FrmRN2u
Medical –Surgical (Adult Health) Exit HESI
Client developed syndrome of inappropriate antidiuretic hormone (SIADH) assoc with small cell CA of
lung and preparing for DC. When teaching about self-management with demeclocycline (declomycin),
instruct to report what?
Muscle cramping
Determining the client position for insertion of indwelling catheter, Most important?
Orthopnea
Nurse teaching male with multiple sclerosis (MS) how to empty bladder using creude method. When
performing return demonstration pt applies pressure to the umbilical area of his abdomen. What
instruction?
Apply downward manual pressure at the suprapubic region
35 yr old female client admitted to post anesthesia recovery unit following a partial thyroidectomy. What
statement reflects accurate understanding of expected outcome for client?
Supplemental hormone therapy will probably be necessary
Following insertion of a LeVeen shunt in client with cirrhosis, which assessment finding indicates the
shunt is effective?
Decreased abdominal girth
Finding a client sitting on the floor, nurse calls for help from UAP. Which task can ask to do?
Get a BP cuff
Client diagnosed with frontal lobe Glioma, benign tumor. Teaching about tumor what information?
Personality changes or expressive aphasia are likely
Greatest benefit for the client with which problem related to DM to change from the use of insulin
syringes to using an insulin pen for med administration?
Diminished dexterity due to dinger paresthesias
Nurse evaluating asthmatic client’s response to an inhaled corticosteroid med. What assess finding
indicates the med has been effective in controlling asthma symptoms.
Increased peak flow meter rates
Planning care for client with diagnosis of “impaired mobility” nurse instructs the UAP to assist client
with ambulation. HCP has prescription for bed rest. Action
Change the planned interventions to include range of motion exercises rather than ambulation
Nurse is preparing DC client from hosp who has aphasia secondary to CVA. What instruction to family to
help communicate?
Be consistent in using the same words each time a Q is asked
When assessing a restless, intubated client on mechanical ventilation, nurse auscultates breath sounds on
right side only. Action
Reposition the depth of the ET tube
, FrmRN2u
Nurse is assessing a client following a thoracotomy and left lung pneumonectomy. What assess finding
anticipate?
Absent breath sounds on the left side of the chest
Male client with type 1 DM takes a combination of short-acting and intermediate-acting insulin. Client
complains of headache when awakening, blood glucose average for the past week has been 210ng/dl.
Nurse recognizes client is experiencing a daily or rebound effect. Which dosing method
Move the PM intermediate-acting dose to bedtime
Which condition would likely cause secondary polycythemia
High altitude exposure
Nurse caring for 42 year old male excreting less sodium than consuming. If continues, what
complication?
Edema
What instruction is most important for the nurse to provide a client with neutropenia
Avoid sources of potential infection
Client with acute laryngitis reports feeling “SOB”. Nurse assesses RR and it has increased from 16 to 28.
What intervention?
Assess for stridor and increased respiratory effort
When caring for client who had craniotomy yesterday for removal of pituitary tumor, which finding
indicates further info is needed?
UO for 8 hrs is 2000 ml with specific gravity of 1.001
Nursing action has highest priority in preventing post-op bleeding following a sub-mucosal resection for
deviated septum?
Maintain intact nasal packing
Female client chooses prophylactic mastectomy for positive BRCA1, mother died of breast CA at age 30,
cousin diagnosed at age 28. Intervention
Ensure adequate pain control using postoperative analgesics
Client with pneumonia admitted with severe SOB, ABGs pH 7.30, PaO2 60, PaCO2 62, HCO3 35.
Which needs immediate communication to HCP?
Drowsiness and diff in arousing
Nurse is caring for client with acute renal failure who complains of SOB, weakness, headache, and
swelling of lower legs and feet. Intervention
Elevate the HOB at least 45 degrees
Client with acute low back pain reports pain radiating down buttocks to below knee. Initial nursing
actions?
This pain is along the path of the sciatic nerve
Medical –Surgical (Adult Health) Exit HESI
Client developed syndrome of inappropriate antidiuretic hormone (SIADH) assoc with small cell CA of
lung and preparing for DC. When teaching about self-management with demeclocycline (declomycin),
instruct to report what?
Muscle cramping
Determining the client position for insertion of indwelling catheter, Most important?
Orthopnea
Nurse teaching male with multiple sclerosis (MS) how to empty bladder using creude method. When
performing return demonstration pt applies pressure to the umbilical area of his abdomen. What
instruction?
Apply downward manual pressure at the suprapubic region
35 yr old female client admitted to post anesthesia recovery unit following a partial thyroidectomy. What
statement reflects accurate understanding of expected outcome for client?
Supplemental hormone therapy will probably be necessary
Following insertion of a LeVeen shunt in client with cirrhosis, which assessment finding indicates the
shunt is effective?
Decreased abdominal girth
Finding a client sitting on the floor, nurse calls for help from UAP. Which task can ask to do?
Get a BP cuff
Client diagnosed with frontal lobe Glioma, benign tumor. Teaching about tumor what information?
Personality changes or expressive aphasia are likely
Greatest benefit for the client with which problem related to DM to change from the use of insulin
syringes to using an insulin pen for med administration?
Diminished dexterity due to dinger paresthesias
Nurse evaluating asthmatic client’s response to an inhaled corticosteroid med. What assess finding
indicates the med has been effective in controlling asthma symptoms.
Increased peak flow meter rates
Planning care for client with diagnosis of “impaired mobility” nurse instructs the UAP to assist client
with ambulation. HCP has prescription for bed rest. Action
Change the planned interventions to include range of motion exercises rather than ambulation
Nurse is preparing DC client from hosp who has aphasia secondary to CVA. What instruction to family to
help communicate?
Be consistent in using the same words each time a Q is asked
When assessing a restless, intubated client on mechanical ventilation, nurse auscultates breath sounds on
right side only. Action
Reposition the depth of the ET tube
, FrmRN2u
Nurse is assessing a client following a thoracotomy and left lung pneumonectomy. What assess finding
anticipate?
Absent breath sounds on the left side of the chest
Male client with type 1 DM takes a combination of short-acting and intermediate-acting insulin. Client
complains of headache when awakening, blood glucose average for the past week has been 210ng/dl.
Nurse recognizes client is experiencing a daily or rebound effect. Which dosing method
Move the PM intermediate-acting dose to bedtime
Which condition would likely cause secondary polycythemia
High altitude exposure
Nurse caring for 42 year old male excreting less sodium than consuming. If continues, what
complication?
Edema
What instruction is most important for the nurse to provide a client with neutropenia
Avoid sources of potential infection
Client with acute laryngitis reports feeling “SOB”. Nurse assesses RR and it has increased from 16 to 28.
What intervention?
Assess for stridor and increased respiratory effort
When caring for client who had craniotomy yesterday for removal of pituitary tumor, which finding
indicates further info is needed?
UO for 8 hrs is 2000 ml with specific gravity of 1.001
Nursing action has highest priority in preventing post-op bleeding following a sub-mucosal resection for
deviated septum?
Maintain intact nasal packing
Female client chooses prophylactic mastectomy for positive BRCA1, mother died of breast CA at age 30,
cousin diagnosed at age 28. Intervention
Ensure adequate pain control using postoperative analgesics
Client with pneumonia admitted with severe SOB, ABGs pH 7.30, PaO2 60, PaCO2 62, HCO3 35.
Which needs immediate communication to HCP?
Drowsiness and diff in arousing
Nurse is caring for client with acute renal failure who complains of SOB, weakness, headache, and
swelling of lower legs and feet. Intervention
Elevate the HOB at least 45 degrees
Client with acute low back pain reports pain radiating down buttocks to below knee. Initial nursing
actions?
This pain is along the path of the sciatic nerve
