Borough of Manhattan Community College: hesi medsurg ,100% CORRECT

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The nurse is planning care for a client who is receiving medications and IV fluids for metabolic alkalosis. Which statement is most important for the nurse to include in the part of care? a. Provid... e the client with a walker b. Maintain IV fluids with supplemental electrolytes at the prescribed rate c. Insert a NG tube and apply intermittent low suction d. Encourage the client to rise slowly from a sitting or standing position. While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizure stops. Which intervention should the nurse implement first? a. Document details of the seizure activity b. Observe for lacerations to the tongue c. Observe for prolonged period of apnea d. Evaluate for evidence of incontinence The nurse prepares a teaching plan for an adult client with metabolic syndrome. Which findings should the nurse address to help the client reduce the risk for diabetes mellitus and vascular disease. (Select all that apply) a. Hypothyroidism b. Blood pressure of 150/96 mmHg c. Elevated high density lipoproteins d. Abdominal obesity e. Increased triglyceride levels f. Hyperglycemia After several days of coughing and taking acetaminophen to treat temperatures of 101 degree Fahrenheit, a client with diabetes mellitus (DM) is admitted to the hospital with an upper respiratory infection. Several hours after admission, the client reports having a severe headache and feeling dizzy. Which intervention should be should the nurse implement first? A. Administer an antipyretic B. Obtain a fingerstick glucose C. Reassess vital signs D. Obtain sputum, for culture After 3 days of persistent epigastric pain, a female client presents to the clinic. She has been taking oral antacids without relief. Her vital signs are heart rate 122 beats/minute. Respirations 16 breaths/minute, oxygen saturation 96%, and blood pressure 116/70 mmhm. The nurse obtains a 12-lead electrocardiogram (egg). Which assessment finding is most critical? a. Complaint of radiating jaw pain b. Bile colored emesis c. Irregular pulse rate d. ST elevation in three leads A female client who recently married returns to the clinic with recurrent cystitis and urethritis. The client presents with pain on urinating, urinary frequency and urgency. Which additional information should the nurse obtain? a. Review a recent urinalysis for calcium oxalate precipitants. b. Ask if she has recently had a streptococcus infection. c. Examine client’s history of any genetic renal disease. d. Inquire about her hygiene practices and sexual intercourse. A client is admitted with a deep and productive cough, hemoptysis, and a low-grade fever. The client’s Mantoux skin test has a 15 mm induration. Which intervention should the nurse implement first? A. Administer the initial dose of rifampin and isoniazid. B. Collect a sputum specimen for acid fast bacillus. C. Provide a mask for the client to wear in public areas. D. Initiate airborne particulate isolation precautions. A client receiving combination chemotherapy for treatment of metastatic carcinoma. When monitoring the client for systemic side effects, which finding warrants intervention by the nurse? a. Ascites b. Nystagmus c. Polycythemia d. Leukopenia The nurse is taking a client’s blood pressure and observes carpal spasms after the sphygmomanometer cuff is inflated. Which actions should the nurse experiment first? A. Assess the client’s recent serum calcium level B. Prepare to seizure precautions C. Administer a prescribed PRN antianxiety agent D. Notify the healthcare provider of the findings An older male client tells the nurse that he is losing his sleep because he has to get up several times at night to go to the bathroom, that he has trouble starting his urinary stream and he does not feel like his bladder is completely empty. Which intervention should the nurse implement? a. Review the client’s fluid intake prior to bedtime b. Collect a urine specimen for culture analysis c. Palpate the bladder above the symphysis pubis d. Obtain a fingerstick blood glucose level A male client with acute abdominal pain, persistent nausea and projectile vomiting is admitted to the hospital for observation. Acetaminophen is administered as prescribed for his oral temperature of 103 degree fahrenheit and an effusion of normal saline is initiated at 250 ml/hr. Which assessment finding should the nurse report to the healthcare provider immediately? A. Dark green colored emesis B. Petechial hemorrhage under client’s eyes C. Right lower abdomen rebound tenderness D. Severe headache with photosensitivity The nurse is developing a plan of care for an adult client with cardiovascular disease who reports blurred vision. Which outcome should the nurse plan of care for this client? a. The client’s daily blood pressure will be less than 140/80 mmhg this month b. The client’s blood pressure readings will be less than 160/90 mmhg c. The nurse will encourage the client to walk thirty minutes every day d. The client will take unto 4 nitroglycerine tablets sublingually for chest pain An older client who is agitated, dyspneic, and using accessory muscles to breathe is admitted for further treatment. Initial assessment included a heart rate 128 beats/min and irregular, respirations 38 breaths/minute, blood pressure 168/100 mmhg, wheezes and crackles in all lung fields. An hour after the administration of furosemide 60 mg IV. Which assessment should the nurse obtain to determine the client’s response to the treatment? (SATA) a. Urinary output b. Pain scale c. Oxygen saturation d. Skin elasticity e. Lung sounds Following a lumbar puncture, a client voices several concerns. Which concern indicates to the nurse that the client is experiencing a complication of the procedure? a. I have a headache that gets worse when I sit up b. My throat hurts badly when I swallow and when I talk c. I am having pain in my lower back when I move my legs d. I feel sick to my stomach and am going to throw up The nurse is assessing a group of older adults. Which factor in a client’s history places the client at greatest risk for developing colon cancer? a. Is excessively exposed to sunlight b. Has intestinal polyps c. Smokes cigar d. Eats high-fat diet A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehiscences and eviscerates. The nurse moistens and available sterile dressing and places it over the wound. Which intervention should the nurse implement first? a. Prepare the client to return to the operating room b. Auscultate the abdomen for bowel sound activity c. Bring additional sterile dressing supplies to the room d. Obtain a sample of the drainage to send to the lab [Show More]

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