BSN HESI 266 Med Surg Exam (2026/ 2027 Updated Edition) Comprehensive Qs&As|100% Correct| Graded A- Nightingale

BSN HESI 266 Med Surg Exam (2026/ 2027 Updated Edition) Comprehensive Qs&As|100% Correct| Graded A- Nightingale When explaining dietary guidelines to a client with acute glomerulonephritis (AGN) which instruction should the nurse include in the dietary teaching? A. Select protein rich food daily B. Restrict sodium intake C. Eat high potassium foods D. Avoid foods high in carbohydrates B. Restrict sodium intake Acute glomerulonephritis (AGN) is a condition of inflammation of the glomeruli of the kidneys. This can manifest as nephritic syndrome, where there is significant hematuria, and/or nephrotic syndrome, where edema is pronounced. In this disease the nurse should include restriction of sodium intake as part of dietary adjustments because the kidneys are not able to filter blood well if inflamed. Thus buildup of sodium may occur if intake is not lowered. An older client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment. Which assessment would the nurse complete to determine if a patient with type 2 DM is experiencing long term complications? SATA A. Skin condition of lower extremities B. Sensation in feet and legs C. Visual acuity D. Signs of respiratory tract infection E. Serum Creatinine and Blood Urea Nitrogen (BUN) A: Helps identify complications like diabetic ulcers B: Assessing sensation in feet and legs helps detect neuropathy. C: Helps identify diabetic retinopathy. E: Helps assess kidney function and identify nephropathy. NGN: Scenario 1 A 57 year old male client is brought to the emergency department by emergency medical services (EMS) with reports of chest pain. The client was mowing his lawn and noticed chest pain presenting as tightness and pressure. The pain continued to increase over about 30 minutes when the client decided to rest. The clients wife called EMS when the pain was unrelieved after 20 minutes of rest. The client reports no other incidents of experiencing this pain, The clients medical history includes hypertension, obesity, and a 20 year history of smoking, having quite about 5 years ago. Medications: Metoprolol 25 mg PO once daily. Answer on next card Scenario 1: Click to highlight findings for follow up: Neurological: Alert and orientated. Agitated. Denies headaches Cardiovascular: Reported chest pain described as pressure and tightness that is unrelieved with rest. Rapid regular rhythm. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 sec. Respiratory: Rapid and shallow breaths. Clear breath sounds throughout bilateral lungs. Gastrointestinal: Within normal limits (WNL) Musculoskeletal: WNL Pain reported 7 on a 0 to 10 pain scale, tightness and pressure in chest, started approximately 2 hours ago and got progressively worse, unrelieved by rest. *Neurological: Agitation *Cardiovascular: Chest pain described as tightness and pressure, rapid regular rhythm. *Respiratory: Rapid and shallow breathing *Pain: Reported 7 on a 0-10 scale, tightness and pressure in chest. Scenario 1: Select which one or both if they are angina or myocardial infarction: Epigastric distress Chest Pain radiating down arm Pain only relieved by opioids Occurring without cause Feelings of fear Pain relieved by nitroglycerin Epigastric distress: MI Chest Pain radiating down arm: Both Pain only relieved by opioids: MI Occurring without cause: MI Feelings of fear: MI Pain relieved by nitroglycerin: Angina Scenario 1: Chest pain Choose the most likely options for the information missing from the statement by selecting from the list of options provided. The nurse determines that the client has ________ as evidenced by ST depression on electrocardiogram and normal__________ New onset angina Troponin Scenario 1: Chest Pain Drag and drop word choices to complete the sentence. If healthcare providers see a narrowed heart vessel while performing a percutaneous coronary intervention (PIC), they may perform a balloon angioplasty to compress the plaque against the vessel and hold it there with a stent, which will lessen_______ and_________ Vaso Pain Scenario 1 Chest pain: For each medication, choose the drug classification and medication action: A. Amlodipine B. Aspirin C. Lisinopril D. Nitroglycerin Classification Nitrate Ace Inhibitor Calcium channel blocker antiplatelet Medication action: Promotes peripheral dilation Lessens contractility of smooth muscle Results in vasodilation Inhibits cyclooxygenase and thromboxane A2 Amlodipine: Calcium channel blocker-Lessens contractility of smooth muscle Aspirin: Antiplatelet: Inhibits cyclooxygenase and thromboxane A2 Lisinopril: Ace inhibitor- Results in vasodilation Nitroglycerin: Nitrate- Promotes peripheral dilation Scenario 1: Chest pain: Which 2 statements from the client should the nurse recognize as a need for further education" A. I will take the nitroglycerin 1 or 2 more times 10 minutes apart if the pain does not get better B. I will chew my nitroglycerin tabs as soon as pain begins C. I will wait 5 minutes after taking my nitroglycerin to see if the pain improves. D. I will wear a medication alert bracelet to indicate my history of heart problems E. I will keep my nitroglycerin tablets with me all the time. F. I will call 911 if there is no improvement in my chest pain after taking nitroglycerin G. I will lie down o sit if I start to feel any chest discomfort A. I will take the nitroglycerin 1 or 2 more times 10 minutes apart if the pain does not get better. B. I will chew my nitroglycerin tabs as soon as pain begins. Which information should the nurse include when giving discharge instructions to a client following a left eye cataract extraction with a lens implants? A. Observe pupil response of the right eye. B. Turn, cough, and deep breathe every 2 hours. C. Sleep flat in a supine position D. Administer a stool softener D. Administer a stool softener A stool softner can help prevent straining during bowel movements, which could increase intraocular pressure and potentially harm the surgical site. Additionally the nurse should advise the client to avoid activities that could increase pressure in the eye, such as bending at the waist, lifting heavy objects, or engaging in strenuous activities for a certain period post surgery, The nurse administering the second unit of whole blood to an older adult client who was admitted yesterday with gastrointestinal (GI bleeding) which parameters should the nurse monitor that indicate fluid overload? A. Bounding pulse, hypertension, and distended neck veins B. Thready pulse, hypotension and chest or back pain C. Urticaria, itching and wheezing D. Chills, fever, and tachycardia A. Bounding pulse, hypertension and distended neck veins Bounding pulse, hypertension and distended neck veins are signs of fluid overload which can occur during blood transfusions especially in older adults. Thready pulse, hypotension, and chest or back pain are more indicative of shock or severe anemia rather than fluid overload Urticaria itching, and wheezing suggest an allergic reaction Chills, fever, and tachycardia can indicate a febrile or transfusion reaction but are not specific to fluid overload The nurse is teaching a client with cancer about skincare for the portal site receiving external beam radiation, Which client action about skincare indicates a need for further teaching? A. Washes the radiation site with antibacterial soap and water B. Applies prescribed lotions to the radiation site C. Wears clothing to cover the radiation site. D. Dries the area with patting motions after taking a shower. A. Washes the radiation with antibacterial soap and water. Washing the radiation site with antibacterial soap and water is not recommended. Clients undergoing radiation therapy are typically advised to use gently, mild soaps and to avoid scrubbing or using harsh cleansers on the treated area, Antibacterial soap may be to harsh and could lead to skin irritation. Applying prescribed lotions to the radiation site is generally a recommended part of skin care during radiation therapy, as it helps keep the skin moisturized and reduces irritation Wearing clothing to cover the radiation site is a good practice to protect the area from sun exposure and potential irritations Drying the area with patting motions after taking a shower is the correct way to dry the radiation site, as it minimizes friction and reduces the risk of skin damage. The nurse observes that a client with Parkinson's disease (PD) has a mask like face. Which follow up assessment is MOST important for the nurse to implement? A. Determine ability to chew and swallow B. Note the frequency of drooling C. Assess patterns of speech D. Observe the appearance of oral mucosa A. Determine the ability to chew and swallow. The ability to chew and swallow is crucial for preventing aspiration and maintaining nutrition While noting the frequency of drooling is important it is not the most critical Observing the appearance of oral mucosa is less critical than ability to swallow Assessing speech patterns is important but secondary to swallowing ability in terms of immediate safety NGN scenario 2: Amputation The client is a 48 year old male with gangrene of the right lower leg which has not been responsive to treatment. A below the knee amputation (BKA) of the right lower leg has been performed. The client has a history of peripheral vascular disease and hypertension and has a peacemaker for 2nd degree Type II heart block. Highlight the assessment findings that require follow up by the nurse? Right leg hanging Right leg cool to touch Left leg whole paragraph NGN Scenario 2: Amputation: Select the 3 assessment findings that indicate ineffective peripheral tissue perfusion for this client: Capillary refill Edema Pale skin NGN Scenario 2: Amputation: Drag the word choices to complete the sentence. The client is at risk for _______, ________ and ____________. Infection Contractures Neuroma NGN Scenario 2: Amputation: For each action click to indicate whether the actions are indicated or contraindicated for postoperative amputation. B. Assessment for grieving C. Instructions on equipment D. Strengthening exercises F. Collaborative care NGN Scenario 2 Amputation: which items should the nurse teach the client? SATA A. Alternating position B. Use of equipment C. Therapeutic coping D. Prevention of skin breakdown NGN Scenario 2: Amputation: For each client activity, click to indicate whether the activity shows positive or negative health promotion post amputation due to extensive peripheral vascular disease. A. Insures about blood pressure: Positive B. Ask questions about self care-Positive C. Avoids looking at residual limb-negative D. Requests nurse to perform wound care-negative E. Turns side to side-Positive F. Executes pull ups on trapeze bar-positive Which client has the highest risk for developing skin cancer? A. A 65 year old fair skinned client who is a construction worker. B. A 70 year old fair skinned client who works as a secretary. C. A 25 year old dark skinned client whose mother had skin cancer D. A 16 year old dark skinned client who tans in tanning beds once a week. A. A 65 year old fair skinned client who is a construction worker. When caring for a client with a cervical spinal cord injury, which intervention is the MOST important for the nurse to implement? A. Immobilize the head in anatomical alignment. B. Assess the extremity reflexes C. Logroll to change positions D. Obtain hourly neurological assessments A. Immobilize the head in anatomical alignment. Immobilizing the head in anatomical alignment is crucial to prevent further injury to spinal cord. Proper immobilization helps stabilize the cervical spine and protects the spinal cord from additional damage. A client is to receive progesterone 10mg IM daily. The medication is labeled progesterone 50mg/mL. How many mL should the nurse administer? 0.2 mL A client with a gram positive bacterial skin infection is receiving daptomycin 500 mg IV every 24 hours. The pharmacy delivers a secondary infusion of 0.9% sodium chloride with daptomycin 500 mg/100mL to be infused in 30 minutes, How many mL /hour should the nurse program the infusion pump? 200mL Convert 30 minutes to hours: 30/60=0.5 Find the infusion rate (mL/hour): infusion rate= Total volume 100mL ---------------=- -------= Time in hours 0.5 200 mL/hr NGN-Amputation A 24 year old female client presents to the ED with reports of abdominal pain... Choose the most likely options for the information missing from the statements by selecting: The nurse recognizes that the client has _________ as evidence by___________and_________ Appendicitis CT scan results WBC A client with edema receives a prescription for a one time dose of furosemide 20 mg IV. The medication is available in a 10 mg/mL vial. How many mL should the nurse administer? 2 mL A client arrives to the ED following a motor vehicle collision. The nurse observes the client experiencing increasing dyspnea and notes absent breath sounds on the left side. Which procedure should the nurse prepare for the client? A. Chest tube insertion B. Bronchoscopy C. Endotracheal intubation D.. Pulmonary function test A. Chest tube insertion Because absent breath sounds on one side and increasing dyspnea suggest pneumothorax, which requires chest tube insertion to re-expand the lung. Bronchoscopy is used for visualizing the airways and not for treating a pneumothorax Endotracheal intubation is for airway management Pulmonary function tests are not relevant in an emergency situation with suspected pneumothorax The nurse plans to provide diet instructions to a client who was recently diagnosed with diverticulosis. Which dietary medication should the nurse include in the teaching plan? A. Increase intake of insoluble fiber B. Augment intake of dairy products C. Eliminate caffeine and chocolate D. Decrease foods high in fat or trans fats. A. Increase intake of insoluble fiber Increasing intake of insoluble fiber can help prevent constipation and reduce the risk of diverticulitis by promoting regular bowel movements. Augmenting intake of dairy products is not specific to managing diverticulosis Eliminating caffeine and chocolate is not necessary unless these foods cause symptoms While reducing high fat foods is good dietary advice it is not specific to diverticulosis management The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with type 2 DM. Which outcomes should the nurse include in the plan of care for this client? A. The clients hemoglobin A1C will be less than 7% in 3 months. B. The clients blood pressure reading will be less than 160/90 C. The nurse will demonstrate the procedure for accurate eye care D. The nurse will encourage the client to walk thirty minutes everyday. A. The clients hemoglobin A1c will be less than 7% in 3 months B. Controlling blood pressure is important in managing cardiovascular disease, the specific outcome should reflect the target blood pressure goal of less than 140/80 to reduce the risk of complications D. Encouraging physical activity is beneficial for cardiovascular health but the outcome should focus on BP management which is more directly related to clients reported symptoms of blurred vision. A client with a new diagnosis of glaucoma is concerned about going blind. To help prevent blindness due to glaucoma, the nurse should instruct the client to implement which action? SATA A. Meticulously follow the regimen for administering prescribed eye drops. B. Schedule regular appointments to measure eye pressure. C. Report any changes in vision perception immediately D. Maintain a diet high in vegetables particularly carotene. E. Avoid excessive eye strain by limiting computer screen time. A. Meticulously follow the regimen for administering prescribed eye drops. B. Schedule regular appointments to measure eye pressure. C. Report any changes in vision perception immediately. Following the prescribed regimen for eye drops helps manage intraocular pressure, which is crucial for preventing optic nerve damage in glaucoma. Reporting any changes in vision can help detect progression of glaucoma early and allow for timely intervention Regular eye pressure checks help monitor the effectiveness of treatment and prevent progression of glaucoma A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the clients postoperative discharge instructions? A. monitor the urinary stream for a decrease in output. B. Report when hematuria becomes pink tinged C. Use an incentive spirometer D. Restrict physical activities A. monitor the urinary stream for a decrease in output. A. Correct monitoring urinary stream for a decrease in output is crucial to detect complications such as obstruction or infection after lithotripsy B. Incorrect: Hematuria is expected after lithotripsy and should be monitored but it is not the most critical C. Incorrect D. Incorrect: Restricting physical activity is not necessary unless advised by the health care provider One hour after abdominal surgery a client in the post anesthesia care unit (PACU) has a BO of 136/80. Fifteen minutes later it is 114/72. Which actions should the nurse take FIRST? A. Check the abdominal surgical dressing B. Increase frequency of BP assessment C. Encourage the client to breathe deeply D. Review the clients baseline BP trends. A. Check abdominal surgical dressing A: Correct this can help identify if there is postoperative bleeding or other complications at the surgical site which could be causing the drop in blood pressure B: incorrect. increasing the frequency of BP assessments is important to monitor the clients condition but it does not address the potential cause of the drop in BP C: incorrect: reviewing baseline provides useful info but does not address the cause of a drop in BP Which findings during the admission assessment should the nurse document that are related to a client diagnosed with Cushing's syndrome? A. Central type obesity with thin extremities B. Husky voice and complaints of hoarsness C. Warm, soft, moist salmon colored skin D.. Visible swelling of the neck with no pain A. Central obesity with thin extremities. A: Correct: Central type obesity with thin extremities is common feature which is caused by excess cortisol production or exposure. Cortisol causes fat redistribution to the trunk, face, and back of the neck while causing muscle wasting and weakness in the arms and legs B. Incorrect husky voice and complaints of hoarseness are not related to Cushing's syndrome but may indicate a thyroid disorder or vocal cord damage. C. Incorrect, warm soft moist salmon colored skin may be seen in hyperthyroidism or infection D. Incorrect, may indicate goiter or thyroid enlargement A client with gouty arthritis reports tenderness and swelling of the right ankle and great toe. The nurse observes the area of inflammation extends above the ankle area, The client receives prescriptions for colchicine and indomethacin. Which instructions should the nurse include in the discharge teaching? A Return for periodic liver function studies. B. Consume high protein foods to reach an ideal body weight C. Use an electric heating pad when the pain is severe D. Encourage active range of motion exercises to prevent stiffness. A. Return for periodic liver function studies. Gouty arthritis is a form of inflammatory arthritis that occurs when uric acid crystals accumulate in the joints causing severe pain and inflammation, Drinking plenty of water can help to flush the uric acid out of the body reducing the risk of crystal formation and subsequent inflammation. NGN: Amputation: Scenario 3 The client is a 68 year old female with a history of type 2 DM, hypertension, coronary artery disease, and recently diagnosed with ERSD. She has been on hemodialysis three times a week for the last month. She presented to the ED with fatigue, generalized weakness, muscle cramps, tingling sensation in arms and legs, and lightheadedness following 3 days of illness during which her husband reported she had bouts of nausea and had a poor appetite and was not able to go for her scheduled dialysis. A. Call the healthcare provider to notify changes in vital signs B. Perform a 12 lead ECG Stat C. Administer calcium gluconate STAT E. Clarify order of lisinopril with the health care provider F. Draw potassium level stat J. Perform a focused cardiovascular assessment ECG: Echocardiogram uses sound waves to create images of the heart and its valves, chambers, and blood flow CT: Uses Xray to create detailed pics of organs and structures in the abdomen Basic metabolic panel: Blood test that measures the levels of electrolytes, glucose, calcium, and kidney function (electrolyte imbalance or kidney failure) A male client who had abdominal surgery 5 days ago and hospitalized because of a surgical wound infection tells the nurse that he feels like his insides just spilled out when he coughed. What action should the nurse take first? A. Visualize the abdominal incision B Notify the healthcare provider C. Obtain sterile towel soaked in saline D. Assure the client that such feelings occur with wound infections. A. Visualized the abdominal incision A: Correct this will help assess wound for dehiscence or evisceration which is immediate intervention. C: Incorrect obtaining sterile towels soaked in saline is important if dehiscence or evisceration is confirmed but not first action before assessing wound A client tells the clinic nurse about experiencing burning on urination and assessment reveals that the client had sexual intercourse four days ago with a person who was a casual acquaintance which action the nurse implement? A. Obtain a specimen of urethral drainage for culture. B. Observe the perineal area for a chancre like lesion C. Identify all sexual partners in the last four days D. Assess for perineal itching, erythema, and excoriation A. Obtain a specimen of urethral drainage for culture A: Correct this diagnosis a potentially sexually transmitted infection and guide appropriate treatment. A client experiences and ABO incompatibility reaction after multiple blood transfusions, which finding should the nurse report immediately to the health care provider? A. Low back pain and hypotension B. Delayed painful rash with urticaria C. Acute rhinitis and nasal stiffness D. Arthritic joint changes and chronic pain. A. Lower back pain and hypotension A: Correct lower back pain and hypotension are symptoms of an ABO incompatibility reaction, which is a serious complication of blood transfusion, This reaction occurs when the client receives a blood type that is incompatible with their own, It can cause a rapid and severe response including back pain, hypotension, fever and chills this should be reported immediately to provider. Two days after a nephrectomy the client reports abdominal pressure and nausea. Which assessment should the nurse implement? A. Auscultate bowel sounds B. Ambulate the client in the hallway C. Palpate the abdomen D. Measure hourly urine output. A: Correct helps assess for the return of gastrointestinal function and identify potential complications such as ileus which can cause abdominal pressure and nausea A client with orthopnea expresses concern about the ability to get enough air during a scheduled thoracentesis, On which information should the nurses response be based? C. The procedure is performed with client in an upright position. which group of foods is best for the nurse to recommend for clients with a strong family history of colon and rectal cancers? A. Oatmeal raisin and fruit with skin B. Lean beef, salads, and baked potatoes C. Potatoes, low fat breads and applesauce D. Chicken, rice, and wheat products A. oatmeal raisin and fruit with skin Oatmeal, raisins and fruit with skin are high in fiber which promotes gut health and is beneficial for colorectal cancer prevention, The nurse is caring for a client with a burn that is severely edematous with a wound bed that is brown and yellow appearance. The client expresses feeling no pain, which classification of burn depth should the nurse document? A. Superficial partial thickness B. Deep partial thickness C. Deep full thickness D. Full thickness D. Full thickness Full thickness burn involves total destruction of the epidermis and dermis and in some cases the underlying tissue, muscle, and bone the description of the burn as severely swollen with a wound bed that appears brown and yellow and the pt reports no pain is consistent with full thickness burn A. Incorrect: Superficial partial thickness burn involves the destruction of the epidermis and possibly a portion of the dermis. B: Incorrect: Deep partial thickness burn involves the destruction of the epidermis and upper layers of the dermis and injury to the deeper portions of the dermis, C. Incorrect: Deep full thickness burns are a more severe form of full thickness burns that extend beyond the dermis into deeper tissues. A male client is admitted to the emergency department while vomiting dark brown foul smelling emesis, he reports having a surgical repair of a recurrent inguinal hernia a week ago and is troubled by intense abdominal pain, After finding that his bowel sounds are hyperactive which prescription should the nurse implement first? A. Insert a nasogastric tube (NGT) and attach to low intermittent suctions (LIS) B. Place an indwelling urinary catheter and attach a bedside drainage unit C. Give a prescribed analgesics for temp above 101 F orally D. Send the client to Xray for a flat plate of the abdomen. A. Insert a nasogastric tube and attach to low intermittent suction A: Correct: Inserting a NG tube and attaching it to low intermittent suction helps decompress the stomach and relieve symptoms of bowel obstruction. While performing a neurovascular assessment distal to a clients fracture site the nurse determines that the clients pulse is present, regular and full which nursing action should be taken next? A. Document the NV assessment as normal A. Document the NV assessment as normal A 35 year olde women who works as a legal secretary presents to the outpatient clinic for assessment of consistent pain in her hands, The client reports that the pain is the same in both hands and wrists but is worse upon waking. The pain and stiffness have been going on for the past 3 months, She shares that she thinks she has arthritis because her mother and grandmother both have arthritis? Based on the data provided determine the most likely condition the client is experiencing, two actions the nurse should take to address that condition and two parameters to monitor to assess progress: A. Rheumatoid Arthritis B. Osteoarthritis C. Carpal Tunnel syndrome D. Gout A. Potential conditions: Rheumatoid arthritis A: Correct: RA is a chronic inflammatory disorder that can affect more than just your joints. In some people the condition can damage a wide variety of body systems, including the skin, eyes, lungs, heart and blood vessels, Signs and symptoms: Tender, warm, swollen joints, joint stiffness that is usually worse in the mornings and after inactivity, fatigue, fever and loss of appetite. B Actions to take: Consult dietician for nutrition and weight loss, educate on disease process. C, Parameter to monitor: Pain and physical activity Carpal tunnel syndrome: condition that causes numbness, tingling and other symptoms in the hand and arm, Caused by compressed nerve in carpal tunnel a narrow passageway on the palm side of your wrist. The anatomy of your wrist, health problems and possibly repetitive hand motions can contribute to carpal tunnel. Gout: Common complex form of arthritis that can affect anyone, Its characterized by sudden severe attacks of pain, swelling, redness and tenderness in joints, often the joint at the base of the big toe, An attack of gout can occur sudden often waking you up in middle of night with sensation of big toe on fire, the affected joint is hot, swollen and so tender that even weight of sheet is intolerable, A client with chronic syndrome of inappropriate antidiuretic hormone (SIADH) reports to the nurse of being constantly thirst. Which action should the nurse take? A. Encourage the client to use hard candy frequently to help relieve thirst. B. Measure the clients capillary glucose reading at regular intervals C. Withhold the next diuretic dose until contacting the health care provider. D. Provide the client with additional oral fluids of her preference. A. Encourage the client to use hard candy frequently to help relieve thirst. Hard candy helps relive the sensation of thirst without causing fluid overload. C: incorrect: Withholding diuretics without medical advise could be harmful and is not related to managing thirst D: incorrect: providing additional oral fluids may exacerbate fluid retention in SIADH A client with eczema is applying 10% urea cream onto the affected skin areas. which finding reflects the expected therapeutic response? A. Reduced pain in eczematous areas B. Hydration of affected dry skin areas C. Healing with a return to normal skin appearance D. Decreased weeping of ulcerations in affected areas. B Hydration of affected dry skin areas. B: Correct: Urea is a natural moisturizing factor that helps retain water in the skin, Applying urea cream to affected dry skin areas is expected to hydrate the skin, reduce dryness, and improve overall moisture balance. The parent of an adolescent tells the clinic nurse my child has athletes feet, I have been applying triple antibiotic ointment for two days but there has been no improvement which instruction should the nurse provide? A. Antibiotics take two weeks to become effective against infections such as athletes foot B. Stop using the ointment and encourage complete drying of feet and wearing clean socks C. Continue using the ointment for a full week even after the symptoms diappear. D. Applying to much ointment can deter its effectiveness. Apply a thin layer to prevent maceration.. B. Stop using the ointment and encourage complete drying of feet and wearing clean socks B: Correct: Athletes foot is fungal infection and proper foot hygiene including keeping the feet dry and wearing clean socks is essential for tx. A: incorrect: Antibiotics are not effective against fungal infections like athletes foot Following a transurethral resection of the prostate (TURP) a client is discharged from the hospital with an indwelling urinary catheter. which instruction is most important for the nurse to include in the discharge teaching plan? A. Eliminate all spicy foods from your diet B. Clamp the catheter when taking a shower C. Drink 3 liters of water each day D. Avoid driving a car for 2 weeks C: Drink 3 liters of water each day C: Correct Drinking 3 liters of water each day is important as it helps flush the bladder and reduce the risk of UTI which are common complications after a TURP Two hours before a clients scheduled surgery the nurse is completing the preoperative checklist. Which information requires the most immediate action by the nurse? A preoperative serum potassium level is 2.8 B. Surgical consent form is not signed C. Clients pulse ox reading is 96% D. Preoperative serum potassium level is 2.8 A: Preoperative serum potassium level is 2.8 Potassium reference ranges: 3.5-5) A: Correct a serum potassium level of 2.8 is critically low. Hypokalemia can lead to severe complications, including cardiac arrhythmias and muscle weakness which can significantly impact the clients ability to safely undergo surgery, This requires immediate attention to correct electrolyte imbalance before sx A client with a history of asthma reports having episodes of bronchoconstriction and increased mucus production while exercising, Which action should the nurse implement? A. Determine if the client is using an inhaler before exercising. B. Assess client for signs of symptoms of upper airway infection C. Teach client to use pursed lip breathing when episode occur D. Review the clients routine asthma management prescriptions. A. Determine if the client is using an inhaler before exercising. (review the clients routine asthma management prescription) The nurse is developing a plan of care for a client with type 2 diabetes mellitus wen providing teaching on lowering blood glucose levels and increasing serum high density lipoprotein (HDL) levels which instruction should the nurse include? A. Regular exercise with medical approval B. Limit calories on days unable to exercise C. Monitor blood glucose levels daily D. Monthly appts with dietitian A. Regular exercise with medical approval A: incorrect: Regular exercise is a vital component of managing type 2 diabetes. It helps to lower blood glucose levels, improve insulin sensitivity and increase HDL (THE good cholesterol) levels. However it is important for the client to obtain medical approval before starting or modifying an exercise regimen, The healthcare provider can assess the clients overall health status and provide specific recommendations regarding the type, duration, and intensity of exercise suitable for the clients individual needs and any potential limitations. The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis, Which diagnostic procedure should the nurse prepare the client for? A. Lumbar puncture B. Skull radiography C. Magnetic resonance imaging D. CT A. Lumbar puncture A lumbar puncture is the primary diagnostic procedure for suspected bacterial menigitis. The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD), which subjective data reported by the client supports this medical diagnosis? A. Sever abdominal cramps and diarrhea after eating spicy foods. B. Frequent use of chewable and liquid antacids for indigestion C. Upper mid abdominal pain described as gnawing and burning D. Marked loss of weight and appetite over the last 3 or 4 months. C. Upper mid abdominal pain described as gnawing and burning Peptic ulcer disease involves the formation of open sores in the lining of the stomach or the duodenum, The characteristics symptom of PUD is abdominal pain, typically located in upper mid abdomen, This pain is often described as gnawing, burning or aching in nature, The pain may occur shortly after eating especially when the stomach is empty (gastric ulcer) or it may occur 2-3 hours after eating typically at night (duodenal ulcer) A: incorrect describes symptoms more suggestive of irritable bowel syndrome (IBS) or gastrointestinal sensitivity to spicy foods leading to cramps and diarrhea, D: incorrect: Suggests more severe systemic issues such as malignancy or chronic diseases NGN: A 68 year old male client is 24 hours postoperative from left hip surgery on the orthopedic floor, The surgery was due to a fall, No surgical complications were noted. Total right knee surgery was done due to osteoarthritis 18 months ago and the client has a significant history of tobacco use smoking half a pack per day for 25 years. complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing? Potential condition: Surgical complication of DVT Actions to take: anticoagulation therapy STAT and early ambulation Parameters to monitor: Development of pulmonary embolus and CBC, platelet count, coagulation studies, and stool for occult blood. which nursing problem has the highest priority when planning care for a client with osteomalacia? A, Risk for injury B. Altered tissue perfusion C. Sleep pattern disturbance D. Risk for infection A. Risk for injury People with osteomalacia have weakened bones ad are at high risk for fractures making injury prevention the highest priority An adult women with Graves disease is admitted with severe dehydration and malnutrition she is currently restless and refusing to eat. which action is most important for the nurse to implement? A. Teach the client relaxation techniques B. Determine the clients food preferences C. Keep room temp cool D. Maintain a patient intravenous site D. Maintain a patient intravenous site Maintaining a patent iv site is the most important action a paten iv site can allow the nurse to administer fluids electrolytes medications and nutrients to the client who is at risk of dehydration, malnutrition and complications from graves disease such as thyroid storm cardiac arrhythmias and infection. Nurse should monitor the clients VS, fluid intake and output, BG, and thyroid function test and adjust iv therapy accordingly The nurse is teaching a client how to collect a sputum specimen, which steps should the nurse instruct the client to follow when collecting a sputum? A. Restrict fluids before expectorating the sputum specimens B. Obtain the specimen before bedtime C. Avoid Mouth care prior to collecting the sputum D. Breathe deeply, followed by coughing up the sputum D. Breathe deeply, followed by coughing up sputum Taking deep breaths followed by coughing helps produce sputum form the lungs which is necessary for accurate diagnostic testing A client with pernicious anemia takes supplemental folate and self administer monthly vitamin B 12 injections, The client reports feeling increasingly fatigued. Which laboratory value should the nurse review? A, Complete blood count B. Platelet count C. Liver enzymes D. Serum electrolytes A. Complete blood count CBC provides information about hemoglobin and hematocrit levels which are directly impacted by pernicious anemia and can explain fatigue An older adult client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half the food on the meal tray. The clients family expresses concern about the clients nutritional status, How should the nurse respond to the family's concern? A. Demonstrate the use of visual scanning during meals to the client and family B. Explain that weight loss will be reversed after the acute phase of the stroke has ended C. Suggest that the family brings food from home that the client enjoys eating D. Encourage the family to offer to feed the client when she does not eat her entire meal A. Demonstrate the use of visual scanning during meals to the client and family demonstrating the use of visual scanning during meals can help the client overcome the difficulty with visual perception, which is a common problem after a CVA, Visual perception is the ability to interpret and process the information received from the eyes. A CVA can damage the parts of the brain that are responsible for visual perception causing impairments such s hemianopia, neglect or agnosia, Visual scanning is a technique that involves moving the eyes or the head from side to side to scan the entire visual field and compensate for the missing or distorted information, Visual scanning can help the client see all the food on the tray and eat more adequately An older adult client with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. She is anxious and is complaining of a dry mouth Which intervention should the nurse implement? A. Assist client to an upright position B. Administer a prescribed sedative C. Encourage client to drink water D. Apply a high flow venturi mask A. Assist client to an upright position Upright position helps improve respiratory mechanics by reducing the pressure on the diaphragm and allowing better lung expansion, This position enhance the efficiency of breathing and alleviate symptoms of breathlessness A client with cholelithiasis is admitted with jaundice due to obstruction to the common bile duct. which finding is most important for the nurse to report to the health care provider A. Bile stained emesis B. Clay colored stool C. Radiating, sharp pain in the right shoulder D. Distended, hard rigid abdomen D. Distended, hard, and rigid abdomen Distended, hard, and rigid abdomen suggest peritonitis or perforated organ which requires immediate medical attention C:: incorrect radiating sharp pain in the right shoulder is common in gallbladder issues but is not immediately life threatening as distended hard rigid abdomen B: Clay colored stool is a sign of bile duct obstruction but in to urgent A: Biles stained emesis indicates an obstruction but not as immediate as distended hard and rigid abdomen Which information should the nurse include in the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD)? MINIMIZE SYMPTOMS BY WEARING LOOSE, COMFORTABLE CLOTHING Which group of foods is best for the nurse to recommend for clients with a strong family history of colon and rectal cancers? OATMEAL, RAISINS, AND FRUIT WITH SKIN The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the client for the healthcare provider? LUMBAR PUNCTURE A client who has small cell carcinoma of the lung is admitted with symptoms of syndrome of inappropriate antidiuretic hormone (SIADH). As the client responds to treatment, the client's serum sodium level increases from 120 mEq/L (120 mmol/L) to 125 mEq/L (125 mmol/L). Based on this finding, which intervention should the nurse implement? WITHHOLD NEXT SCHEDULED DOSE OF TREATMENT A nurse is preparing a client for discharge who was recently diagnosed with Addison's disease. Which instruction is most important for the nurse to include in this client's discharge teaching? TAKE PRESCRIBED CORTISONE ACCURATELY While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values? WHITE BLOOD CELL (WBC) COUNT An adult client who had a gastric bypass surgery 2 weeks ago, is admitted with possible anastomosis leakage. The client's abdomen is tender to touch, and the vital signs are" temperature 101 F (38.3 C), heart rate 130 beats/minute, respiratory rate 26 breaths/minute, and blood pressure 100/50 mm Hg. Which intervention is most important for the nurse to include in the client's plan of care? STRICT INTRAVENOUS (IV) FLUID REPLACEMENT The nurse is providing teaching to a client admitted with a blood glucose level of 580 mg/dL about preventing complications related to diabetes mellitus. Which information stated by the client indicates understanding? INCLUDE NO MORE THAN 1-2 ALCOHOLIC BEVERAGES IN DIET PER DAY The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes the following vital signs: heart rate 140 beats/minute, respirations 26 breaths/minute, and blood pressure 140/90 mm Hg. Which intervention is most important for the nurse to implement? MEDICATE FOR PAIN AND MONITOR VITAL SIGNS ACCORDING TO PROTOCOL The nurse assesses a client with cirrhosis and find 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis? HYPOALBUMINEMIA THAT RESULTS IN A DECREASED COLLOIDAL ONCOTIC PRESSURE The home health nurse provides teaching about insulin self injection to a client who was recently diagnosed with diabetes mellitus. When the client begins to perform a return demonstration of an insulin injection into the abdomen as seen in the video, which instructions should he nurse provide? (Video of client Picture of thighs) CONTINUE WITH THE INSULIN INJECTION A client arrives to the medical-surgical unit 4 hours after a transurethral resection of the prostate. A triple-lumen catheter for continuous *** irrigation with normal saline is infusing and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag. What action should the nurse take? MONITORING CATHETER DRAINAGE A client arrives to the emergency department reporting an intermittent fever and night sweats for the past 3 weeks and has developed a productive cough containing small amounts of blood. Which intervention should the nurse prioritize? MOVE INTO AIRBORNE ISOLATION A client with right hydronephrosis and a history of renal calculi is preparing for discharge following a retrograde pyelogram. Which instruction should the nurse include in the client's discharge instructions? MONITOR URINARY STREAM FOR DECREASED OUTPUT While caring for a client with Guillain-Barre syndrome, the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse? SENSORY LOSS AT T-8 Which action should the nurse implement to reduce the risk of vesicant extravasation in the client who is receiving intravenous chemotherapy? MONITOR THE CLIENT’S INTRAVENOUS SITE HOURLY DURING THE TREATMENT The nurse is providing discharge teaching to an older adult client hospitalized for treatment of venous leg ulcers. Which instruction(s) should the nurse include in the teaching plan? (Select all that apply.) INSPECT ANKLES DAILY FOR AREAS OF DARKENING SKIN. EAT A DIET THAT IS HIGH IN PROTEIN AND VITAMINS A AND C. KEEP LEGS ELEVATED WHEN SITTING OR LAYING DOWN. After falling down the basement steps, a client is brought to the emergency room. X-rays confirms that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse? RIGHT FOOT PALE WITH SLUGGISH CAPILLARY REFILL The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about huff coughing to clear secretions. During the client's return demonstration, he client uses pursed lips during exhalation. Which action should the nurse do next? INSTRUCT THE CLIENT AFTER INHALING DEEPLY TO QUICKLY AND FORCEFULLY EXHALE 2 TO 3 TIMES. A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse immediately to the healthcare provider? LOWER BACK PAIN AND HYPOTENSION The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client mange the pain, which assessment data is most important for the nurse to obtain? EATING PATTERNS OF DIETARY INTAKE A client with gouty arthritis reports tenderness and swelling of the right ankle and great toe. The nurse observes the area of inflammation extends above the ankle area. The client receives prescriptions for colchicine and indomethacin. Which instruction should the nurse include in the discharge teaching? DRINK AT LEAST 8 CUPS (1920 ML) OF WATER A DAY An older client is admitted with an acute onset of diverticulitis and intravenous antibiotic therapy is initiated. Which intervention should the nurse implement next? MAINTAIN THE CLIENT’S NPO STATUS A young adult client with osteoarthritis of both knees tells the nurse the desire to continue daily walks in the park with friends. How should the nurse respond? ENCOURAGE CONTINUED MAINTENANCE OF THE WALKING ROUTINE A client receives a prescription for 1 liter of 0.9% sodium chloride. USP intravenously (IV) to be infused over 4 hours. The IV administration set delivers 10 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding, round to the nearest whole number) 42 A client in the operating room received succinylcholine. The client is experiencing muscle rigidity and has an extremest high temperature. Which action should the nurse implement? PREPARE ICE PACKS FOR PLACEMENT IN THE CLIENT’S AXILLARY AREA An adult who was recently diagnosed with glaucoma tells the nurse, "It feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client? MAINTAIN PRESCRIBED EYE DROP REGIMEN A nurse is assessing a client who has an arteriovenous (AV) graft in the right forearm for hemodialysis access. The nurse auscultates a bruit over the graft area. Which intervention should the nurse implement? DOCUMENT THE FINDINGS An older client who is agitated, dyspneic, orthopneic, and using accessory muscles to breath is admitted for further treatment. Initial assessment includes a heart rate 128 beats/minutes and irregular, respirations 38 breaths/minute, blood pressure 168/100 mm Hg, wheezes and crackles in all lung fields. An hour after administration of furosemide 60 mg intravenous (IV), which assessment(s) should the nurse obtain to determine the client's response to treatment? (Select all that apply.) URINARY OUTPUT. LUNG SOUNDS. OXYGEN SATURATION. The healthcare provider prescribes penicillin 200,000 units intramuscularly for a client with pneumonia. The available vial is labeled, "Penicillin 500,000 units/mL." How many mL should the nurse administer to this client? (Enter numerical value only. If rounding, round to the nearest tenth.) 0.4 The healthcare provider prescribes diagnostic tests for a client whose chest x-ray indicates pneumonia. Which diagnostic test should the nurse review for implementation in the most therapeutic of the pneumonia? SPUTUM CULTURE AND SENSITIVITY The nurse is caring for a client with a burn that is severely edematous with a wound bed that is brown and yellow in appearance. The client expresses feeling no pain. Which classification of burn depth should the nurse document? FULL-THICKNESS While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the client's fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take? DISCUSS APPROACHES TO CHRONIC PAIN CONTROL WITH THE CLIENT The nurse is obtaining a health history from a new client who has a history of kidney stones. Which statement by the client indicates and increased risk for renal calculi? EAT A VEGETARIAN DIET WITH CHEESE 2 TO 3 TIMES A DAY A client presents to the emergency department reporting chest pain that is radiating to the left arm, shortness of breath, and diaphoresis. Which medication should the nurse anticipate being prescribed by the healthcare provider? MORPHINE The nurse is evaluating a client's understanding of diet teaching about the DASH (Dietary Approaches to Stop Hypertension) eating plan. Which behavior indicates that the client is adhering to the eating plan? ENJOYS FAT-FREE YOGURT AS AN OCCASIONAL SNACK FOOD The nurse is providing teaching to a client with Type 2 diabetes mellitus and peripheral neuropathy. Which information should the nurse provide? FAMILY MEMBERS CAN HELP WITH REGULAR FOOT EXAMS A client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse? Hematocrit [Reference Range: Male: 42% to 52% (0.42 to 0.52 volume fraction)] FURTHER DECLINE IN LEVEL OF CONSCIOUSNESS A client receives a prescription for 1 liter of lactated Ringer's intravenously (IV) to be infused over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.) 125 A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client's medical record should the nurse recognize as a contraindication for peritoneal dialysis? CROHN’S DISEASE WITH COLECTOMY A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 0 to 10 scale. Which intervention should the nurse implement? ADMINISTER OPIOD AND NON-OPIOID MEDICATION SIMULTANEOUSLY A client who has developed acute kidney injury (AKI) due to an aminoglycoside antibiotic has moved from the oliguric phase to the diuretic phase of AKI. Which parameters are most important for the nurse to plan to carefully monitor? HYPOVOLEMIA AND ELECTROCARDIOGRAPHIC (ECG) CHANGES The nurse is caring for client who reports a sudden, severe headache, and facial numbness. The nurse asks the client to smile and observes an uneven smile with facial droop to the right side and a hand grasps strength that is weaker on the right side than the left. The client denies a recent history of headaches or trauma. Which intervention should the nurse should perform in the immediate management of the client? START TWO LARGE BORE IV CATHETERS AND REVIEW INCLUSION CRITERIA FOR IV FIBRINOLYTIC THERAPY The parent of an adolescent tells the clinic nurse. "My child has athlete's feet. I have been applying triple antibiotic ointment for two days, but there has been no improvement." Which instruction should the nurse provide? STOP USING THE OINTMENT AND ENCOURAGE COMPLETE DRYING OF FEET AND WEARING CLEAN SOCKS The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving a psoralen and ultraviolet A light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment? TENDERNESS UPON PALPATION AND GENERALYZED ERYTHEMA An obese client with emphysema who smokes at least a pack of cigarettes daily is admitted after experiencing a sudden increase in dyspnea and activity intolerance. Oxygen therapy is initiated and it is determined that the client will be discharged with oxygen. Which information is most important for the nurse to emphasize in the discharge teaching plan? GUIDELINES FOR OXYGEN USE An overweight, young adult client who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. The client reports feeling very weak and jittery. Which action(s) should the nurse implement? (Select all that apply.) MEASURE PULSE AND BLOOD PRESSURE. ASSESS SKIN TEMPERATURE AND MOISTURE. CHECK FINGERSTICK GLUCOSE LEVEL. A client with multiple sclerosis has urinary retention to sensorimotor deficits. Which action should the nurse include in the client's plan of care? TEACH THE CLIENT TECHNIQUES FOR PERFORMING INTERMITTENT CATHETERIZATION A client who was recently diagnosed with Raynaud's disease is concerned about pain management. Which nursing instruction should the nurse provide? WEARING GLOVES WHEN HANDLING COLD ITEMS GUARDS AGAINST PAINFUL SPASMS The nurse is preparing a client for surgery who was admitted to the emergency center following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently received heparin sodium 5,000 units subcutaneously daily. Which is the priority nursing action? NOTIFY THE HEALTHCARE PROVIDER OF THE CLIENTS MEDICATION HISTORY The nurse is caring for a client with human immunodeficiency virus (HIV) who has developed oral thrush and is experiencing burning and soreness in the mouth. Which intervention should the nurse implement first? ADMINISTER A TOPICAL ANALGESIC The nurses assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review? PLATELET COUNT Following a transurethral resection of the prostate (TURP), a client is discharged from the hospital with an indwelling urinary catheter. Which instruction is most important for the nurse to include in the discharge teaching plan? DRINK 3 LITERS OF WATER EACH DAY