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MED SURG HESI V2 - 2024/2025 EXAM QUESTIONS, Exams of Nursing

MED SURG HESI V2 - 2024/2025 EXAM QUESTIONS AND VERIFIED ANSWERS GUARANTEED SUCCESS

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2024/2025

Available from 07/15/2025

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MED SURG HESI V2 - 2024/2025 EXAM QUESTIONS
AND VERIFIED ANSWERS GUARANTEED SUCCESS
“What information should the nurse include in the teaching plan of a client diagnosed with
GERD?
A. Sleep without pillows
B. Adjust food intake to three full meals per day with no snacks
C. Minimize symptoms by wearing loose comfortable clothing
D. Avoid participation in any aerobic exercise program - CORRECT ANSWER Minimize
symptoms by wearing loose comfortable clothing"
"The nurse is teaching a client with glomerulonephritis about self care. Which dietary
recommendations should the nurse encourage the client to follow.
A. increase intake of high-fiber foods, such as bran cereal.
B. Restrict protein intake by limiting meals and other high-protein foods
C. limit oral fluid intake of 500/ml/day
D. Increase intake of potassium rich foods such as bananas and cantaloupe - CORRECT
ANSWER Restrict protein intake by limiting meals and other high-protein foods"
"An overweight young adult male who was recently diagnosed with type 2 DM is admitted for a
hernia repair. he tells the nurse that he is feeling very weak and jittery. Which actions should the
nurse implement? Select all that apply.
A.Check his fingerstick glucose
B. Assess his skin temperature and moisture
C. Measure his pulse and BP
D. Document anxiety on the surgical checklist
E. Administer a PRN dose of regular insulin - CORRECT ANSWER Check his fingerstick
glucose, assess his skin temperature and moisture, measure his pulse and BP"
"A client with Cushing Syndrome is recovering from an elective laparoscopic procedure. which
assessment finding warrants immediate intervention by the nurse?
A. Irregular apical pulse
B. Purple marks on skin of the abdomen
C. Quarter sized blood spot on the dressing
D. Pitting ankle edema - CORRECT ANSWER Irregular apical pulse"
"An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her
fingers. After warming her hands, the fingers turn red and the client reports a burning sensation.
What action should the nurse take?
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Download MED SURG HESI V2 - 2024/2025 EXAM QUESTIONS and more Exams Nursing in PDF only on Docsity!

MED SURG HESI V2 - 2024/2025 EXAM QUESTIONS

AND VERIFIED ANSWERS GUARANTEED SUCCESS

“What information should the nurse include in the teaching plan of a client diagnosed with GERD? A. Sleep without pillows B. Adjust food intake to three full meals per day with no snacks C. Minimize symptoms by wearing loose comfortable clothing

D. Avoid participation in any aerobic exercise program - CORRECT ANSWER Minimize

symptoms by wearing loose comfortable clothing" "The nurse is teaching a client with glomerulonephritis about self care. Which dietary recommendations should the nurse encourage the client to follow. A. increase intake of high-fiber foods, such as bran cereal. B. Restrict protein intake by limiting meals and other high-protein foods C. limit oral fluid intake of 500/ml/day

D. Increase intake of potassium rich foods such as bananas and cantaloupe - CORRECT

ANSWER Restrict protein intake by limiting meals and other high-protein foods"

"An overweight young adult male who was recently diagnosed with type 2 DM is admitted for a hernia repair. he tells the nurse that he is feeling very weak and jittery. Which actions should the nurse implement? Select all that apply. A.Check his fingerstick glucose B. Assess his skin temperature and moisture C. Measure his pulse and BP D. Document anxiety on the surgical checklist

E. Administer a PRN dose of regular insulin - CORRECT ANSWER Check his fingerstick

glucose, assess his skin temperature and moisture, measure his pulse and BP" "A client with Cushing Syndrome is recovering from an elective laparoscopic procedure. which assessment finding warrants immediate intervention by the nurse? A. Irregular apical pulse B. Purple marks on skin of the abdomen C. Quarter sized blood spot on the dressing

D. Pitting ankle edema - CORRECT ANSWER Irregular apical pulse"

"An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red and the client reports a burning sensation. What action should the nurse take?

A. Apply a cool compress to the affected fingers for 20 minutes B. Secure a pulse oximeter to monitor the client's oxygen saturation C. Report the finding to the healthcare provider as soon as possible

D. Continue to monitor the fingers until color returns to normal - CORRECT ANSWER

Continue to monitor the fingers until color returns to normal" "A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. lung are coarse with diminished bibasilar breath sounds. Vital signs are T: 101 degrees, HR: 128, RR: 28, B/P: 122/82. Which interventions is most important for the nurse to implement first? A. Obtain oxygen saturation level. B. Encourage incentivize spirometry C. Assess lower extremity circulation

D. Administer oral PRN antipyretic - CORRECT ANSWER Administer oral PRN antipyretic"

"A client with cancer is receiving chemotherapy with a known vesicant. the clients IV has been in place for 72hrs. The nurse determines that a new IV site cannot be obtained and leaves present IV in place. What is greatest clinical risk? A. impaired skin integrity B. fluid volume excess C. Acute pain and anxiety

D. Peripheral neuron vascular dysfunction - CORRECT ANSWER Impaired skin integrity"

"A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the post-anesthesia unit. Before selecting which medication to administer, which action should the nurse implement? A. Document client report of pain in EMR B. Determine which prescription will have quickest onset action C. Compare the clients pain scale rating w/prescribed dosing

D. Ask the client to choose which medication is needed for pain - CORRECT ANSWER

Compare the clients pain scale rating w/prescribed dosing" "While assisting a female client to the toilet, the client begins to have a seizure and the nurse eases her to the floor. The nurse calls for help and monitors the client until the seizing stops. Which interventions should the nurse implement first? A. Document details of the seizure activity B. Observe for lacerations to the tongue C. Observe for prolonged periods of apnea

D. Evaluate the evidence of incontinence - CORRECT ANSWER Document details of the

seizure activity"

"The nurse is obtaining a clients fingerstick glucose level. After gently milking the clients finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take? A. Collect the blood sample B. Assess radial pulse volume C. Apply pressure to the site

D. Select another finger - CORRECT ANSWER Collect the blood sample"

"A client being admitted to a surgical unit is being evaluated for an intestinal obstruction. The HCP prescribes a NG tube to be inserted and placed to intermittent low wall suction. which intervention should the nurse implement to facilitate proper tube placement. A. Soak NG tube in warm water B. Insert tube with clients head tilted back C. Apply suction while inserting tube

D. Elevate head of bed to 60 to 90 degrees - CORRECT ANSWER Elevate head of bed to 60 to 90

degrees" "A young female client with 7 children is having frequent morning headaches, dizziness, and blurred vision. Her b/p is 168/104. The client reports that her husband recently lost his job and she is not sleeping well. After administering a STAT dose of an antihypertensive IV med, which intervention is important? A. Measure urine output hourly to assess for renal perfusion B. Request a prescription for pain medication C. Use an automated BP machine to monitor for hypotension

D. Provide privacy - CORRECT ANSWER Use an automated BP machine to monitor for

hypotension"

"expressive aphasia - CORRECT ANSWER slurred speech or inability to speak; they're unable

to get out what they want to say" "No heavy lifting or bending over at the waste (nothing that will increase IOP ) Wear bandage or shield to protect the eye Eyes will feel like scratchy sand-like feeling in their eyes Need to have someone to drive for them 1st 24 hrs after surgery, they just need to relax (they can watch TV & read; nothing that will cause pressure) Don't want patient rubbing or pressing on their eye

Shouldn't drink alcohol for at least 24 hours - CORRECT ANSWER Cataract extraction

surgery education"

"-Report if they are coughing up blood -Recognize if there is a rupture, there will be bleeding & immediate action needs to be taken -No spicy foods!! -To prevent pressure, you have to control their high blood pressure

Majority of people who come in w/ esophogeal varices are alcoholics - CORRECT ANSWER

Teaching for esophageal varices"

"esophagel varices - CORRECT ANSWER enlarged, swollen, varicose veins at the lower end of

the esophagus"

"people that like to drink (alcohol) - CORRECT ANSWER Esphogeal varices are very common

in __"

"Decreased course crackles - CORRECT ANSWER Which assessment finding would you

expect to see in a patient who had recently been suctioned via endotracheal tube? A. Increased course crackles B. Decreased course crackles C. Decreased fine crackles D. Increased fine crackles" "The patient's sclera is yellow (inflammation b/c of gallstones, the stones can get lodged in the

bile duct, which backs up & causes damage in the liver) - CORRECT ANSWER Which

assessment information will be most important for the nurse to report to the health care provider about a patient with cholelithiasis? A. The patient's urine is bright yellow B. The patient's sclera is yellow C. The patient has increased pain after eating D. The patient complains of chronic heartburn"

"cholelithiasis - CORRECT ANSWER gallstones in the gallbladder"

"Place the client in high Fowler's position. (They are in respiratory acidosis)

Primary assessment: respiratory (listen to lungs, rate & depth) - CORRECT ANSWER A client

with pneumonia presents with the following arterial blood gases of pH 7.28, PaCO2 of 74, HCO3 of 28 meq/L, and PO2 of 45. Which of the following is the most appropriate nursing intervention? A. Administer a sedative B. Place client in left lateral position C. Place client in high-fowlers position D. Assist the client to breathe into a paper bag What would be your primary assessment for this patient?"

-Will always have to use eyedrops for the rest of their lives -S/S of open angle glaucoma: will have decreased peripheral vision, also it happens very slowly,

you use lose vision before you ever even know there is a problem (Chronic) - CORRECT

ANSWER Teaching plan for the client with open angle glaucoma"

"F,H are incorrect - CORRECT ANSWER A nurse is assessing a client who has a seizure

disorder. The client reports he thinks he is about to have a seizure. Which of the following actions by the nurse are incorrect? (Select all that apply) A. Monitor for prolonged apnea B. Ease the client to the floor if standing C. Move furniture away from the cient D. Loosen the clients clothing E. Protect the clients head with padding F. Restrain the client G. Turn on side H. Place tongue blade in clients mouth I. Record the time & document details of seizure J. Document details of the seizure" "Looking for a bowel movement (they are going to have massive liquid diarrhea b/c Kayexalate

causes potassium to exchange from sodium in the intestines & potassium goes out via BM) -

CORRECT ANSWER A renal failure client with a potassium level of 5.5 mEq/L is to receive

sodium polystryene sulfonate (kayexalate) orally. What do you want to monitor for immediately after this medication is given?" "D, C, A,B

Once you confirm that it's in place, you would listen to bowel sounds - CORRECT ANSWER

Sequence the procedure for verifying feeding tube placement: A. Measure the pH of aspirate, compare the color of the strip with the color on the chart provided by the manufactor B. Discard used supplies, remove gloves and discard, and perform hand hygiene C. Draw back on syringe & obtain 5 to 10 mL of gastric aspirate observe appearance of aspirate D. Perform hand hygiene. Apply clean gloves, draw up 30 mL of air into syringe, then attach to end of feeding tube, flush tube with 30 mL of air" "- check for increased HR, respirations, & temp

  • BP will drop
  • May have hemolytic rash & be itching
  • May see flushing
  • Chest or flank pain
  • Blood has to run off on a pump TIME FRAME FOR GIVING BLOOD HAS TO BE LESS THAN 4 HOURS; IF STILL BLOOD IN AFTER 4

HOURS, YOU HAVE TO TAKE IT DOWN - CORRECT ANSWER S/S of blood transfusion

reaction?"

"first thing to do is to stop the infusion & start flushing - CORRECT ANSWER What is nursing

priority when a transfusion reaction is suspected? A. vital signs B. call the MD C. administer benadryl D. stop the infusion" "Assess immediately and hourly thereafter (something has changed; this is different from their

norm) - CORRECT ANSWER An older adult client who is predominantly argumentative and

combative becomes calm & sleeps through the night. What is the nurse's priority intervention? A. Assess immediately and hourly thereafter B. Call the MD C. Document the client is resting D. Allow the patient to rest and document a round every 4 hours" "A. Diet & exercise regimen (least invasive)

(metformin would be the next; first drug of choice) - CORRECT ANSWER A 36 year old male

is newly diagnosed with type 2 diabetes. Which of the following treatments do you expect the patient to be started on initially? A. Diet and exercise regimen B. Metformin BID by mouth C. Regular insulin subcutaneous D. None, monitoring at this time is sufficient enough" "Review their dietary log (check what they have been eating & keep up with what foods are

causing the adjustments) - CORRECT ANSWER For patients with blood sugar ranges

fluctuating high and low, what should be the nursing intervention? A. Increase the patients short acting insulin B. Decrease the patients long acting insulin C. Draw a serum glucose D. Review their dietary log"

complication that can occur after abdominal surgery:

  • they can get an ileus (a painful obstruction of the ileum or other part of the intestine)
  • blocked bowel after surgery

(important to get them up & giving stool softeners; dont feed until you hear bowel sounds) -

CORRECT ANSWER A patient who received an emergency appendectomy 2 days ago is now

experiencing abdominal pain on the med-surg unit. What shoud the RN consider to be the primary assessment? A. Pedal pulses B. Jugular vein distention C. Bowel sounds in all 4 quadrants D. Urinary output of 30 cc per hour" "- Expect to see no BP or sticks in that arm

  • Cannot use right away b/c it has to have time to heal
  • Auscultate to bruit
  • Palpate for thrill - CORRECT ANSWER Care of a newly inserted AV fistula" "- Check feet everyday; make sure you dry your feet
  • Wear proper shoes
  • Don't want them walking around bearfoot
  • Make sure bath water isn't too hot - CORRECT ANSWER Education needed regarding foot care on diabetic patients." "Sit the patient in high fowler's

Priority nursing assessment: respiratory (listening to what their lungs sound like) - CORRECT

ANSWER A patient diagnosed CHF present to the ER with SOB, dyspnea, rhonchi, dry cough,

and tachycardia. What is the RN's first response? A. Complete chest percussions on bilateral lungs B. Push 1 amp o fmetoprolol C. Place the patient in trendelenburg D. Sit the patient in high fowler's What is the priority nursing assessment?" "Assess potassium level (when you're giving insulin & dextrose it pulls K+ out of cells too; it will drop)

(check glucose BEFORE meals, not after) - CORRECT ANSWER An order is given to the RN to

administer dextrose + insulin combined as a one time stat dose. What will be most important to include in this patient's plan of care?

A. Assess range of motion B. Assess oxygen level C. Assess potassium level D. Assess glucose readings after each meal" "- Monitor glucose

  • Check amylase & lipase levels
  • May have to put an NG down & put it to suction
  • one of the most common causes of pancreatitis is alcohol abuse, so talk about that
    • They will always be NPO*
  • Ultrasound - CORRECT ANSWER List all nursing interventions for a patient diagnosed with pancreatitis:" "popped, twisted, enlarged veins

-legs ache, painful, feel heavy (S/S) - CORRECT ANSWER varicose veins"

"RLS (restless leg syndrome) (unable to control the urge to move their legs)

(typically happens at night/evenings; can occur whether you are sitting or lying down) -

CORRECT ANSWER unpleasant sensations (itching, twitching, tingling, crawling) in the

lower legs; irresistible urge to move the legs temporarily relieving the sensation but not disurbing sleep." "Risks: Diabetes, Smoking, Hypertension, Diet (fatty foods/high cholesterol), Family History

Interventions: Diet and Exercise - CORRECT ANSWER Risk for developing Coronary Artery

Disease: What interventions do you instruct the patient to slow progression of CAD?" "- Stool will be red (bloody diarrhea) (lower)

  • rectal bleeding
  • Blood count may show low H&H, may be anemic - CORRECT ANSWER S/S of ulcerative colitis"

"apply oxygen by non-rebreather mask (too much carbon dioxide cause respiratory acidosis) -

CORRECT ANSWER After reviewing ABG's the patient is in respiratory acidosis. What is the

nurses's primary intervention? A. apply oxygen by non-rebreather mask B. sedate w/ ativan 1mg/kg C. Administer bicarb 1 amp D. Administer a bronchoocnstrictor"

l. Socioeconomic (greater in lower socioeconomic areas)

m. Stress - CORRECT ANSWER Risk factors for HTN"

"a. Pursed lips b. Barrel chest (increase anteroposterior diameter) c. Tripod positioning d. Use of accessory muscles e. ALSO: chronic cough, sputum production, dyspnea, wheezing

f. Medications: bronchodilators, incentive spirometer, CPT, O2 - CORRECT ANSWER COPD

S/S"

"a. Increase fluid intake to 3L/day if tolerated

b. Intake can be IV or PO - CORRECT ANSWER What to do when a patient needs to

expectorate thick lung secretions?" "a. Increase water intake to 3L / day b. DECREASE calcium, struvite (uric acid: gout), infections (bacterial: UTIs) c. Strain urine (shows composition of the stone) d. Increase ambulation *Foods to AVOID: calcium (milk, dairy, green leafy vegetables) & caffeine (coffee, tea, soda, chocolate); spinach nuts, wheats, brans, *Take thiazide diuretics to prevent calcium stones; allopurinol or colchicine to prevent uric acid stones; and antibiotics for bacteria (struvite)

*S/S: male over ager 40, N/V, pain radiates to flank area, hematuria - CORRECT ANSWER

Interventions for patient with renal calculi:" "a. Weak cough

b. Speaking, swallowing, drooling - CORRECT ANSWER What calls for an immediate ALS

(amyotropic lateral sclerosis) intervention? RESPIRATORY (MS lose cognitive function)" "a. Increased protein in the blood; decrease serum albumin b. Edema/swelling/abdominal edema

c. Increase weight gain - CORRECT ANSWER Indicators of nephrotic syndrome"

"Show pictures of charts to communicate - CORRECT ANSWER What to do when a patient is

experiencing expressive aphasia?" "a. No lifting/straining/bending b. No driving for > 2 days c. No contacts d. No alcohol for >24 hours

e. No rubbing or pressing on eyes

f. No bright lights - CORRECT ANSWER Cataract surgery education"

"a. Manage airway!!! b. Decrease BP MUST STAY LOW à if ruptures, can bleed easily c. Coughing up blood (red or coffee grounds) d. Avoid acidic/spicy foods & aspirin, alcohol, NSAIDS e. Use beta blockers to keep BP low f. If bleeding occurs: Manage airway (suction) à stabilize the patient à IV therapy (octreotide

[sandostatin] or vasopressin) - CORRECT ANSWER Esophageal varices: **COMMIN IN

LIVER CIRRHOSIS** -> medical emergency" "a. Yellow sclera, jaundice (because backing into the liver) b. Avoid fatty/spicy foods and alcohol c. S/S:

  • RUQ pain
  • Tachycardia/ diaphoresis
  • Pain 3-6 hours after a high fat meal or when laying down d. Management:
  • NPO with NG tube
  • IV fluids
  • Low fat diet

iv. Fat soluble vitamins - CORRECT ANSWER What do you report to the HCP with

cholelithiasis?" "a. Place patient in high fowlers (allows better oxygen) b. Check RR, respiratory depth, and O2 sat c. Use nonrebreather to keep O2 and release CO d. pH decreased; PaCO2 INCREASED; HCO3- normal or increased (compensation)

e. NORMALS: pH:7.35-7.45 PaCO2:35-45 HCO3:22-26 - CORRECT ANSWER Respiratory

acidosis (CO2 excess)" "a. Check cultures (blood, sputum, urine) before starting antibiotics b. Give antibiotics if culture answer is NOT an option

c. Establish IV access - CORRECT ANSWER Cellulitis from needle stick (worried about

infection)"

"Crackles, dyspnea, orthopnea, paroxysmal nocturnal dyspnea - CORRECT ANSWER Left

ventricular diastolic failure signs and symptoms:" "Safety risk factors:

"Food DECREASES symptoms -> HELPS Mid-epigastric pain beneath xiphoid

Bloating, nausea, vomiting & fullness - CORRECT ANSWER Duodenal ulcers"

"a. Black dome vision "Tunnel vision" ->LOSE PERIPHERAL VISION -> 1ST symptom!!!! b. Pressure eyedrops - lifetime medication

c. Check surroundings - CORRECT ANSWER Teaching for open angle glaucoma:"

"-Sudden excruciating pain in or around the eye with N/V

-Colored halos, blurred vision, & ocular redness - CORRECT ANSWER Teaching for closed-

angle glaucoma" "-> treatment of High K+ levels a. Watch for DIARRHEA (pulls out potassium and excretes through the bowels) b. If question asks what to look for INITIALLY à Diarrhea

c. If diarrhea has already passed, look for POTASSIUM levels or EKG changes - CORRECT

ANSWER Kayexalate"

"Hand hygiene/gloves -> Draw 20-30 mL air ->attach tube -> push air -> listen for bubbles ->

aspirate pH -> observe aspirate ->measure pH (should be <5) -> discard supplies - CORRECT

ANSWER Verify tube placement"

"1. Blood should not transfuse more than 4 hours ALWAYS ON A PUMP a. Itching b. Flank/chest pain c. Swelling

d. Decrease BP; INCREASE RR, HR, & temp - CORRECT ANSWER Blood transfusion reaction"

"a. Metabolic EMERGENCY b. Rapid release of components due to chemo & radiation into system à renal failure, hyperkalemia, hyperuricemia, hyperphosphatemia, HYPOcalcemia *hypocalcemia means that the body tries to pull calcium out of the bones, which leads to brittle

bone syndrome - CORRECT ANSWER Tumor lysis syndrome"

"1. Do not want patient to sit there and let fluid buildup a. Prevent pneumonia/atelectasis

b. If patient refuses to ambulate -> SCDs (sequential compression devices) - CORRECT

ANSWER Early ambulation for patients"

"a. Check POTASSIUM b. *Rationale: insulin pulls K+ out with glucose

c. *Add D5 or D10 when BS reaches a level of 250 mg/dL DKA: pH decrease, acidosis (fruity breath) TYPE 1

HHS: no acidosis, BS >600 TYPE 2 - CORRECT ANSWER Dextrose + insulin combined"

"a. NPO!!!! b. NG suction c. Abdominal ultrasound d. Amylase/lipase levels

e. AVOID alcohol - CORRECT ANSWER Pancreatitis interventions"

"(UC is lower GI) a. Abdominal pain b. Bloody diarrhea / rectal bleeding à main s/s!!!

c. Low H & H à anemia - CORRECT ANSWER Ulcerative colitis S/S"

"After hospitalization for SIADH, a client develops pontine myelinolysis. Which intervention should the nurse implement first? A. Reorient client to room B. Place a patch on one eye C. Evaluate clients ability to swallow

D. Perform range of motion exercises - CORRECT ANSWER Reorient client to room"

"A male client with heart failure calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain? A. What time did he take his medication? B. Has his weight changed in the last several days? C. Is he still able to tighten his belt buckle?

D. How many hours did he sleep last night? - CORRECT ANSWER Has his weight changed in

the last several days?" "An older adult woman with a long history of COPD is admitted with progressive shortness of breath and a persistent cough, is anxious, and is complaining of dry mouth. which intervention should the nurse implement? A. Administer a prescribed sedative B. Encourage client to drink water C. Apply a high flow Venturi mask

D. Assist her to an upright position - CORRECT ANSWER Assist her to an upright position"

"The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft to promote burn healing. Which information should the provider this client? A. Grafting increase the risk for bacterial infections B. The xenograft is taken from a non-human source. C. Grafts are later removed by a debriding procedure

D. As the burns heals, the graft permanently - CORRECT ANSWER The xenograft is taken

from a non-human source" "A male client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning him, the wound dehiscences and ulcerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next. A. Bring additional sterile dressing supplies to the room. B. Prepare the client to return to the OR C. Obtain a sample of the drainage to send to the lab

D. ausculate the abdomen for bowel sounds - CORRECT ANSWER Bring additional sterile

dressing supplies to the room" "A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117/meq. Which nursing problem should the nurse include in the clients plan of care. A. Altered urinary elimination B. Impaired gas exchange C. Fluid volume excess

D. Decreased cardiac output - CORRECT ANSWER Fluid volume excess"

"A female client enters the clinic and insists on being seen. She is weak, nervous and reports a racing heart beat and recent weight loss of 15 pounds. After ruling out substance withdrawal, the MD suspects hyperthyroidisms and admits her for testing. which action should the nurse do? A. Begin preparing the client for thyroidectomy procedure B. Space the clients care to provide periods of rest C. Assess the client for hyperactive bowel sounds

D. Provide warm blanket to prevent heat loss - CORRECT ANSWER Assess the client for

hyperactive bowel sounds" "The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomy under general anesthesia. which finding warrants notification of the HCP prior to proceeding with the scheduled procedure? A. light yellow coloring of the clients skin and eyes. B. The clients blood pressure reading 184/88mm C. The client vomits 20 mL of clear yellowish fluid

D. the IV insertion site is red, swollen, and leaking IV fluid - CORRECT ANSWER The clients

blood pressure reading 184/88"

"A client who has a history of hyperthyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse? A. Facial puffiness and periorbital edema B. Hematocrit of 30% C. cold and dry skin

D. Further decline in LOC - CORRECT ANSWER Further decline in LOC"

"Following surgical repair of the bladder, a female client is being discharged from the hospital to home with an indwelling urinary catheter. Which instruction is most important for the nurse to provide to this client? A. Avoid coiling the tubing and keep if free of kinks B. Cleanse the perineal area with soap and water twice daily C. Keep the drainage bag lower than the level of the bladder

D. Drink 1,000 ml of fluids daily to irrigate catheter - CORRECT ANSWER Keep the drainage

back lower than the level of the bladder" "Which client has the highest risk for developing skin cancer? A. A 16 year old dark skinned female who tans in tanning bed once a week. B. A 65 year old fair skinned male who is a construction worker C. A 25 year old dark skinned male who mother had skin cancer.

D. A 70 year old fair skinned female who works as a secretary - CORRECT ANSWER A 65 year

old fair skinned male who is a construction worker" "When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain? A. Daily weight B. Vital signs C. Level of consciousness

D. Bowel sounds - CORRECT ANSWER Daily weight"

"A female client client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in prep for an open reduction internal fixation (ORIF) the nurse determines that her distal pulse are diminished in the left foot. Which interventions should the nurse implement? (SATA) B. Verify pedal pulses using a Doppler C. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure

D. Evaluate the splint to the left leg - CORRECT ANSWER Verify pedal pulses using a Doppler,

monitor left leg for pain, pallor, paresthesia, paralysis, pressure, evaluate the splint to the left leg" "A male client with heroes zoster (shingles) on his thorax tells the nurse that he is having difficulty sleeping. what is the etiology of this problem?