance periods of rest and activity." "Use a strong soap when washing the skin." "Expose the skin to the sun as often as possible."
"Wear a large-brimmed hat." "Take your temperature daily." "Balance periods of rest and activity." Rationale A fever is the major sign of an exacerbation. A balance of rest and activity conserves energy and limits fatigue. Malaise, fatigue, and joint pain are associated with SLE. SLE can cause alopecia, and hair care recommendations include the use of mild protein shampoos and avoidance of harsh treatments, like permanents or highlights, and use of large-brimmed hat for skin protection. Mild, not strong, soap and other skin products should be used on the skin. The skin should be washed, rinsed, and dried well and lotion should be applied. Exposing the skin to the sun as often as possible is not recommended. Exposure to ultraviolet light may damage the skin and aggravate the photosensitivity associated with SLE.
When receiving chemotherapy for non-Hodgkin lymphoma, a client states, "I get so sick to my stomach. The medication is useless." What is the best response by the nurse that uses the technique of paraphrasing? "You get sick to your stomach." "Tell me more about how you feel." "I'll get a prescription for an antiemetic." "You don't think the medication is helping you."
"You don't think the medication is helping you." Rationale Rewording of the client's statement is paraphrasing that promotes further verbalization. The response "You get sick to your stomach" is not paraphrasing; this repeats the client's exact words. The response "Tell me more about how you feel" is clarifying, a therapeutic technique; it is not paraphrasing. The response "I'll get a prescription for an antiemetic" is not an interviewing technique; it does not address the theme in the client's statement, and it cuts off communication.
During auscultation of the heart, where does the nurse expect the first heart sound (S 1) to be the loudest? Base of the heart Apex of the heart Left lateral border Right lateral border
Apex of the heart Rationale The first heart sound is produced by closure of the mitral and tricuspid valves; it is heard best at the apex of the heart. The base of the heart is where the second heart sound (S 2) is best heard; S 2 is produced by closure of the aortic and pulmonic valves. The left lateral border covers a large area; the auscultatory areas that lie near it are the pulmonic and mitral areas. The right lateral border covers a large area; the only auscultatory area near it is the aortic area.
What are the diagnostic abnormalities present in a client with fat embolism syndrome? Select all that apply. Decreased PaO 2 Increased platelet count Increased fat cells in urine Decreased hematocrit level Decreased prothrombin time
Decreased PaO 2 Increased fat cells in urine Decreased hematocrit level Rationale The diagnostic abnormalities present in a client with fat embolism syndrome are decreased PaO 2, increased fat cells in urine, decreased hematocrit level, decreased platelet count, and prolonged prothrombin time.
When a Schilling test is prescribed for a client suspected of having cobalamin deficiency because of pernicious anemia, what should the nurse plan to do? Give medications on time Prescribe foods low in vitamin B 12 Keep an accurate intake and output Collect a 24-hour to 48-hour urine specimen
Collect a 24-hour to 48-hour urine specimen Rationale A 24-hour to 48-hour urine specimen assesses parietal cell function. After radioactive cobalamin is administered, its excretion is measured; if cobalamin cannot be absorbed, as in pernicious anemia, very little is excreted in the urine. This test is not affected by medications. The results of this test are not affected by food; with pernicious anemia there is a deficiency of intrinsic factor, which is necessary for vitamin B 12 use. Intake and output records are not necessary with a Schilling test.
A client's laboratory findings showed increase in serum alkaline phosphatase and urinary hydroxyproline levels. Which condition will the nurse most likely observe in the client's electronic medical chart? Osteomalacia Osteoporosis Osteomyelitis Osteitis deformans
Osteitis deformans Rationale In osteitis deformans, or Paget's disease, there will be an increase in serum alkaline phosphatase and urinary hydroxyproline levels. In osteomalacia, a decrease in vitamin D, calcium, and phosphorous levels is observed. In osteoporosis, there will be a decrease in calcium level and vitamin D; the alkaline phosphatase level is usually normal. Osteomyelitis is a bone infection in which there is an increase in white blood cell count and a blood culture test is performed to identify the infectious organism.
A client with hepatitis B (HBV) develops cirrhosis and is hospitalized. One potential sequela of chronic liver disease is fluid and electrolyte imbalance. The nurse determines that this may be attributed to a decrease in serum albumin level. Which of these conditions results from this imbalance? Hemorrhage with subsequent anemia Diminished resistance to bacterial insult Malnutrition of cells, especially hepatic cells Reduction of colloidal osmotic pressure in the blood
Reduction of colloidal osmotic pressure in the blood Rationale Albumin is an essential component of the bloodstream that helps maintain both osmotic pressure and fluid and electrolytes. This is not a cause of hemorrhage. Blood components such as platelets, thrombin, and erythrocytes are involved in the prevention of hemorrhage or anemia. Diminished resistance to bacterial insult is not involved directly with immunity and resistance. Blood components, such as T and B lymphocytes, are involved in this process; the liver synthesizes specific proteins intrinsic to the function of antibodies. The serum albumin level is not related to nutrition of cells.
