Hessi: Re-Take (Med Surge)

1. A female client with possible acute renal failure (ARF) is admitted to the hospital

and mannitol (Osmitrol) is prescribed as a fluid challenge. Prior to carrying out

this prescription, what intervention should the nurse implement?

• No specific nursing action is required

• Instruct the client to empty the bladder

• Collect a clean catch urine specimen

• Obtain vital signs and breath sounds

2. The nurse positions a male client for a lumbar puncture by placing him in the

side-lying position with his knees flexed and pulled toward his trunk. What action

should the nurse implement next?

• Call another nurse to assist the healthcare provider

• Provide a small pillow for the client to curl around

• Instruct the client to perform a Valsalva maneuver

• Support the client’s head bent forward to the chest

3. When teaching a client with osteoporosis to increase weight-bearing exercise,

how should the nurse explain the purpose of this activity?

• Strengthen leg muscles

• Promote venous return

• Increase bone strength

• Restore range of motion

4. A male tells the clinic nurse that he is experiencing burning on urination, and

assessment that he had sexual intercourse four days ago with a woman he casually

met. Which action should the nurse implement?

• Observe the perineal area for a chancroid-like lesion

• Obtain a specimen of urethral drainage for culture

• Identify all sexual partners in the last four days

• Assess for perineal itching, erythemia, and excoriation

5. An older female client with long term type 2 diabetes mellitus (DM) is seen in the

doctor routine health assessment. To determine if the client is experiencing any

long-term complications of DM, which assessments should the nurse obtain?

Select all that apply:

• Visual acuity

• Serum creatinine and blood urea nitrogen (BUN)

• Signs of respiratory tract infection

• Sensation in feet and legs

• Skin condition of lower extremities

6. Which laboratory test result is most important for the nurse to report to the

surgeon prior to a client’s scheduled abdominal surgery?

• Potassium level of 4 mEq/liter

• Blood glucose of 90 mg/dl

• Serum creatinine of 5 mg/dl

• Hemoglobin level of 13 grams

7. When caring for a client with nephrotic syndrome, which assessment is most

important for the nurse to obtain?

• Level of consciousness

• Bowel sounds

• Vital signs

• Daily weight

8. A client who has a history of long-standing back pain treated with methadone

(Dolophine), is admitted to the surgical unit following urological surgery. What

modifications in the plan of care should the nurse make for this client’s pain

management during the postoperative period?

• Use minimal parenteral opioids for surgical pain, in addition to oral

methadone

• Maintain client’s methadone, and medicate surgical pain based on pain rating

• Consult with surgeon about increasing methadone in lieu of parenteral opioids

• Make no changes in standard pain management for this surgery and hold

Methadone

9. The nurse applies an automatic external defibrillator (AED) to a client who

collapsed in an exam room at a community clinic. What action should the nurse

takes next?

• Determine the defibrillator reading

• Assess the client’s oxygen saturation

• Bring a crash cart to the exam room

• Measure the client’s blood pressure

10. Which change in lab values would indicate to the nurse that treatment for gout is

successful?

• Decreased serum uric acid

• Decreased serum purine