EVOLVE ELSEVIER HESI MED SURG EXAM|| ACCURATE AND FREQUENTLY TESTED QUESTIONS AND 100% CORRECT ANSWERS WITH RATIONALES|| LATEST AND COMPLETE UPDATE WITH EXPERT VERIFIED SOLUTIONS|| SURE PASS!!

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EVOLVE ELSEVIER HESI MED SURG EXAM||
ACCURATE AND FREQUENTLY TESTED QUESTIONS
AND 100% CORRECT ANSWERS WITH RATIONALES||
LATEST AND COMPLETE UPDATE WITH EXPERT
VERIFIED SOLUTIONS|| SURE PASS!!
The nurse is providing care to a client admitted to the emergency room with a
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blood glucose level of 40 mg/dL and is semiconscious. What are the nurse's next
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actions? (Select all that apply.)
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-Start an IV of Normal Saline.
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-Obtain a 50% dextrose solution.
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-Administer glucagon as per the standing order. M M M M M M




-Turn the client to the side.
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Rationale:
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Oral carbohydrates, such as sugar and honey, should never be given to the
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semiconscious or unconscious clients with low blood sugar levels, for concern for
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aspiration. Glucagon can be administered immediately, followed by starting an IV.
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Await the orders for the 50% dextrose solution. Place the client in a side lying
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position as there is a risk for vomiting and aspiration with these clients.
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An 81-year-old client has emphysema. The client lives at home with a cat and
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manages self-care with no difficulty. When making a home visit, the nurse notices
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that this client's tongue is somewhat cracked and his eyeballs appear sunken.
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Which nursing action is indicated?
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Help the client determine ways to increase fluid intake.
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Rationale:
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Clients with COPD should ingest 3 L of fluids daily but may experience a fluid
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deficit because of shortness of breath. The nurse should suggest creative methods
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to increase the intake of fluids, such as having fruit juices in disposable containers
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Mreadily available. M




A 58-year-old client who has no health problems asks the nurse about receiving the
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pneumococcal vaccine. Which statement given by the nurse would offer the client
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accurate information about this vaccine?
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The immunization is administered once to older adults or those at risk for illness.
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Rationale:
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It is usually recommended that persons older than 65 years and those with a history
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Mof chronic illness should receive the vaccine once in their lifetime. Some
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Mrecommend receiving the vaccine at 50 years of age. The influenza vaccine is
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M given once a year. Although the vaccine might be given to a person traveling
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Moverseas, that is not the main rationale for administering the vaccine. The vaccine
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Mis usually given once in a lifetime, but with immunosuppressed clients or clients
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Mwith a history of pneumonia, revaccination is sometimes required.
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The clinic nurse is teaching a client with osteoarthritis to the knees bilaterally
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about self-care. Which teaching points will the nurse include in the client's plan of
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care? (Select all that apply.)
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-Apply heat packs to your knees as needed for pain.
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-Support your knees while you are in bed with a pillow or a rolled towel.
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-Get 7 to 8 hours of sleep every night.
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-Eat a balanced diet, including fish with Omega-3 fatty acids.
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Rationale:
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The maximum daily dose of acetaminophen is 4 g, the instruction includes up to 6
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g/per day. The best type of exercise does not place additional stress on the knee
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joints, such as biking or swimming. Apply heat to increase circulation and ice
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packs to decrease swelling. Support to the knees can take the strain off of the joint.
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Getting rest will help with coping with the pain of the disease. Eating a balanced
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diet may help with weight loss; additional weight places strain on the
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joint.


The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12
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hours after chest tube insertion for hemothorax. What is the best initial action for
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the nurse to take?
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Assess for kinks or dependent loops in the tubing.
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Rationale:
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The least invasive nursing action should be performed first to determine why the
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drainage has diminished.
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During report, the nurse learns that a client with tumor lysis syndrome is receiving
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an IV infusion containing insulin. Which action should the nurse complete first?
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Monitor the client's serum potassium and blood glucose levels.
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Rationale:
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Clients with tumor lysis syndrome may experience hyperkalemia, requiring the
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addition of insulin to the IV solution to reduce the serum potassium level. It is
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most important for the nurse to monitor the client's serum potassium and blood
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glucose levels to ensure that they are not at dangerous levels.
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For the client undergoing hemodialysis, the nurse suspects the client has an air
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embolism. What symptoms lead the nurse to this conclusion? (Select all that
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apply.)
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-Dyspnea

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-Chest pain M




-Anxiety
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Rationale:
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For the client experiencing an air embolism, the nurse will see hypotension and not
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hypertension. The O2 saturation will also fall with an air embolism. The remaining
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are signs of an air embolism.
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A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid
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ventricular response. Based on this finding, the nurse anticipates assisting the
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physician with which treatment?
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Perform synchronized cardioversion. M M




Rationale:
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With uncontrolled atrial fibrillation, the treatment of choice is synchronized
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cardioversion to convert the cardiac rhythm back to normal sinus rhythm.
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The post-operative client states to the nurse, "I hate the feeling of those
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compression stockings as they inflate and deflate all the time. It keeps me awake."
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What is the nurse's best response?
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"Tell me what you know about the intermittent compression stockings."
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Rationale:
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The purpose of the intermittent compression stockings is to decrease the risk of
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blood clots forming in the legs. By assessing the client's knowledge about the
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devise, the nurse can determine if the client is aware of the potential for blood clots
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and the sequela that clots have.
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