HESI MED SURG VERSION 1 2020-2021 QUESTIONS AND ANSWERS

32- In planning care for a client with pneumonia, which nursing problem should the nurse identify as the priority? • Impaired gas exchange related to the effects of alveolar-capillary membrane changes • Acute pain related to the effects of inflammation of the parietal pleura • Deficient fluid volume related to fever, infection, and increased metabolic rate • Disturbed sleep pattern related to pain, dyspnea, and hospitalization 33.A hospitalized client with chemotherapy-induced stomatitis complains of mouth pain. What is the best initial nursing action? • Encourage frequent mouth care • Administer a topical analgesic per PRN protocol • Cleanse the tongue and mouth with glycerin swabs • Obtain a soft diet for the client 33- A client returns from surgery following a hiatal hernia repair via Nissen fundoplication. Which position should the nurse implement for this client? • Right side-lying to promote stomach emptying • Prone to apply external pressure to the suture line • Left side-lying to reduce stress on the suture line • 30 degree semi-Fowler’s to drop the diaphragm 34- An adult woman with Grave’s disease is admitted with severe dehydration is currently restless and refusing to eat. Which action is most important for the nurse to implement? • Keep room temperature cool • Determine the client’s food preferences • Maintain a patent intravenous site • Teach the client relaxation techniques 35- The nurse admits a client who has a medical diagnosis of bacterial meningitis to the unit. Which intervention has the highest priority in providing care for this client? • Administer initial dose of broad-spectrum antibiotic • Instruct the client to force fluids hourly • Obtain results of culture and sensitivity of CSF • Assess the client for symptoms of hyponatremia 36- A client uses triamcinolone (Kenalog), a corticosteroid ointment, to manage pruritis caused by a chronic skin rash. The client calls the clinic nurse to report increased erythema with purulent exudate at the site. What action should the nurse implement? • Schedule an appointment for the client to see the healthcare provider • Advise the client to apply plastic wrap over the ointment to promote healing • Explain that the client needs to complete all prescribed doses of the medication • Instruct the client to continue the ointment until all erythema is relieved 37- During a paracentesis, two liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed, and 50 ml of clear, straw-colored fluid drains within the first hour. What action should the nurse implement? • Palpate for abdominal distention • Clamp drainage tube for 5 minutes • Continue to monitor the fluid output • Send fluid to the lab for analysis 38- The nurse assesses the dressing of a client who has just returned from postanesthesia and finds that the dressing is wet with a moderate amount of bright red bloody drainage. What action should the nurse take? • Replace dressing with a new sterile dressing, and monitor the wound hourly until bleeding is stopped • Call surgery and request that the surgeon see the wound prior to leaving the hospital • Reinforce the dressing and document that a moderate amount of sanguineous drainage was on the dressing • Document that the dressing was saturated with serious drainage, and do not change the dressing 39- While the home health nurse is making a home visit, a client with a history of seizures demonstrates tonic-clonic seizure activity. What action should the nurse implement first? • Direct a family member to call emergency services • Ascertain the trigger event • Protect the client’s head with a pillow • Observe the postictal breathing pattern 40- A client who weighs 176 pounds is admitted to the intensive care unit with a serum glucose level of 600 mg/dl and a serum acetone level of 50 mg/dl. Regular insulin at a rate of 0.1unit/kg/hour is prescribed. The pharmacy provides a solution of Regular insulin 100 units/100 ml of normal saline. The nurse should set the infusion pump to deliver how many ml/hour? (Enter numeric value only) = 8ML/H 41- A client whose history includes IV drug abuse is admitted to the intensive care unit (ICU) with Kaposi’s sarcoma associated with Acquired Immune Deficiency Syndrome (AIDS). Which intervention is most important for the nurse to include in the client’s plan of care? • Observe for adverse medication reactions • Assess for signs of AIDS dementia • Identify signs of opportunistic infections • Locate local HIV support groups 42-(Photo) The charge nurse observes a newly employed nurse gathering equipment to obtain a venous blood sample from a client’s implanted port. The nurse has obtained the equipment seen in the photo. What actions should the charge nurse take? (Select all that apply) • Guide the nurse in inserting the needle at a 45 degree angle • Remind the nurse to wear sterile gloves for this procedure • Instruct the nurse to obtain several red-topped tubes • Determine if the nurse has ever performed this skill • Assist in obtaining the correct needle to access the por