BSN 266 HESI Med Surg Exam (New 2026/ 2027 Update) Questions and Verified Answers|100% Correct| Graded A- Nightingale

BSN 266 HESI Med Surg Exam (New 2026/ 2027 Update) Questions and Verified Answers|100% Correct| Graded A- Nightingale Q. Pleurodesis ANSWER A procedure aimed at preventing the formation of a pleural effusion by causing the pleural spaces to seal together. Q. Radiation therapy consequences ANSWER Chronic esophagitis with gastroesophageal reflux is a potential consequence of radiation therapy for breast cancer. Q. Pathologic fracture ANSWER Fractures that occur without evidence of trauma, often due to loss of bone density from radiation damage. Q. Sexual activity after myocardial infarction ANSWER Sexual intercourse after an MI requires no more energy expenditure or cardiac stress than walking briskly up two flights of stairs. Q. Percutaneous endoscopic gastrostomy (PEG) tube ANSWER A type of feeding tube that differs from a gastrostomy tube primarily in the method of insertion. Q. PEG tube ANSWER A tube inserted endoscopically through the esophagus into the stomach, held in place by a bumper and a water-filled balloon. Q. Proctosigmoidoscopy preparation ANSWER Includes obtaining consent, a clear-liquid diet for 24 to 48 hours prior, administration of an enema, and fasting on the morning of the procedure. Q. Dysuria in diabetes ANSWER Elevated fingerstick glucose levels (e.g., 300 mg/dl) need to be reported to adjust the care plan. Q. Right renal calculi nursing diagnosis priority ANSWER Acute pain related to movement of the stone. Q. Chemotherapy initiation ANSWER Starting chemotherapy early increases the chance of eradicating cancer cells, as 50% of tumor cells are killed with each dose. Q. Asterixis ANSWER A clinical sign of liver disease characterized by a flapping tremor of the hands. Q. Clear-liquid diet ANSWER A diet consisting of clear fluids, often required 24 to 48 hours before certain medical procedures. Q. Enema ANSWER A procedure to introduce liquid into the rectum to stimulate a bowel movement or cleanse the bowel before a procedure. Q. Fasting protocol ANSWER Refraining from all food and drink for a specified period, often required before medical procedures. Q. Suprapubic pain ANSWER Pain located in the lower abdomen, often associated with urinary issues. Q. Bounding pulse ANSWER A pulse that feels strong and full, often measured at 100 beats/minute in this context. Q. Small vesicular perineal lesions ANSWER Fluid-filled blisters in the perineal area, which may indicate an infection or other medical condition. Q. Acute pain ANSWER Severe discomfort that arises suddenly, often related to conditions like renal calculi. Q. Impaired urinary elimination ANSWER Difficulty in passing urine, often due to obstruction. Q. Risk for infection ANSWER Increased likelihood of developing an infection, often due to conditions like urinary stasis. Q. Deficient knowledge ANSWER A lack of understanding or information regarding a specific health condition or its management. Q. Collateral circulation ANSWER Alternative pathways of blood flow that develop as a response to blockage or narrowing of blood vessels. Q. Cell cycle rate ANSWER The speed at which a cell progresses through the phases of growth and division, impacting its sensitivity to chemotherapy. Q. Tumor cell count reduction ANSWER The process by which chemotherapy reduces the number of cancer cells, with each dose killing approximately 50%. Q. Asterixis ANSWER A hand-flapping tremor that is often seen frequently in hepatic encephalopathy, induced by extending the arm and dorsiflexing the wrist. Q. Postoperative Observation ANSWER The observation of a pulse change from 85 to 160 beats/minute lasting more than 10 minutes should alert the nurse to call the Rapid Response Team (RRT). Q. Rapid Response Team (RRT) ANSWER A team called to intervene for a client with an acute life-threatening change. Q. Valsalva Maneuver ANSWER Straining with bowel movements while holding one's breath, which increases intracerebral pressure (ICP) and may induce bleeding or rupture of cerebral blood vessels. Q. HIV Post-Test Counseling ANSWER Encouraging retesting supports hope and gives the client time to cope with the diagnosis. Q. Safety Checklist for Surgery ANSWER Items such as nail polish, contact lenses, and partial dentures should be removed to provide accurate pulse oximetry readings and prevent damage during surgery. Q. Nail Polish Removal ANSWER Removal provides a more accurate pulse oximetry reading and evaluation of capillary refill. Q. Monitoring for Battle's Sign ANSWER A nursing action that should be included in the plan of care for a client admitted with a hemorrhagic stroke. Q. Active Range of Motion ANSWER Performing active range of motion three times daily is a nursing action for post-stroke care. Q. Temperature and WBC Count ANSWER A temperature of 103.1 F and a white blood cell (WBC) count of 16,000 mm3 are significant observations postoperatively. Q. Surgical Wound Dressing ANSWER Fresh bleeding noted on abdominal surgical wound dressing is a concerning observation for a postoperative client. Q. Diaphoresis and Weakness ANSWER Weakness, diaphoresis, and complaints of feeling faint with BP 100/56 mm Hg are signs that may indicate a need for urgent care. Q. Dorsiflexing the Wrist ANSWER A movement that induces asterixis when attempting to hold the position. Q. Client's Arm Position for Asterixis Test ANSWER The client should extend the arm, dorsiflex the wrist, and extend the fingers. Q. Orthopedic Surgery Preparation ANSWER Completing a safety checklist before transport to the operating room is essential. Q. Hearing Aid Removal ANSWER Hearing aids should be removed to prevent damage, loss, or misplacement during surgery. Q. Wedding Band Removal ANSWER Wedding bands should be removed to prevent injury during surgery. Left Leg Brace Removal Left leg braces should be removed as part of the safety checklist before surgery. Contact Lenses Removal Contact lenses should be removed to prevent damage or loss during surgery. Partial Dentures Removal Partial dentures should be removed to prevent damage or loss during surgery. Tachycardia A pulse change resulting in tachycardia for a prolonged time in a post-operative client is a critical observation. Postoperative Client Monitoring Monitoring for significant changes in vital signs is crucial for postoperative care. Client Education on HIV Informing the client how to protect sexual and needle-sharing partners is essential during post-test counseling. Self-catheterization technique Catheterize every 3 to 4 hours. Sterile technique Although sterile technique is indicated in healthcare facilities, clean technique is often followed by the client when performing self-catheterization at home. Fungal infection (candidiasis) Good handwashing is all that is needed to prevent nosocomial spread. Wheezing in asthma If the client is successfully responding to bronchodilators and respiratory treatments, wheezing should become louder as the air flow increases in the airways. PEG tube feeding protocols Keeping the head of the bed elevated 30 degrees, changing the enteral-feeding bag every 24 hours, checking the placement of the tube by means of gastric aspiration, and flushing the tube with 50 ml of normal saline solution after each feeding are interventions used to provide care of the client with a PEG tube. Assessment of residual amounts Residual amounts should be assessed each time, prior to each feeding. Residual amounts Should be assessed each time, prior to each feeding. Hospice care Provides symptom management and pain control during the dying process and enhances the quality of life for a client who is terminally ill. Hospice practical nurse (PN) Administers medications for pain relief, shortness of breath, and nausea. Sperm count and smoking Smoking can decrease the quantity and quality of sperm. Cessation of smoking Improves general health and fertility. Sperm specimen collection Sperm specimens should be collected in 2 subsequent days. Radiation therapy side effects Dry, itchy skin changes may occur, along with the possibility of long bone pain and permanent pigment changes to the breast. Low-residue diet May be ordered to reduce the likelihood of diarrhea. Mycobacterium avium complex (MAC) An opportunistic infection that presents as a tuberculosis-like pulmonary process. Desired outcome for MAC client Return to pre-illness weight using oral, enteral, or parenteral supplementation as needed. Secondary syphilis precautions Gloves should be worn during direct contact with the client's skin. Infection control Handwashing is required before and after contact with the client. Client education on breast cancer treatment Important to include information on potential dry, itchy skin changes. Pain management in hospice Administering medication and monitoring for therapeutic and adverse effects is within the scope of practice for the PN. Client behaviors and symptoms Clarifying family members' feelings about the meaning of client behaviors and symptoms is a nursing activity. Plan of care development Developing a plan of care after assessing the needs of the client and family is a nursing responsibility. Signs of client discomfort Teach the family to recognize restlessness and grimacing as signs of client discomfort. Semen analysis The first semen analysis should be repeated to confirm sperm counts. Therapeutic effects monitoring Monitoring for therapeutic and adverse effects is essential in hospice care. Quality of life in terminal illness Hospice care enhances the quality of life for a client who is terminally ill. Skin changes from radiation Side effects from radiation to the breast most often include temporary skin changes such as dryness, tenderness, redness, swelling, and pruritis. Opportunistic infections MAC is a major contributing factor to the development of wasting syndrome. Secondary stage of syphilis A systemic blood-borne disease that presents with skin lesions and rashes that may drain the highly contagious spirochete. Contact precautions Precautions that should be taken to prevent the spread of infections through direct contact with the client's skin. Glaucoma A condition that increases intraocular pressure, which can be exacerbated by certain over-the-counter medications. OTC medications Over-the-counter medications that may contain ephedrine, phenylephrine, or pseudoephedrine, which can cause adrenergic side effects. Transcutaneous electrical nerve stimulation (TENS) unit A device used for chronic pain relief that requires evaluation of the client's ability to control pain by adjusting the voltage. Cerebral spinal fluid Fluid that should be evaluated in nasal discharge following a head injury to determine if there is a tear in the dura. Premenstrual syndrome A condition characterized by symptoms such as heart palpitations, sleeplessness, increased appetite, and food cravings. Heart palpitations A symptom that can be characteristic of premenstrual syndrome. Hypersomnia Excessive sleepiness that can be a symptom associated with premenstrual syndrome. Stress incontinence A symptom that may be experienced by individuals with premenstrual syndrome. Anorexia A lack of appetite that can be associated with premenstrual syndrome. PET scan A diagnostic imaging technique commonly used with oncology clients to provide information about inflammation, infection, and tumors. Serosanguineous nasal drainage A finding that should be assessed further after a head injury to check for the presence of cerebral spinal fluid. Pain rating scale A tool used to determine the client's level of discomfort. Facial expressions for pain Observations that can indicate a client's level of discomfort. Intraocular pressure The pressure within the eye, which can be increased by certain medications. Adrenergic side effects Side effects caused by medications that stimulate the adrenergic receptors, potentially leading to increased heart rate and blood pressure. Oliguria A condition of reduced urine output that can be a characteristic feature of premenstrual syndrome. Enuresis Involuntary urination that can occur as a symptom of premenstrual syndrome. Dizziness A symptom that may accompany nausea and transient confusion after a head injury. Nausea A feeling of sickness with an inclination to vomit, which can be a symptom after a head injury. Transient confusion A temporary state of confusion that may occur following a head injury. Scalp laceration An injury that may ooze blood and should be assessed in the context of a head injury. Imaging of tumors Imaging of tumors without exposure to radiation. Metastatic sites of cancer An image that describes metastatic sites of cancer. PET scans PET scans provide information regarding certain diseases of the heart, brain, and early detection of tumors and their metastasis. Thyroid-stimulating hormone (TSH) TSH influences the amount of thyroxine secretion which increases the rate of metabolism to maintain body temperature near normal. Eutectic mixture of lidocaine and prilocaine (EMLA) A topical anesthetic cream that should be applied to the puncture site at least 60 minutes to 2 hours before the insertion of an IV catheter. Manual bag-valve-mask resuscitator A device used to maintain respirations for a client on a ventilator while being moved away from the oxygen wall outlet and fire source. Lovastatin (Mevacor) A prescription medication used to lower both LDL-C and triglyceride levels, with a potential side effect of rhabdomyolysis manifested by severe muscle pain. Rhabdomyolysis A potential, serious side effect of statin therapy that is manifested by severe muscle pain and aching. Normal urinalysis parameters for older adults Findings that are within the expected parameters of a normal urinalysis for an older adult. Body mass index (BMI) A measurement that may be assessed in relation to elevated TSH levels. Skin elasticity and turgor An assessment that may be made in relation to elevated TSH levels. Thought processes and speech An assessment that may be made in relation to elevated TSH levels. Exposure to cold environmental temperatures A condition that stimulates the hypothalamus to secrete thyrotropin-releasing hormone, increasing TSH release. Topical anesthetic application The action of applying a liberal amount of cream into the skin thoroughly to maximize therapeutic effect. Gauze dressing A covering that may be used after applying topical anesthetic cream. Therapeutic effect of EMLA Maximized by leaving the cream on the skin for 1 to 2 hours before the procedure. Emergency protocol for ventilator clients The priority nursing action while caring for a client on a ventilator during an electrical fire. Severe muscle pain A symptom that should be reported to the healthcare provider immediately when on lovastatin. Visual disturbances A symptom that may be associated with statin therapy but is not the priority to report. Terrible nightmares A symptom that is not directly related to the use of lovastatin. Increased nocturia A symptom that is not directly related to the use of lovastatin. pH 6 An expected finding in a normal urinalysis for an older adult. Nitrate small. Protein small. Sugar negative. Bilirubin negative. Specific gravity 1.015. Normal pH range for urine A pH of 6.0. Normal range of urine specific gravity 1.001 to 1.035. Chronic infection of Hepatitis C virus (HCV) Scheduled for a liver biopsy. Post-liver biopsy intervention Assess for signs of bleeding and hypovolemia. Risk after liver biopsy Internal bleeding. Best-qualified nurse for discharge instructions The registered nurse (RN) case manager for the unit with 1 year's experience. Nurse's action after PTCA with chest pain Administer sublingual nitroglycerin tablet. Acute chest pain after PTCA May indicate cardiac ischemia related to restenosis, stent thrombosis, or acute coronary syndrome. Vaginal discharge appearance Described as having a 'cottage-cheese' appearance. First prescription for vaginal infection Instill the first dose of nystatin (Mycostatin) vaginally per applicator. Assessment for signs of bleeding Should be implemented after a liver biopsy. Position after liver biopsy Client should be placed in the right lateral position. Nurse's role in discharge education Assess and provide discharge educational needs, obtain resources for the client. Nurse's action for acute chest pain First action is to administer nitroglycerin. Vulva irritation and vaginal infection Described by a college student. Common health problems associated with aging Renal insufficiency, urinary incontinence, urinary tract infection, and enlarged prostate. Normal changes associated with aging Include decreased creatinine clearance and decreased concentrating and diluting abilities. Candidiasis Also known as a yeast infection, characterized by a white, vaginal discharge with a 'cottage-cheese' appearance. Nystatin (Mycostatin) Should be implemented first to initiate treatment for candidiasis to provide relief of symptoms. Radical neck dissection and total laryngectomy Surgical procedures where the stoma should never be covered after surgery. Febrile, nonhemolytic reaction The most common type of reaction related to blood transfusion, caused by leukocyte incompatibility. Assessment finding for febrile, nonhemolytic reaction Flushed skin and headache are important signs to identify. Older Adult Resource Services Center Instrument (OARS) A specific assessment tool designed for older adults to provide accurate health information. Geriatric Depression Scale An assessment tool used to evaluate depression in older adults. Braden Scale An assessment tool used to evaluate skin breakdown risk in older adults. Human papillomavirus (HPV) An STI that is estimated to cause 70% of cervical cancers. CDC (2017) estimate on HPV It is estimated that at least 80% of all women who are sexually active will contract HPV in their lifetime. Serum potassium level of 4.5 mEq/L A finding that should be documented as the only action if no further action is required. Coronary artery bypass surgery graft (CABG) A surgical procedure for patients with a history of hypertension, myocardial infarction, and heart failure. Esophageal speech Techniques that are relatively easy to learn with practice after total laryngectomy. Prognosis after treatment The prognosis after treatment for radical neck dissection and total laryngectomy is excellent. Stoma An opening created during surgery which should never be covered after a radical neck dissection. Signs of febrile reaction Chills, fever, headache, and flushing are common symptoms of a febrile, nonhemolytic blood transfusion reaction. Physical assessment of older clients Using reliable assessment tools provides the most accurate information during a physical assessment. Caregiver information Obtaining a client's information from a caregiver may not provide the most accurate health history. Past medical record review Reviewing past medical records for medications is less effective than using specific assessment tools. Neisseria gonorrhoea An STI that should be included in discussions about cervical cancer risk. Chlamydia trachomatis An STI that may be discussed in relation to cervical cancer risk. Herpes simplex virus An STI that is less directly linked to cervical cancer compared to HPV. Coronary artery bypass surgery graft (CABG) Places a client at risk for hypokalemia from hemodilution, nasogastric suction, or diuretic therapy, so the serum potassium level is maintained between 4 and 5 mEq/L to avoid dysrhythmias. Atrophic vaginitis A condition in menopausal women where the vaginal mucous membrane responds to low estrogen levels, causing the vaginal walls to become thinner, drier, and susceptible to infection. Perineal cutaneous candidiasis Contributes to manifestations of vaginal infections, such as vaginal irritation, burning, pruritus, increased leukorrhea, bleeding, and dyspareunia. Impaired comfort The primary nursing diagnosis for a client with atrophic vaginitis and perineal cutaneous candidiasis. Serum creatine kinase-MB (CK-MB) The most reliable indicator of myocardial necrosis. Troponin levels An elevated serum troponin has become the cardiac marker of choice for diagnosing an acute MI, becoming evident within 2-3 hours of an MI. Cuffed tracheostomy tube A device used in clients who are breathing spontaneously to evaluate if they can tolerate cuff deflation to promote speaking and swallowing. Aspiration risk evaluation Involves instructing the client to swallow a small amount of colored water and observing for coughing up colored sputum. Synchronous pacemaker A device that maintains a heart rate of 60 beats per minute by firing an impulse every second. Ventricular irritability prevention Achieved by the constant rate setting of the pacemaker. Ectopic stimulus suppression Accomplished by the device usurping depolarization in the atria. Serum myoglobin levels Needed to confirm myocardial damage. Serum cardiac markers Inconclusive in determining myocardial injury after waiting several days. Normal potassium level Maintained between 4 and 5 mEq/L to avoid dysrhythmias. Menopausal vaginal changes Result in thinner, drier vaginal walls due to low estrogen levels. Vaginal infections manifestations Include vaginal irritation, burning, pruritus, increased leukorrhea, bleeding, and dyspareunia. Coughing colored sputum An indicator of aspiration risk after deflating a cuffed tracheostomy tube. Cardiac marker of choice An elevated serum troponin for diagnosing an acute MI according to ACC guidelines. Documentation of normal finding Indicated at the time of maintaining serum potassium levels. Nursing diagnosis priority Impaired comfort for a client with atrophic vaginitis and perineal cutaneous candidiasis. Chest pain evaluation Involves assessing laboratory findings for serum CK-MB and troponin levels. Tracheostomy suctioning Performed to check for the presence of colored water after swallowing. Electrical stimulus Discharged when no ventricular response is sensed. Artificial cardiac pacemaker An electronic device used to pace the heart when the normal conduction pathway is damaged or diseased. Synchronous pacing modes Impulse generated on demand or as needed according to the patient's intrinsic rhythm. Myocardium stimulation An electrical signal from the pacemaker stimulates the myocardium to contract when no ventricular depolarization is sensed. Compromised psychological adjustment Risk associated with clients after a hysterectomy, particularly for those still in childbearing years. Primipara A client who is having her first child and is at highest risk for unresolved conflicts about the end of her childbearing opportunities. Midazolam (Versed) A benzodiazepine sedative commonly used for conscious-sedation intraoperatively. Surgical consent form Should be signed before administering midazolam, as it interferes with cognition and level of consciousness. Myocardial infarction (MI) A condition where increased pulmonary congestion, increased heart rate, and cold, clammy skin may indicate impending cardiogenic shock. Cardiogenic shock A common complication of myocardial infarction that requires immediate notification of the healthcare provider. Colonoscopy recovery The nurse must report immediately any increased abdominal pain with rebound tenderness. Emergency echocardiography A procedure prepared for in cases of increased pulmonary congestion and heart rate changes in MI patients. Cold, clammy skin A sign of potential cardiogenic shock in patients with myocardial infarction. Increased heart rate A change from 80 to 102 beats per minute indicating possible complications in a patient with MI. Tympanic abdomen A finding that may be present after a colonoscopy, but not necessarily alarming. Hyperactive bowel sounds A potential finding post-colonoscopy that may not require immediate reporting. Rebound tenderness A clinical sign indicating potential complications that should be reported immediately. Rebound tenderness Positive rebound tenderness following a colonoscopy may be an indication of a perforation and the development of peritonitis and requires follow-up immediately. Carbon monoxide poisoning The saturation of hemoglobin molecules with carbon monoxide molecules, instead of oxygen molecules and the subsequent vasodilation induced cherry red color of the mucous membranes is an indication of carbon monoxide poisoning. Inguinal herniorrhaphy Swelling at the surgical site in the immediate postoperative period can impact the bladder and prostate area causing the client to experience difficulty voiding due to pressure on the urethra. Priapism Priapism, a urologic emergency, is common during sickle cell crisis due to sickle cells clogging the microcirculation in the penis, causing a reduction of blood flow and oxygenation to the penis. Yellowish discoloration of the sclerae In a geriatric client, a yellowish discoloration (jaundice) of the sclerae is not a normal finding and may indicate liver damage and requires further assessment. Empty surgical drains Once a week using procedure gloves. Report inflammation Of the incision site or the affected arm. Wear clothing with snug sleeves Over the arm on the operative side. Avoid lifting More than 4.5 kg (10 lb) or reaching above her head. Urinary catheter obstruction after TURP Often due to blood clots, and sterile irrigation should be implemented to remove the clots blocking the catheter. Prostatic stent A cylinder shape tube that is placed in the urethra to relieve prostatic pressure from an enlarged prostate and improve urine flow. Catheterization through the prostatic stent Should not be done for at least three months after stent placement. Total hysterectomy and bilateral salpingo-oophorectomy Indicates that further teaching is needed if the client believes they can still have sexual intercourse. Endotracheal tube (ETT) placement confirmation Best confirmed by using an end-tidal CO2 detector. End-tidal carbon dioxide detector Indicates the presence of CO2 by a color change or number indicated on the detector. Nursing intervention for Meniere's disease Encourage fluids to 3000 ml per day. Change the client's position Every two hours for a client with vertigo. Meniere's disease A condition characterized by episodes of vertigo, tinnitus, and hearing loss, where minimizing visual stimuli and rotational movement is crucial during acute attacks. Deficient knowledge The primary nursing problem for a client with asymptomatic primary syphilis, indicating the client is unaware of the disease and needs education to prevent transmission and recurrence. Circumferential burn A type of burn that can create an eschar, leading to compromised blood flow due to increased tissue pressure, requiring monitoring for slow capillary refill and absent distal pulses. Vital signs after mastectomy Blood pressure should be obtained from the arm on the non-operative side to prevent injury to the compromised lymphatic drainage of the operative side. Tension pneumothorax A life-threatening condition that requires immediate action if diagnostic tests indicate a mediastinal shift on a chest x-ray. Acute pain One of the potential nursing problems for clients, but not the primary concern for asymptomatic primary syphilis. Risk for injury A potential nursing diagnosis that may be relevant but is not the primary nursing problem for a client with asymptomatic primary syphilis. Sexual dysfunction A potential nursing diagnosis that may be relevant but is not the primary nursing problem for a client with asymptomatic primary syphilis. Full thickness burns Burns that extend through the entire dermis and may require different management compared to partial thickness burns. Supination and pronation of extremity The ability to rotate the forearm; inability to fully pronate may indicate compromised circulation in the context of a circumferential burn. Capillary refill A clinical test used to assess blood flow to the extremities, where slow refill can indicate compromised circulation. Escharotomy A surgical procedure performed to relieve pressure from a circumferential burn that compromises blood flow. Post-op mastectomy care Includes elevating the operative side arm and obtaining blood pressure from the non-operative side to avoid complications. Serum amylase An enzyme level that, if elevated, may indicate pancreatic issues but is not an immediate concern in tension pneumothorax. Serum sodium A measure of sodium in the blood; a level of 134 mEq/L is generally not critical but should be monitored. Mediastinal shift A condition observed on chest x-ray indicating potential tension pneumothorax, requiring immediate nursing intervention. Mediastinal shift A condition that can precipitate life-threatening cardiovascular collapse as the great cardiac vessels become kinked and compressed due to the tension pneumothorax. Tamoxifen (Nolvadex) An estrogen receptor blocking agent used for the treatment of breast cancer that can cause hot flashes. High-protein, high-fat, low-carbohydrate diet A diet prescribed for clients recovering from gastric surgery that is slowly digested and reduces the possibility of dumping syndrome. Subnormal temperature A common finding in elderly clients, such as an oral temperature of 97.2 F (36.4 C). Auscultation The technique performed next in the abdominal examination after visual inspection, used to assess bowel sounds. Acute appendicitis A condition that can cause anxiety and loss of sleep, particularly concerning missing final examination week at college. Psychological discomfort An experience that may be as real as physical pain for the client and should be prioritized in care. Dumping syndrome A condition that can occur due to rapid gastric emptying, which is reduced by a diet high in proteins and fats. Vital sign graphic sheet A document where temperature readings and other vital signs are recorded. Client education Information provided to clients regarding their treatment, including managing menopausal-like symptoms from medications like tamoxifen. Plan of care A structured approach that includes interventions and outcomes for client management. Intervention An action taken by the nurse to address a client's needs or concerns. Nursing assessment The process of evaluating a client's health status through various techniques, including auscultation. Elderly clients Individuals, typically over the age of 65, who may present with different physiological responses, such as subnormal temperatures. Hot flashes A common side effect of tamoxifen that requires client coping strategies. Fluid intake The amount of fluids consumed, which may need to be monitored in certain dietary plans. Calcium intake The consumption of calcium-rich foods, which may be encouraged in clients for bone health. Temperature reading The measurement of body temperature, which can indicate health status. Nursing diagnosis A clinical judgment about individual, family, or community responses to actual or potential health problems. Client coping Strategies employed by clients to manage stressors related to their health condition. Nurse's rationale The reasoning behind a nurse's actions or interventions in a client's care plan. Nursing intervention Specific actions taken by nurses to improve patient outcomes. Abdominal examination A physical assessment of the abdomen that includes techniques like inspection, auscultation, percussion, and palpation. Type II diabetes A condition where the body does not properly use insulin, leading to elevated blood glucose levels. Blood glucose of 50 mg/dL A low blood sugar level indicating hypoglycemia. 6 ounces of orange juice A common treatment for hypoglycemia that provides quick sugar to raise blood glucose. Capillary glucose of 74 mg/dL A blood glucose level that is considered normal and above the hypoglycemic threshold. Regularly scheduled meal or snack A meal or snack that contains protein and carbohydrates to prevent recurring hypoglycemia. Log rolling technique A method used to move a patient while maintaining spinal alignment and minimizing movement. Lumbar laminectomy A surgical procedure that involves removing a portion of the vertebrae in the lower back. Spinal alignment The correct positioning of the spine to prevent injury, especially post-surgery. Nonsteroidal anti-inflammatory drug (NSAID) A class of medications used to reduce inflammation and relieve pain. Piroxicam (Feldene) An NSAID prescribed for treating rheumatoid arthritis. Prostaglandin synthesis The process by which prostaglandins are produced, which NSAIDs inhibit to reduce inflammation. Rheumatoid arthritis An autoimmune disease that causes chronic inflammation of the joints. Osteoarthritis A degenerative joint disease characterized by the breakdown of cartilage. Low impact exercise Physical activity that does not put excessive strain on joints, such as walking or swimming. High-impact aerobic exercise A type of exercise that involves more vigorous activity and can stress the joints. Human papillomavirus infection (HPV) A sexually transmitted infection caused by human papillomavirus. Reportable disease A disease that must be reported to public health authorities. Acute and chronic pain Pain that is either short-term (acute) or long-lasting (chronic), often associated with inflammation. Bone grafts A surgical procedure that involves transplanting bone tissue to repair or rebuild bones. Glycosylated hemoglobin specimen A blood test that measures average blood glucose levels over the past 2-3 months. Serum glucose level A measure of glucose in the blood, used to assess diabetes management. Cheese and bread Foods that contain protein and carbohydrates, recommended for preventing hypoglycemia. Dizziness prevention Maintaining stability and preventing lightheadedness, especially after surgery. Strength-building exercises Physical activities designed to improve muscle strength, often using weights or resistance. Dependent edema Collects in dependent areas, such as the flank and upper buttocks of the client who is persistently flat in bed. PSA density A measurement used to assess the risk for prostate cancer; clients with a PSA density less than 0.15 ng/ml are considered at low risk for prostate cancer. Atrial fibrillation A heart condition that requires preparation for anticoagulation therapy to prevent cardioembolic events. Osteoporosis prevention Weight bearing on the skeletal system stimulates bone formation, making weight resistance exercises the most important measure for post-menopausal women. Upper gastrointestinal (UGI) series An x-ray procedure that may last for several hours. Compression of flank and upper buttocks A method to assess for possible dependent edema by determining if any pitting edema is present. Prostate-specific antigen (PSA) exam A test used to evaluate the risk of prostate cancer based on PSA density. Anticoagulation therapy A treatment protocol for clients experiencing atrial fibrillation to prevent blood pooling. Weight resistance exercises Exercises that are crucial for preventing osteoporosis in post-menopausal women. Barium instillation A procedure that may involve the insertion of a nasogastric tube (NGT) during an upper gastrointestinal (UGI) series. Emotional reaction to STI diagnosis Anger is a common response, often leading to blame directed at the sexual partner. HPV A sexually transmitted infection that is not reportable in many states but requires informing all contacts. Pitting edema A condition that can be assessed by compressing dependent areas of the body. Cardioembolic events Complications that can arise from blood pooling in the fibrillating atria. Multivitamin daily A suggested measure for health, but not the most important for preventing osteoporosis. Low fat milk products Dietary choice that is not the most important measure for preventing osteoporosis. Bicycle exercise A physical activity that is beneficial, but not the most important for osteoporosis prevention. Teaching plan for post-menopausal client Should include the importance of weight resistance exercises to prevent osteoporosis. Assessment of client in bed Involves evaluating for dependent edema by compressing specific body areas. Informed contacts about infection All contacts should be informed of the infection, treatment, transmission, and precautions. Rationale for informing about STI To allow the person to take precautions to prevent the spread of infection. Legal distribution of documents The distribution of the document is illegal. Marketplace for study materials S is a platform to buy and sell study materials. NPO Nothing by mouth is allowed for 6 to 8 hours before the study. Naproxen (Naprosyn) A medication that can have gastrointestinal side effects such as nausea and gastric burning. Sickle Cell Crisis A condition where pain management is the priority, requiring evaluation of narcotic analgesics for effectiveness. Metabolic Syndrome Risk Factor An increase in abdominal girth, specifically men with waist size 40 inches or larger and women 35 inches or larger. Small Bowel Obstruction A condition where parenteral fluids with sodium chloride, bicarbonate, and potassium should be administered to prevent electrolyte imbalance and dehydration. Subcutaneous Emphysema A complication indicating air is leaking beneath the skin surrounding the chest tube. Gastrointestinal Disturbance A potential side effect of Naproxen that includes nausea and gastric burning. Pain Management The priority nursing action during a sickle cell crisis, requiring frequent evaluation of narcotic analgesics. Abdominal Fat Deposits An increase in abdominal girth that is a risk factor for metabolic syndrome. IV Fluids with Electrolytes Recommended for clients with small bowel obstruction to prevent electrolyte imbalance and dehydration. Tidaling Fluctuation of fluid in the water-seal chamber of a chest tube system. Constant Air Bubbling A finding in the suction-control chamber that requires further assessment. Pain Rating A subjective measure of pain, such as a rating of '8' on a scale of 0-10. Secondary Intention Healing A type of wound healing process that occurs when a surgical wound on the coccyx is healing. Electrolyte Imbalance A condition that can occur when the bowel is obstructed and fluids are not absorbed. Narcotic Analgesics Medications used for pain control during a sickle cell crisis. Chest Tube A medical device attached to suction and a closed drainage system that requires monitoring for complications. Fluids and Food Intake Should be limited during a sickle cell crisis. Gastrointestinal Upset A condition that can be avoided by taking Naproxen with food. Assessment of Risk Factors A nursing action that involves evaluating findings such as thinning hair, appetite changes, and abdominal fat. Nausea A gastrointestinal side effect of Naproxen. Gastric Burning A gastrointestinal side effect of Naproxen. Ambulation Encouraged for clients during a sickle cell crisis as tolerated. Client Education Teaching the client about the prevention of crises during sickle cell anemia management. Priority nursing diagnosis for discharge instruction Risk for infection. Rationale for risk of infection A wound healing by secondary intention is an open wound at risk for infection, and the location of the wound near the anal area increases the risk for infection even more. Best response for infertility support Get involved with a support group. I will give you some names. Rationale for support group A support group provides a safe haven for the couple to share their feelings and experience and gain insight from others dealing with the same experience and lets them know they are not alone in their situation. Client to assess first A 55-year-old newly admitted client complained of jaw pain and indigestion. Rationale for assessing jaw pain and indigestion The 55-year-old client should be assessed first to rule out cardiac involvement because jaw pain and indigestion are common descriptors of myocardial injury. Additional assessment for 85-year-old male client Measure the blood pressure. Rationale for measuring blood pressure in elderly clients Elderly clients who take antihypertensive medications often experience side effects, such as hypotension, which causes tachycardia, a compensatory mechanism to maintain adequate cardiac output. Understanding post-operative care after left orchiectomy I should continue to perform testicular self-examination (TSE) monthly on my remaining testicle. Rationale for testicular self-examination Although testicular cancer protocols focus on the primary site of testicular cancer, these treatments do not reduce the risk of testicular cancer in the remaining testicle, so early recognition is the best prevention. Monthly TSE A procedure to check for changes in size, shape, or consistency of the testis that may indicate early cancer. Intraperitoneal hemorrhage A life-threatening condition indicated by periumbilical discoloration, often associated with splenic rupture. Postoperative abdominal distention A condition caused by decreased peristalsis after surgery, leading to discomfort and gas pains. Early ambulation A nursing intervention that stimulates peristalsis, allows flatus passage, and minimizes abdominal distention. Stoma assessment The evaluation of a colostomy stoma's appearance, which should be reddish pink and moist to indicate proper perfusion. Ischemic stoma A stoma that appears dry, firm, flaccid, or dark red/purple, indicating a lack of blood flow and requiring immediate surgical notification. Antibiotic treatment for osteomyelitis High doses of parenteral antibiotics for 4 to 8 weeks, followed by oral antibiotics for another 4 to 8 weeks. Right-sided hemiplegia positioning A nursing care strategy to maintain optimal functioning in clients who have suffered an acute stroke affecting the right side. Right lateral position A position where the patient lies on their right side. Left lateral position A position where the patient lies on their left side. Supine position A position where the patient lies on their back. Prone position A position where the patient lies on their stomach. Acute stroke positioning schedule A schedule that minimizes lying on the affected side to prevent circulation impairment and pain. Flexion contractures of the hips A condition that can occur when the hips are not properly positioned, leading to limited movement. Superior vena cava syndrome A condition that occurs when the superior vena cava is compressed, impeding blood return to the heart. Metastatic cancer Cancer that has spread from the primary site to other parts of the body, often causing compression of structures like the superior vena cava. Chronic prostatitis discharge instructions Guidelines provided to reduce the risk of spreading infection in the urinary tract. Reservoir for microorganisms A location, such as the prostate, where microorganisms can reside and potentially cause infections. Genital herpes simplex initial outbreak The first occurrence of genital herpes, which is characterized by severe discomfort. Promotion of comfort The primary focus in nursing care during the initial outbreak of genital herpes simplex. Bronchoscopy post-procedural care Nursing interventions implemented immediately after a bronchoscopy procedure. NPO status after bronchoscopy The requirement for the client to not consume anything until the gag reflex returns. Peptic ulcer disease (PUD) A condition that can lead to gastrointestinal bleeding due to ulceration. Gag reflex A reflex that prevents aspiration; it must return before oral intake is allowed post-bronchoscopy. Vital signs monitoring post-bronchoscopy Checking the patient's vital signs every 15 minutes for two hours after the procedure. Fluid intake encouragement Promoting fluid intake to help eliminate contrast media after certain procedures. Chronic cough with blood-tinged sputum A symptom that may indicate an underlying condition requiring bronchoscopy. Turning schedule for stroke patients A plan that includes alternating positions to prevent complications. Compression of the superior vena cava A result of external structures, such as tumors, affecting blood flow to the heart. Intercourse or masturbation frequency Recommended to be at least twice a week to reduce infection risk in chronic prostatitis. Local anesthetic in bronchoscopy Used to anesthetize the nasal and oral pharynx to prevent gag reflex during the procedure. Blood-tinged sputum Sputum that contains blood, often a sign of respiratory issues. Hypersecretion of gastric juices Causes of ulceration due to an increased number of parietal cells that stimulate secretion. Thrombocytopenia A condition indicated by platelet counts less than 100,000/mm3, commonly a side effect of chemotherapy. Action for client with non-Hodgkin's lymphoma and low platelet count Check stools for occult blood. Action for client with type 1 diabetes mellitus on surgery day Obtain a prescription for an adjusted dose of insulin. Vagal stimulation A factor that increases the secretion of caustic fluids. Decreased duodenal inhibition A factor that increases the secretion of caustic fluids. Hypersecretion of hydrochloric acid A potential cause of increased gastric secretions. Increased level of stress A condition that can lead to elevated serum glucose levels. Oral hygiene for thrombocytopenia Should be provided every 2 hours to prevent complications. Monitoring for fever in thrombocytopenia Should be checked every 4 hours. Insulin administration for NPO clients Clients with type 1 DM should receive an adjusted dose of insulin when NPO. Platelet count of 10,000/ml Indicates severe thrombocytopenia requiring careful monitoring for bleeding. Surgery stressors Can increase serum glucose levels in diabetic patients. Sliding scale insulin Not appropriate for NPO clients; an adjusted dose should be prescribed instead. Occult bleeding assessment Should include checking emesis, sputum, feces, urine, nasogastric secretions, or wounds. Parietal cells Cells that stimulate the secretion of gastric juices. NPO A status where a client is not allowed to eat or drink before surgery. Chemotherapy side effects Can include thrombocytopenia and increased risk of bleeding. Fluid intake recommendation for chemotherapy patients Encouraged to maintain adequate hydration, typically around 3000 ml/day. Gastric ulceration causes Often linked to hypersecretion of gastric juices and increased parietal cells.