EVOLVE MED SURG HESI Reviews Questions and
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Terms in this set (125)
The nurse is concerned about Correct Answer: A,B,C
infection for a client after an
esophagogastrostomy for Rationale:One hour post op is too soon to
esophageal cancer. Which actions ambulate for this client. Visitors help support the
should the nurse include in the patient and are encouraged to visit. Oral care is
client's plan of care? (Select all that necessary as the client will be NPO. To decrease
apply.) the risk of infection post operatively, implement
routine pulmonary exercises. The client will have an
A. Frequent oral care every 2 hours NG tube in place, likely to intermittent suction, to
while awake. decompress the stomach post surgery.
B. Use incentive spirometer every 2
hours.
C. Empty contents from NG tube
every 8 hours.
D. Ambulate within 1 hour of return
from the PACU.
E. Limit visitors until postoperative
day 2.
,The client is return demonstrating Correct Answer: A
wrapping of the left limb amputated Rationale:The waist is the anchor point for the
above the knee. The nurse evaluates bandage for an above the knee amputation.
the client is starting the wrapping
method correctly when the client
places the end of the bandage at
which point?
A.Around the waist
B.At the inner aspect of the left stump
C.At the outer aspect of the left
stump
D.At the left groin area
A nurse is assisting an 82-year-old Correct Answer: B
client with ambulation and is Rationale:Stooped posture results in the upper
concerned that the client may fall. torso becoming the center of gravity for older
Which area contains the older persons. The center of gravity for adults is the hips.
person's center of gravity? However, as a person grows older, a stooped
A. Head and neck posture is common because of changes caused by
B. Upper torso osteoporosis and normal bone degeneration.
C. Bilateral arms Furthermore, the knees, hips, and elbows flex. The
D. Feet and legs head and neck and feet and legs are not the center
of gravity in the older adult. Although the arms
comprise a part of the upper torso, they do not
reflect the best and most complete answer.
,A client with hypertension has been Correct Answer: A
receiving ramipril, 5 mg PO, daily for Rationale:The client's blood pressure is within
2 weeks and is scheduled to receive normal limits, indicating that the ramipril, an
a dose at 0900. At 0830, the client's antihypertensive, is having the desired effect and
blood pressure is 120/70 mm Hg. should be administered. Options B and C would be
Which action should the nurse take? appropriate if the client's blood pressure was
A. Administer the prescribed dose at excessively low (<100 mm Hg systolic) or if the
the scheduled time. client were exhibiting signs of hypotension such as
B. Hold the dose and contact the dizziness. This prescribed dose is within the normal
health care provider. dosage range, as defined by the manufacturer;
C. Hold the dose and recheck the therefore, option D is not necessary
blood pressure in 1 hour.
D. Check the health care provider's
prescription to clarify the dose.
The nurse is providing care for a Correct Answer: A,B
client diagnosed with trigeminal Rationale:Trigeminal neuralgia is characterized by
neuralgia (tic douloureux). Which paroxysms of pain, similar to an electric shock, in
symptoms will the nurse be looking the area innervated by one or more branches of the
for in the focused assessment related trigeminal nerve (cranial V). The remaining
to this condition? (Select all that symptoms are not related to trigeminal neuralgia.
apply.)
A. Facial muscle spasms
B. Sudden facial pain
C. Unilateral facial weakness
D. Difficulty in chewing
E.Tinnitus
F.Hearing difficulties
, In caring for a client with acute Correct Answer: A
diverticulitis, which assessment data
warrants an immediate nursing Rationale: A hard rigid abdomen and elevated
action? WBC is indicative of peritonitis, which is a medical
A. The client has a rigid hard emergency and should be reported to the health
abdomen and elevated WBC. care provider immediately. Options B and C are
B. The client has left lower quadrant expected clinical manifestations of diverticulitis.
pain and an elevated temperature. Option D does not warrant immediate intervention.
C.The client is refusing to eat any of
the meal and is complaining of
nausea.
D. The client has not had a bowel
movement in 2 days and has a soft
abdomen.
The nurse is caring for a client with a Correct Answer: B
fractured right elbow. Which
assessment finding has the highest Rationale:Compartment syndrome is a condition
priority and requires immediate involving increased pressure and constriction of the
intervention? nerves and vessels within an anatomic
A. Ecchymosis over the right elbow compartment, causing pain uncontrolled by
area opioids and neurovascular compromise. Option A is
B. Deep unrelenting pain in the right an expected finding. Option C related to
arm compartment syndrome cannot be seen, and any
C. An edematous right elbow visible edema is an expected finding related to the
D. The presence of crepitus in the injury. Option D is an expected finding.
right elbow
Verified Answers 100 %Correct
Save
Terms in this set (125)
The nurse is concerned about Correct Answer: A,B,C
infection for a client after an
esophagogastrostomy for Rationale:One hour post op is too soon to
esophageal cancer. Which actions ambulate for this client. Visitors help support the
should the nurse include in the patient and are encouraged to visit. Oral care is
client's plan of care? (Select all that necessary as the client will be NPO. To decrease
apply.) the risk of infection post operatively, implement
routine pulmonary exercises. The client will have an
A. Frequent oral care every 2 hours NG tube in place, likely to intermittent suction, to
while awake. decompress the stomach post surgery.
B. Use incentive spirometer every 2
hours.
C. Empty contents from NG tube
every 8 hours.
D. Ambulate within 1 hour of return
from the PACU.
E. Limit visitors until postoperative
day 2.
,The client is return demonstrating Correct Answer: A
wrapping of the left limb amputated Rationale:The waist is the anchor point for the
above the knee. The nurse evaluates bandage for an above the knee amputation.
the client is starting the wrapping
method correctly when the client
places the end of the bandage at
which point?
A.Around the waist
B.At the inner aspect of the left stump
C.At the outer aspect of the left
stump
D.At the left groin area
A nurse is assisting an 82-year-old Correct Answer: B
client with ambulation and is Rationale:Stooped posture results in the upper
concerned that the client may fall. torso becoming the center of gravity for older
Which area contains the older persons. The center of gravity for adults is the hips.
person's center of gravity? However, as a person grows older, a stooped
A. Head and neck posture is common because of changes caused by
B. Upper torso osteoporosis and normal bone degeneration.
C. Bilateral arms Furthermore, the knees, hips, and elbows flex. The
D. Feet and legs head and neck and feet and legs are not the center
of gravity in the older adult. Although the arms
comprise a part of the upper torso, they do not
reflect the best and most complete answer.
,A client with hypertension has been Correct Answer: A
receiving ramipril, 5 mg PO, daily for Rationale:The client's blood pressure is within
2 weeks and is scheduled to receive normal limits, indicating that the ramipril, an
a dose at 0900. At 0830, the client's antihypertensive, is having the desired effect and
blood pressure is 120/70 mm Hg. should be administered. Options B and C would be
Which action should the nurse take? appropriate if the client's blood pressure was
A. Administer the prescribed dose at excessively low (<100 mm Hg systolic) or if the
the scheduled time. client were exhibiting signs of hypotension such as
B. Hold the dose and contact the dizziness. This prescribed dose is within the normal
health care provider. dosage range, as defined by the manufacturer;
C. Hold the dose and recheck the therefore, option D is not necessary
blood pressure in 1 hour.
D. Check the health care provider's
prescription to clarify the dose.
The nurse is providing care for a Correct Answer: A,B
client diagnosed with trigeminal Rationale:Trigeminal neuralgia is characterized by
neuralgia (tic douloureux). Which paroxysms of pain, similar to an electric shock, in
symptoms will the nurse be looking the area innervated by one or more branches of the
for in the focused assessment related trigeminal nerve (cranial V). The remaining
to this condition? (Select all that symptoms are not related to trigeminal neuralgia.
apply.)
A. Facial muscle spasms
B. Sudden facial pain
C. Unilateral facial weakness
D. Difficulty in chewing
E.Tinnitus
F.Hearing difficulties
, In caring for a client with acute Correct Answer: A
diverticulitis, which assessment data
warrants an immediate nursing Rationale: A hard rigid abdomen and elevated
action? WBC is indicative of peritonitis, which is a medical
A. The client has a rigid hard emergency and should be reported to the health
abdomen and elevated WBC. care provider immediately. Options B and C are
B. The client has left lower quadrant expected clinical manifestations of diverticulitis.
pain and an elevated temperature. Option D does not warrant immediate intervention.
C.The client is refusing to eat any of
the meal and is complaining of
nausea.
D. The client has not had a bowel
movement in 2 days and has a soft
abdomen.
The nurse is caring for a client with a Correct Answer: B
fractured right elbow. Which
assessment finding has the highest Rationale:Compartment syndrome is a condition
priority and requires immediate involving increased pressure and constriction of the
intervention? nerves and vessels within an anatomic
A. Ecchymosis over the right elbow compartment, causing pain uncontrolled by
area opioids and neurovascular compromise. Option A is
B. Deep unrelenting pain in the right an expected finding. Option C related to
arm compartment syndrome cannot be seen, and any
C. An edematous right elbow visible edema is an expected finding related to the
D. The presence of crepitus in the injury. Option D is an expected finding.
right elbow
