Hesi Med Surg Exam review - Revised Answers for All Questions, Download for a GRADE BOOST.

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.A glucagon emergency kit is prescribed for a client with type 1 diabetes mellitus. When should the nurse instruct the client to take the glucagon? a. after meals to increase endogenous insulin sec... retion b. after insulin administration to prevent hypoglycemia c. when recognized signs of severe hypoglycemia occur d. when unable to eat during sick days 30.A client with hyperthyroidism is being treated with radioactive iodine (I131). Which explanation should be included in preparing this client for this treatment? a. b. explain the need for using lead shields for 2 to 3 weeks after the treatment c. describe the signs of goiter because this is a common side effects of radioactive iodine d. explain that relief of the signs/ symptoms of hyperthyroidism will occur immediately 31.A female client is being treated for tuberculosis with rifampin (rifadin) which statement indicates that further teaching is needed? a. I will take my usual contraceptive for birth control 32.A client is discharged with a prescription for warfarin (Coumadin). What discharge instructions should the nurse emphasize to the client? a. take a multi vitamin supplement daily b. use an astringent for superficial bleeding c. avoid going barefoot especially outside d. include large amounts of spinach in the diet 33.In caring for a client with diabetes insipidus who is receiving an antidiuretic hormone intranasal which serum lab test is most important for the nurse to monitor? a. osmolality b. calcium c. platelets d. glucose TestBankWorld.org describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider 34.After administering dihydroergotamine (Migranal) 1 mg subcutaneously to a client with a severe migraine headache the nurse should explain that relief can be expected within what time frame? a. 2 hours b. 5 minutes c. 1 hour d. 15 minutes 35.A client with hypertension who has been taking labetalol for two weeks, reports a five pound (2.2 kg) weight gain. Which follow up assessment is most important for the nurse to obtain? a. capillary refill b. body temperature c. muscle strength d. breath sounds 36.A male client is receiving pilocarpine hydrochloride (Isopto Carpine) ophthalmic drops for glaucoma. He calls the clinic and ask the nurse why he has difficulty seeing at night. What explanation should the nurse provide? a. The eye drops slow pupil response to accommodate for darkness b. The drops increase the fluid in the eyes and cloud the visual field ( possible answer) c. The drug can cause lens to become more opaque d. The medication causes pupils to dilate which reduces night vision 37.A client who is taking and oral dose of tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline? a. toasted wheat bread and jelly b. cheese and crackers c. cold cereal with skim milk d. fruit flavored yogurt 38.The therapeutic effect of insulin in treating type 1 diabetes mellitus is based on which physiologic action? a. Facilitates transport of glucose into the cell b. Increases intracellular receptor site sensitivity c. Stimulates function of beta cells in the pancreas d. Delays carbohydrates digestion and absorption TestBankWorld.org 39.The health care provider prescribe a medication for an older adult client who is complaining of insomnia. And instructs the client to return in 2 weeks. The nurse should question which prescription? a. Eszoplicone (Lunesta)10 mg orally at bed time b. Zolpidem 10 mg orally at bed time c. Temazepan orally at bed time d. Ramelteon orally at bedtime 40.A male client reports to the nurse that he is experiencing GI distress from high dose of a corticosteroid and is planning to stop taking the medication. In response to the client’s statement what nursing action is most important for the nurse to take? a. Encourage the client to take medication with food to decrease GI distress b. c. Review the clients dosing schedule to ensure he is taking the prescribed amount d. Assess the client for other indication of adverse effects of corticosteroid 41.Fifteen minutes after receiving sulfa athenozole. A male client report a burning sensation over his abdomen chest and groin. Which intervention is most important for the nurse to implement? a. Auscultate lung sounds for wheezing b. Review the clients list if drugs allergies c. Add sulfamethinozole to clients allergies d. Check neurological vital signs 42.Antibiotic resistant organism are a major infection control problems. To help minimize the emergence of resistant bacteria what instruction should the nurse provide to the clients? a. stop taking prescribed antibiotics when symptoms decrease b. avoid using antibiotics when suffering from colds or the flu c. ask the healthcare provider to prescribe the newest antibiotic when needed d. request a prescription for first time vancomysin for a sore throat 43.A client with symptoms of influenza that started the previous day ask the clinic nurse about taking oseltamivir (Tamiflu) to treat the infection. Which response should the nurse provide? TestBankWorld.org Advice the client that the medication should be stopped gradually rather than abruptly. a. Advise the client once symptoms occur is too late to receive an influenza vaccination b. c. Explain to the client that antibiotics are not useful in treating viral infections such as influenza d. Instruct the client that over the counter medications are sufficient to manage influenza symptoms 44.Twenty minutes after the nurse starts a secondary IV infusion of cafepime (maxipime) 2 grams using an infusion pump to deliver the dose in one hour, the client reports feeling nauseated. What action should the nurse implement? a. stop medication infusion and notify the healthcare provider of the adverse effect b. increase the rate of the infusion to complete the dose of the medication more rapidly c. d. reassure the client that the nausea is not related to the iv infusion 45.The nurse administer donepezil hydrochloride (Aricept) to a client with Alzheimer’s disease as an intervention for which client problem? a. fluid volume excess b. disturbed thought processes c. chronic pain d. altered breathing patterns 46.To prevent deep vein thrombosis following knee replacement surgery, an adult male client is receiving enoxaparin (Lovenox) subcutaneously daily. Which laboratory finding requires immediate action by the nurse? a. blood urea nitrogen (BUN) 20mg/dl or 7.1 mmol/L (SI) b. Hematocrit 45% c. Serum creatinine 1.0 mg/dl or 88.4 mol/L (SI) d. Platelet count of 100,000/mm3 or 100x10??/ L (SI) TestBankWorld.org Refer the client to the healthcare provider at the clinic to obtain a medication prescription continue the infusion and administer a prn antiemetic prescription 47.A client with type 2 diabetes mellitus is managed with metformin (Glucophage), an oral hypoglycemic agent. The primary health care provider prescribes ad additional medication injected exenatide (byetta). Which information is most important for the nurse to teach this client? a. Administer subcutaneously after meals b. Consume additional sources of potassium c. Notify the healthcare provider if anorexia occurs d. Watch for signs of jitteriness or diaphoresis ( POSSIBLE ANSWER) 48.A client is who is diagnose with schizophrenia receives a prescription for an atypical antipsychotic drug aripipazole (Abilify). Which assessment should the nurse perform to monitor for an adrenergic receptor antagonist side effect that commonly occurs atypical antipsychotic agents? a. observe the client hallucinatory behaviors b. obtain the client finger stick glucose levels c. measure the clients lying and standing blood pressure d. determine the clients abnormal involuntary movements scale (AIMS) TestBankWorld.org 1- A client with pheocromocytoma reports the onset of a severe headache. The nurse observes that the client is very diaphoretic. Which assessment data should the nurse obtain first? Blood pressure 2- The drainage in the chest tube of a client with emphysema has changed fromclear watery fluid. What action would be best for the nurse to take/ Maintain the current IV antibiotic schedule 3- A client is admitted with a sudden onset of right sided the nurse complete first? Observe for peripheral edema 4- When planning care for a client newly diagnose with open angle glaucoma, the nurse identifies a priority nursing diagnosis of “ Visual sensory/perceptual alterations”. This diagnosis is based on which etiology? Decreased peripheral vision 5- A client in the operating room received succinylcholine. The client is experiencing muscle rigidity and has an extremely high temperature. What action should the nurse implement? Call the PACU nurse to prepare for prolonged ventilatory support Also know that PACU is BP, Respiration and Pulse 6- A client who is receiving packed red blood cells develops nausea and vomiting. What action should the nurse take first? Stop the infusion of blood Te lo pueden poner como hemodialysis y tambien es STOP transfusion 7- A client with type 2 diabetes mellitus is admitted to the hospital for uncontrolled DM. Insulin therapy is initiated with initial dose of Humulin insulin at 8:00 at 16:00 the client complains of diaphoresis, rapid heart beat, and feeling shaky. What should the nurse do first? Determine the client current glucose level 8- After suctioning the patient with an endotracheal tube, which assessment finding indicates to the nurse that the intervention was effective? Increase in breath sounds 9- The nurse observes an increase number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). What is the best initial nursing action? Provide additional oral fluid intake TestBankWorld.org Also with TURP you must know that 3l of water a day is needed 10- Which nursing diagnosis should be selected for a client who is receiving thrombolytic infusions for treatment of an acute myocardial infarction? Risk for injury related to effects of thrombolysis 11- The nurse is assessing a client who has returned from surgery following a thoracotomy. Which finding indicates the client is experiencing adequate gas exchange? The client demonstrates effective coughing and deep breathing exercises 12- When caring for a client with nephrotic syndrome which assessment is most important for the nurse to obtain? Daily Weight 13- A client who had a biliopancreatic diversion procedure (BOP) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse? Gastroccult positive emesis 14- 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 breathe sounds 15- 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 16- 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 TestBankWorld.org 17- 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 (POSSIBLE ANSWER) • Identify all sexual partners in the last four days • Assess for perineal itching, erythemia, and excoriation 18- 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 19- Which laboratory test result is most important for the nurse to report to thesurgeon 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 (POSSIBLE ANSWER) • Hemoglobin level of 13 grams 20- 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 21- 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 take next? TestBankWorld.org • Determine the defibrillator reading • Assess the client’s oxygen saturation • Bring a crash cart to the exam room • Measure the client’s blood pressure 22- Which change in lab values would indicate to the nurse that treatment for gout is successful? • Decreased serum uric acid • Decreased serum purine • Increased serum uric acid • Increased serum purine 23- The nurse reports that a client is at risk for a brain attack (stroke) finding?• Jugular vein distention • Palpable cervical lymph node • Carotid bruit • Nuchal rigidity 24- The nurse is assessing a group of older adults. What factor in a male client’shistory puts him at greatest risk for developing colon cancer? • Is excessively exposed to sunlight • Eats a high-fat diet • Smokes cigars (POSSIBLE ANSWER) • Has intestinal polyps 25- While taking routine vital signs at 0400 AM, the nurse notes that a client who had a total knee replacement the previous day has a heart rate of 126 beats/minute. What action should the nurse take first? • Compare heart rate trends with blood pressure trends ( POSSIBLE ANSWER) • Review the medical record for a history of cardiac disease • Check surgical drainage system and bandage for bleeding • Determine current pain level using a 10-point scale 26- A client who suffered an electrical injury on the left foot is admitted to the burn include in this client’s plan of care? (incomplete) • Assess lung sounds q4 hours • Perform passive range of motion • Evaluate level of consciousness TestBankWorld.org • Continuous cardiac monitoring 27- The nurse is taking a client’s blood pressure sphygmomanometer cuff is inflated. What (incomplete) • Administer a prescribed PRN antianxiety (POSSIBLE ANSWER) • Assess the client’s recent serum calcium • Notify the healthcare provider of the • Prepare to implement seizure precautions 28- A client with eczema is using an over-the-counter (OTC) topical product with urea 10% OTC (Aqua Care Cream) to the affected skin areas. Which finding reflects the expected therapeutic response? • Decreased weeping of ulcerations in affected area (POSSIBLE ANSWER) • Healing with a return to normal skin appearance • Reduced pain in eczematous areas • Hydration of affected dry skin areas 29- During an annual health check, the clinic nurse updates an adult female’s health history. When discussing the woman’s history of lactose intolerance, the client reports that it has been years since she last consumed dairy products. What dietary suggestions should the nurse recommend to help ensure that the client receives an adequate intake of calcium? Select all that apply: • Increase intake of salmon, sardines, tofu, and leafy green vegetables • Sip a half-cup of mil during a mid-day meal at least every other day • Eat at least six servings of citrus fruits weekly • Include 2 to 3 servings of yellow and green squash weekly • Take a calcium supplement with vitamin D daily 30- A healthcare worker with no known exposure to tuberculosis has received aMantoux tuberculosis skin test. The nurse’s assessment of the test after 72 hours indicates 5mm of erythema without induration. What is the best initial nursing action? • Review client’s history for possible exposure to TB • Instruct the client to return for a repeat test in 1 week • Refer client to a healthcare provider for isoniazid (INH) therapy • Document negative results in the client’s medical record [Show More]

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