MED SURG HESI

Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires immediate action by the nurse?

Reference Range:

Potassium (3.5 to 5 mEq/L [3.5 to 5 mmol/L])

B. Preoperative serum potassium level is 2.8 mEq/L (2.8 mmol/L)

3 multiple choice options

A client with cholelithiasis is admitted with jaundice due to obstruction of the common bile duct. Which finding is most important for the nurse to report to the healthcare provider?

D. Distended, hard, and rigid abdomen.

3 multiple choice options

An older adult client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half of the food on the meal tray. The client's family expresses concern about the client's nutritional status.

How should the nurse respond to the family's concern?

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

3 multiple choice options

The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this medical diagnosis?

A. Upper midabdominal pain described as gnawing and burning.

3 multiple choice options

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. Which action should the nurse take first?

A. Visualize the abdominal incision.

3 multiple choice options

Which client has the highest risk for developing skin cancer?

C. A 65-year-old fair-skinned client who is a construction worker.

3 multiple choice options

A client with a gram positive bacterial skin infection is receiving daptomycin 500 mg IV every 24 hours. The pharmacy delivers a secondary infusion of 0.9% sodium chloride with daptomycin 500 mg/100 mL to be infused in 30 minutes. How many mL/hour should the nurse program the infusion pump? (Enter the numerical value only.)

200 mL/hr

A client tells the clinic nurse about experiencing burning on urination, and assessment reveals that the client had sexual intercourse four days ago with a person who was a casual acquaintance. Which action should the nurse implement?

B. Obtain a specimen of urethral drainage for culture.

3 multiple choice options

When explaining dietary guidelines to a client with acute glomerulonephritis (AGN), which instruction should the nurse include in the dietary teaching?

D. Restrict sodium intake.

3 multiple choice options

A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?

B. Lower back pain and hypotension

3 multiple choice options

While performing a neurovascular assessment distal to a client's fracture site, the nurse determines that the client's pulse is present, regular, and full force. Which nursing action should be taken next?

D. Observe the color of the extremity.

3 multiple choice options

A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions?

C. Monitor urinary stream for decrease in output

3 multiple choice options

The parent of an adolescent tells the clinic nurse, "My child has athlete's feet. I have been applying triple antibiotic ointment for two days, but there has been no improvement." Which instruction should the nurse provide?

D. Stop using the ointment and encourage complete drying of feet and wearing clean socks.

3 multiple choice options

The nurse observes that a client with Parkinson's disease (PD) has a mask-like face. Which follow-up assessment is most important for the nurse to implement?

D. Determine ability to chew and swallow. (something with swallowing on the hesi)

3 multiple choice options

The nurse is developing a plan of care for a client with type 2 diabetes mellitus (DM). When providing teaching on lowering blood glucose levels and increasing serum high-density lipoprotein (HDL) levels, which instruction should the nurse include?

C. Regular exercise with medical approval.

3 multiple choice options

Which findings during the admission assessment should the nurse document that are related to a client diagnosed with Cushing's syndrome?

D. Central type obesity, with thin extremities.

3 multiple choice options

The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the client for?

A. Lumbar puncture

3 multiple choice options

An older adult client with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. The client is anxious and reports a dry mouth. Which intervention should the nurse implement?

A. Assist client to an upright position.

3 multiple choice options

One hour after major abdominal surgery, a client in the postanesthesia care unit (PACU) has a blood pressure (BP) of 136/80 mm Hg. Fifteen minutes later it is 114/72 mm Hg. Which action should the nurse take first?

C. Check the abdominal surgical dressing.

3 multiple choice options

The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with type 2 diabetes mellitus (DM). Which outcome should the nurse include in the plan of care for this client?Reference Range: Glycosylated hemoglobin (A1C) [Good diabetic control: less than 7%]

D. The client's hemoglobin A1C will be less than 7% in 3 months.

3 multiple choice options

A male client is admitted to the emergency department (ED) while vomiting dark brown, foul-smelling emesis. He reports having a surgical repair of a recurrent inguinal hernia a week ago and is troubled by intense abdominal pain. After finding that his bowel sounds are hyperactive, which prescription should the nurse implement first?

A. Insert a nasogastric tube (NGT) and attach to low intermittent suction (LIS).

3 multiple choice options

The nurse is administering the second unit of whole blood to an older adult client who was admitted yesterday with gastrointestinal (GI) bleeding. Which parameters should the nurse monitor that indicate fluid overload?

D. Bounding pulse, hypertension, and distended neck veins.

3 multiple choice options

Following a transurethral resection of the prostate (TURP), a client is discharged from the hospital with an indwelling urinary catheter. Which instruction is most important for the nurse to include in the discharge teaching plan?

B. Drink 3 liters of water each day.

3 multiple choice options

When caring for a client with a cervical spinal cord injury, which intervention is the most important for the nurse to implement?

C. Immobilize the head in anatomical alignment.

3 multiple choice options

Two days after a nephrectomy, the client reports abdominal pressure and nausea. Which assessment should the nurse implement?

A. Auscultate bowel sounds.

3 multiple choice options

The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action about skin care indicates a need for further teaching?

C. Washes the radiation site with antibacterial soap and water.

3 multiple choice options

The nurse is preparing to administer Tylenol to a client admitted with urination issues who also has difficulty sleeping (OSA).Which interaction is most important for the nurse to implement before leaving the client?

B. Apply the client's positive airway pressure device

3 multiple choice options

The nurse is providing postoperative care for a client who complains of severe pain after receiving codeine 30 mg orally one hour ago.Which intervention should the nurse implement next?

B. Reassess the client and the level of pain.

3 multiple choice options

The healthcare provider prescribes ear drops to an adult client with an ear infection.Which exacting should the nurse follow?

D. Keep the patient in supine position to administer the drops

3 multiple choice options

A client recovering from cardiac surgery experiences a dysrhythmia, noted on the telemetry monitor. Which assessment finding is most likely to have contributed to the development of the dysrhythmia?

Reference Range:

Total Calcium [8.4 to 10.6 mg/dL (2.10 to 2.50 mmol/L)]

Sodium [136 to 145 mEq/L (136 to 145 mmol/L)]

Potassium (K+) [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

D. Calcium level 6.5 mg/dL (1.8 mmol/L).

3 multiple choice options

The nurse is caring for a client recovering from a recent myocardial infarction. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?

B. Provide a bedside commode for toileting.

3 multiple choice options

The nurse is caring for an older adult client with heart failure (HF) whose arterial blood gas (ABG) results include a pH 7.38, PaCO2 40 mm Hg, HCO3- 24 mEq/L (24 mmol/L), and a PaO2 90 mm Hg. Which action should the nurse implement?

Reference Range:

Arterial Blood Gas (ABG)

pH [7.35 to 7.45]

PaCO2 [35 to 45 mm Hg]

HCO3- [21 to 28 mEq/L (21 to 28 mmol/L)]

PaO2 [80 to 100 mm Hg]

A. Continue to monitor the client's condition.

3 multiple choice options

Following a mitral valve replacement, the client suddenly begins to show a large amount of blood on the surgical dressing while in the postanesthesia care unit (PACU). Which intervention should the nurse implement first?

B. Reinforce the incisional dressing.

3 multiple choice options

While assessing a client with type 2 diabetes mellitus (DM), the nurse observes an absence of hair growth on the client's lower legs. Which assessment provides further data to support this finding?

D. Appearance of the skin on the client's legs.

3 multiple choice options

Following cardiopulmonary resuscitation (CPR) and multiple defibrillations, the client's blood is drawn for STAT analysis. The client's heart rate is 130 beats/minute with ST elevation. Which of the client's serum laboratory values is most important for the nurse to monitor?

B. Troponin.

3 multiple choice options

A client with stable angina secondary to ischemic heart disease receives a prescription for sublingual nitroglycerin prior to discharge from the hospital. During discharge teaching, the client assures the nurse a plan to fill the prescription via online mail order service as soon as arriving at home. How should the nurse respond?

C. Explain the importance of obtaining the medication before leaving the hospital.

3 multiple choice options

A client is admitted with a confirmed pulmonary embolism (PE). Six hours after heparin IV infusion is initiated, the client's partial thromboplastin time (PTT) is 152 seconds, so the infusion is discontinued. Which intervention is most important for the nurse to implement?

Reference Range:

Partial Prothrombin Time (PTT)

[27 to 41 seconds]

A. Obtain hemoglobin and hematocrit levels.

3 multiple choice options

A client has developed atrial fibrillation with a ventricular rate of 150 beats/minute observed via telemetry. The client's blood pressure is 80/40 mm Hg. Which finding is most important for the nurse to report to the healthcare provider?

C. Abnormal level of consciousness.

3 multiple choice options

The nurse is assessing a client who is admitted with left-sided heart failure. Which finding indicates that the client is progressing into pulmonary edema?

D. Bilateral crackles in all lung fields.

3 multiple choice options

A client is admitted with chest pain and is rubbing the left arm. The nurse initiates oxygen at 4 L/minute, and administers a dose of aspirin PO, nitroglycerin sublingually, and morphine sulfate IV. Which additional assessment should the nurse consider for a myocardial infarction (MI)?

B. ST segment elevation.

3 multiple choice options

The nurse is assessing a hospitalized client with pulmonary edema who is reporting two pillow orthopnea and paroxysmal nocturnal dyspnea. The nurse observes rapid shallow respirations and use of accessory muscles. Which action should the nurse include in the client's plan of care?

A. Institute a daily fluid restriction while the client is in the hospital.

3 multiple choice options

A client with chronic stable angina reports a new onset of shortness of breath at rest. The nurse obtains vital signs and records a heart rate of 168 beats/minute, respiratory rate 26 breaths/minute, and blood pressure 124/76 mm Hg. While waiting for an electrocardiogram (ECG), which assessment is most important for the nurse to obtain?

A. Rhythm of apical heart rate.

3 multiple choice options

The spouse of a client diagnosed with Parkinson's disease calls the clinic and tells the nurse the client is having involuntary jerky movements of the legs and arms and is confused. Which action should the clinic nurse implement first?

B. Advise the client's spouse to call an ambulance to take the client to the emergency department (ED).

3 multiple choice options

The nurse is preparing to administer the client's morning dose of digoxin. Which action should the nurse take prior to administering the digoxin?

B. Listen to the heart at the left 5th intercostal space.

3 multiple choice options

A client with chronic lower back pain has been taking ibuprofen PO twice a day for several months. Which assessment is most important for the nurse to complete?

C. Determine presence of abdominal pain.

3 multiple choice options

A client with bipolar disorder is receiving valproic acid 1,000 mg PO at bedtime. Prior to administering the medication, the nurse notes that the client's morning valproic acid level was 142 mcg/ml (984.63 mcmol/L). Which action should the nurse implement?

Reference Range:

Valproic Acid [50 to 100 mcg/mL (350 to 700 mcmol/L)]

B. Notify the healthcare provider.

3 multiple choice options

The nurse administers acetylcysteine to a client with thick mucous and a nonproductive cough. To evaluate the effectiveness of the medication, which question should the nurse ask the client?

C. "How much phlegm are you coughing up?"

3 multiple choice options

The nurse is preparing to administer diphenhydramine HCL, to a client with allergic rhinitis. Which desired effect describes the rationale for administering this medication?

D. Antihistamines decrease nasopharyngeal secretions.

3 multiple choice options

Which intervention is most important for the nurse to implement for a client with type 2 diabetes melitus (DM) who is receiving insulin lispro?

A. Provide meals at the same time this insulin is given.

3 multiple choice options

Which instruction should the nurse include in the discharge teaching plan of a client who is prescribed ibuprofen for arthritic pain?

D. Report any signs of gastrointestinal bleeding.

3 multiple choice options

The nurse is interviewing a client who takes a daily antihypertensive medication. Current blood pressure reading is 124/80 mm Hg. Which client statement supports the nursing problem of, "Knowledge deficit about medication regimen?"

B. "I will save my blood pressure medicine for tomorrow since my blood pressure is good today."

3 multiple choice options

A client who is receiving a heparin infusion calls the nurse to report sudden bleeding from the nose and mouth. Which action is most important for the nurse to implement?

D. Give a PRN dose of protamine sulfate subcutaneous.

3 multiple choice options

The nurse is admitting a client who has a diagnosis of chronic obstructive pulmonary disease (COPD). The healthcare provider (HCP) prescribes theophylline. Since the therapeutic range for theophylline is narrow, the nurse plans to observe for signs of toxicity. Which symptoms should the nurse identify as related to theophylline toxicity?

C. Vomiting, dizziness, restlessness, and palpitations.

3 multiple choice options

The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued?

D. Benztropine

3 multiple choice options

A client is receiving miotics for the treatment of open-angle glaucoma. The nurse determines that a priority nursing problem is, "Risk for injury." This nursing problem is based on which etiology?

D. Decreased night vision

3 multiple choice options

Which nursing intervention is most important when caring for a client receiving aspirin 650 mg PO four times a day?

B. Check stool for occult blood.

3 multiple choice options

A client with a history of long term use of ibuprofen receives a prescription for misoprostol. Which finding indicates to the nurse that the medication was effective?

B. Relief of epigastric pain.

3 multiple choice options

The nurse is caring for a client with herpes zoster virus who reports painful, red blisters that align from the back along the thoracic curvature to the anterior chest. Which intervention is the highest priority for the nurse?

B. Administer antiviral medications.

3 multiple choice options

Four days following an abdominal aortic aneurysm (AAA) repair, the client is exhibiting edema of both lower extremities and pedal pulses are not palpable. Which action should the nurse implement first?

D. Assess pulses with a vascular Doppler.

3 multiple choice options

The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?

A. Platelet count.

3 multiple choice options

The nurse is preparing a client for an outpatient thoracentesis. Which statement made by the client should the nurse recognize as needing additional education?

B. Expect a persistent cough after the procedure.

3 multiple choice options

A client has a leg cast following an open reduction for a fractured tibia. Approximately two hours after returning to the unit, the client reports severe pain in the affected extremity, and the nurse observes that the limb is blue and blanched. Which action should the nurse perform first?

C. Notify the healthcare provider of the assessment findings.

3 multiple choice options

A client with Addison's disease started taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor which serum laboratory value?

B. Glucose.

3 multiple choice options

The nurse is caring for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral tissues. Which is the best initial nursing action?

B. Encourage frequent mouth care.

3 multiple choice options

A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain rated 8 on a 0 to 10 scale. Which intervention should the nurse implement?

D. Administer opioid and non-opioid medication simultaneously.

3 multiple choice options

A client who works as a data entry clerk is concerned about how a recent diagnosis of Raynaud's syndrome will affect their job performance. Which instruction should the nurse provide to this client?

C. Use a space heater to keep the workspace warm.

3 multiple choice options

The nurse reports that a client is at risk for a stroke based on which assessment finding?

B. Carotid bruit.

3 multiple choice options

A client who had a C5 spinal cord injury (SCI) 2 years ago is admitted to the emergency department (ED) with a diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?

A. Profuse diaphoresis and severe, pounding headache.

3 multiple choice options

A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cells (PRBCs). When notifying the healthcare provider (HCP), which information should the nurse provide first using the Situation, Background, Assessment, and Recommendation (SBAR) communication process?

D. Begin the report by stating the client's name and admitting diagnosis.

3 multiple choice options

When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain?

D. Daily weight.

3 multiple choice options

The nurse is assessing a client who is one day postoperative from a parathyroidectomy and finds that the client is experiencing tenderness. After notifying the healthcare provider (HCP), the nurse should prepare for which procedure?

D. Tracheostomy placement.

3 multiple choice options

The healthcare provider (HCP) prescribes penicillin G benzathine 1,800,000 units intramuscularly (IM) for a client with a bacterial infection. The prefilled syringe is labeled, "Penicillin G benzathine 1,200,000 units/2 mL." How many mL should the nurse administer to this client? (Enter numerical value only, rounded to the nearest whole number.)

3mL

The healthcare provider (HCP) prescribes diagnostic tests for a client whose chest x-ray indicates pneumonia. Which diagnostic test should the nurse review for implementation to guide the most therapeutic treatment of the pneumonia?

C. Sputum culture and sensitivity.

3 multiple choice options

The nurse obtains a fingerstick blood glucose using a bedside glucose meter for a client with a prescribed sliding scale insulin protocol. The meter indicates 56 mg/dL (3.12 mmol/L). Which intervention should the nurse implement first?

D. Give the client six ounces (180 mL) of non-diet carbonated soda and instruct the client to drink it entirely.

3 multiple choice options

The nurse is caring for a client with acute kidney injury (AKI). Which assessment finding warrants immediate intervention?

A. Dyspnea and sinus tachycardia.

3 multiple choice options

A male client who fractured his right femur from a fall at home is placed in Buck’s skin traction while awaiting surgery. When the client informs the nurse of the need to urinate, which intervention should the nurse implement?

D. Maintain traction while the client uses a urinal.

3 multiple choice options

The nurse is providing discharge instructions to a client who is receiving prednisone 5 mg PO daily for a rash due to contact with poison ivy. Which symptom should the nurse tell the client to report to the healthcare provider?

B. Rapid weight gain.

3 multiple choice options

A client who works at a computer most of the working day comes to the clinic reporting pain in both hands that causes the client to awaken during the night. Which action should the nurse implement to assess for carpal tunnel syndrome?

A. Tap the client's wrists to locate the pain.

3 multiple choice options

A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the postanesthesia care unit (PACU). Before selecting which medication to administer, which action should the nurse implement?

A. Compare the client's pain scale rating with the prescribed dosing.

3 multiple choice options

The nurse is assessing a group of older adult clients. Which factor in a client's history places the client at greatest risk for developing colon cancer?

D. Has intestinal polyps.

3 multiple choice options

Ten hours after successful thrombolysis for ST elevation myocardial infarction (STEMI), a client is receiving lidocaine and heparin infusions. Which assessment(s) should the nurse monitor regularly during the reperfusion period? Select all that apply.

A. Activated partial thromboplastin time (APTT).

B. Electrocardiographic changes.

C. Recurrence of chest pain.

E. Groin access site

1 multiple choice option

The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which is the best initial nursing action?

A. Increase the flow of the bladder irrigation.

3 multiple choice options

A client with diabetes mellitus is admitted with an upper respiratory infection (URI). Which changes in blood glucose management should the nurse tell the client to expect?

D. Higher doses of insulin.

3 multiple choice options

The nurse assesses an adult client 24 hours following abdominal surgery and finds the client’s blood pressure is 98/40 mm Hg. The client is tachycardic, restless, and irritable. Which action should the nurse perform first?

D. Check under the back for evidence of bleeding.

3 multiple choice options

A client with draining skin lesions of the lower extremity is admitted with possible methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention(s) should the nurse include in the plan of care (POC)? Select all that apply.

A. Monitor the client's white blood cell (WBC) count.

B. Institute contact precautions for staff and visitors.

D. Send wound drainage for culture and sensitivity.

2 multiple choice options

Following a motor vehicle collision, a client with chest trauma receives a chest tube to relieve a hemothorax. Two hours after chest tube insertion, the nurse observes the water level in the water-seal chamber rising during inspiration and falling during expiration. Which action should the nurse implement?

B. Continue to monitor the drainage system.

3 multiple choice options

A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?

A. Provide an eye shield to be worn while sleeping.

3 multiple choice options

A nurse is caring for a client with diabetes insipidus (DI). Which data warrants the most immediate intervention by the nurse?Reference Range: Sodium [136 to 145 mEq/L (136 to 145 mmol/L)]

A. Serum sodium of 185 mEq/L (185 mmol/L).

3 multiple choice options

The nurse is performing a physical assessment of a client. Which finding should the nurse recognize as a result of compromised peripheral arterial circulation of the lower extremity?

A. Uneven hair distribution.

3 multiple choice options

A client with chronic kidney disease (CKD) missed dialysis yesterday to attend a funeral. The client's spouse calls the home health nurse and reports that the client is lethargic and hard to arouse. Which instruction is most important for the nurse to provide?

D. Take the client to the emergency department (ED).

3 multiple choice options

After positioning the client upright, which action should the nurse take to assist with ineffective coughing?

A. Coach the client through using huff coughing.

3 multiple choice options

A client with heart failure (HF) is receiving IV fluids at 125 mL/hour. The nurse observes an increase in jugular vein distention (JVD) and pedal edema. Which additional assessment should the nurse make before reporting to the healthcare provider (HCP)?

C. Observe for changes in breathing pattern.

3 multiple choice options

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’s plan of care (POC)?

B. Continuous cardiac monitoring.

3 multiple choice options

A client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about dietary restrictions. In discussing fluid intake, the nurse should include which type of fluid limitation?

B. Citrus fruit juices

3 multiple choice options

The nurse assists a 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. The client tells the nurse of pretending to step over a crack on the floor. How should the nurse respond?

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

3 multiple choice options

The nurse establishes a nursing problem, "Fatigue related to inability to rest comfortably secondary to rheumatoid arthritis." Which nursing intervention should the nurse include in the plan of care (POC) for this client?

D. Assist the client with learning how to set priorities and pace activities.

3 multiple choice options

The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?

D. Remain upright following meals.

3 multiple choice options

The nurse is caring for a client who reports a sudden, severe headache, and facial numbness. The nurse asks the client to smile and observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. After obtaining vital signs, the nurse should implement which intervention?

A. Obtain a focused history to determine recent bleeding and use of anticoagulants.

3 multiple choice options

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

A. Neutrophil count.

3 multiple choice options

The nurse has determined that a client with trigeminal neuralgia has the nursing problem, "Imbalanced nutrition, less than body requirements." Which cause is most likely contributing to the problem?

A. Pain when eating

3 multiple choice options