HESI MED SURG PRACTICE QUESTIONS WITH EXPLANATIONS; Explanation listed from Lewis’s Medical-Surgical

What action should the nurse take? ◦ Secure a pulse ox to monitor the client’s oxygen saturation • Pg 807 ◦ “Raynaud’s phenomenon is characterized by vast spasm-induced color changes of fingers, toes, ears, and nose. • A client w a hx of hypothyroidism was initially admitted w lethargy and confusion. Which additional finding warrants the most immediate action ◦ Hematocrit of 30% • Surgical repair of the bladder, a female client is being dc’d w an in dwelling urinary catheter ◦ Keep the drainage bag lower than the level of the bladder • When caring for a client w nephrotic syndrome, which assessment is most important to obtain • Pg 1034 ◦ “Nephrotic syndrome results when the glomerulus is excessively permeable to plasma protein, causing proteinuria that leads to low plasma albumin and tissue edema…Manifestations include peripheral edema, massive proteinuria, hypertension, hyperlipidemua, Hypoalbuminemia, and foamy urine….A major nursing intervention focuses ion the management of edema. Assess the edema by weighing the pt daily, accurately recording intake and output, and measuring abdominal girth or extremity size.” • When planing care for a client newly diagnose w open angle glaucoma, the nurse identifies a priority nursing diagnosis of “visual sensory/perceptual alterations.” this do is based on whichetiology ◦ Decreased peripheral vision • pg 369 ◦ “Glaucoma is a group of disorders characterized by increased IOP and its consequences, optic nerve atrophy, and peripheral vision field loss.” • A client who is newly diagnosed w emphysema is being prepared for discharge. Which instruction is best for the nurse to provide the client to assist them w dyspnea self-management? ◦ Allow additional time to complete physical activities to reduce oxygen demand • Pg 560 ◦ “Emphysema, the destruction of alveoli without fibrosis, describes one of several structural abnormalities in COPD patients” • A client w cancer is receiving chemo with a known vesicant. the client’s IV has been in place for 72 hrs. The nurse determines that a new IV site cannot be obtained and leaves the present IV in place. What is the greatest clinical risk related to this situation ◦ Impaired skin integrity • Pg 244-245 ◦ “The IV route is the most common method of giving chemo. Major complications associated w IV chemo administration include venous access problems, device or catheter-related infection • A male client tells the nurse that he is experiencing burning on urination, and assessment reveals that he had sexual intercourse 4 days ago w a woman he casually met. Which action should the nurse implement? ◦ Obtain a specimen of urethral drainage for culture • A client w Addison’s disease started taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor GLUCOSE • A client w AIDS has impaired gas exchange from a respiratory infection. An ELEVATED TEMP warrants immediate intervention by the nurse • Fluids are restricted for a client w AKI. He is frustrated and complaining of constant thirst, and the family provides the client w additional fluids. the nurse should PROVIDE THE CLIENT W ORAL SWABS TO MOISTEN THE MOUTH • During a paracentesis, 2 L of fluid are removed from the abdomen of a client w ascites. A drainage bag is placed, and 50 ml of clear, straw colored fluids drains within the first hour. the nurse should CONTINUE TO MONITOR THE FLUID OUTPUT • While assessing a client w degenerative joint disease, the nurse observes Herbeden’s nodes large prominences on the client’s fingers that are reddened. The client reports that the nodes are painful. The nurse should discuss approaches to the chronic pain control w the client • A client who was camping 2 weeks ago in a country w a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. the nurse should report jaundiced sclera • 10 hrs following thrombolysis for an ST elevation MI a client is receiving lidocaine infusion for isolated runs of V-tach. Lidocaine is used for cessation of chest pain • After a CT scan w IV contrast medium, a client returns to the room complaining of SOB and itching. The nurse should prepare a dose of epinephrine bc of allergies • A client is at risk for a stroke based on nuchal rigidity • The nurse is obtaining a client’s fingerstick glucose level. After gently milking the client’s finger, the nurse observes that the distal tip of the finger appears red and engorged. The nurse should collect the blood sample • A client admitted is being evaluated for an intestinal obstruction. The HCP prescribes an NG tube to be inserted and placed to intermittent low wall suction. The nurse should insert the tube w client’s head tilted back • A young female client w 7 children is having frequent morning headaches, dizziness, and blurred vision. Her BP is 168/104….After administering a STAT dose of an anti hypertensive IV meds, the nurse should use an automated BP machine to monitor • The wife of a client w Parkinson’s disease expresses concern bc her husband has lost so much weight. the nurse should invite friends over regularly to share in meals • A client who was discharged 8 mos ago w cirrhosis and ascites is admitted w anorexia and recent hemoptysis. The client is drowsy but responds to verbal stimuli. The nurse programs a BP monitor to take readings every 15 minutes. the nurse should palpate abdomen for tenderness and rigidity • A client recovering from abdominal surgery conducted a day ago is complain of shortness of breath. Assessment reveals diminished breath sounds, dullness over part of the right lung field, and an O2 sat of 89%. What should the nurse suspect is occurring w this client? ◦ Atelectasis ‣ Atelectasis (collapse) of the alveoli, is a common complication following thoracic and abdominal surgery. General anesthesia and surgical manipulation can cause the diaphragm dysfunction and reduce surfactant activity. Post-op superficial breathing (due to postprocedure abdominal pain) may further enhance hypo ventilation and collapse of the alveoli. (Your best Grade) ‣ Pg 531 “Atelectasis is a lung condition characterized by collapsed, airless alveoli. There may be decreased or absent breath sounds and dullness to percussion over the affected area. The most common cause of atelectasis is obstruction of the small airways w secretions. This is common in bedridden patients and in postop abdominal and chest surgery patients.” • For which lab data should the nurse immediately contact the health care provider? ◦ Brain natriuretic peptide level of 1800 mcg/ in a client w lower extremity edema. ‣ The BNP level measures neurohormone secretion in the cardiac ventricles and increases in response to increased volume and fluid overload. The normal level is less than 100 mcg/ml. • 1 60-yo male is brought to the ED w a sudden onset of severe “tearing” chest pain. Upon auscultation, an early diastolic decrescendo murmur is heard. BP is measured on both arms and shows a 30 mmHG difference between L and R arms. ECG recording shows ST a elevation in the anterio-lateral leads. What should the nurse do first to assist the client? ◦ Prepare for emergency surgery ‣ The client is demonstrating classical signs of aortic dissection (acute onset severe chest pain w a tearing character, inter-arm blood pressure difference >20 mmGH, early diastolic decrescendo murmur). • What dietary recommendation should the nurse make to a client who is hospitalized and recovering from a severe exacerbation of COPD? ◦ Increase intake of Iron ‣ Exacerbations of COPD are typically treated w high doses of prednisone. Prednisone impacts nutritional status in several ways. It is known to decrease the absorption of calcium and phosphate from the small intestine, resulting in bone disease. To replenish the losses, the nurse should recommend the client to increase the intake of calcium • Cushing’s Triad ◦ Irregular breathing ◦ Widened pulse pressure (hypertension) ◦ Bradycardia ‣Indicates a loss of compensatory mechanisms within the brain stem • What lab value is most important before doing a guaiac occult test? ◦ Platelet count