hesi med surg exam
An ER nurse is completing an assessment on a patient that is alert but struggles to
answer questions. When she attempts to talk, she slurs her speech and appears very
frightened. What additional clinical manifestation does the nurse expect to find if
nacy's sysmptoms have been caused by a brain attack (stroke)?
A. A carotid bruit
B. A hypotensive blood pressure
C. hyperreflexic deep tendon relexes.
D. Decreased bowel sounds
A) A carotid bruit.
Rationale: the carotid artery (artery to the brain) is narrowed in clients with a brain
attack. A bruit is an abnormal sound heard on auscultation resulting from interference
with normal blood flow. Usually the blood pressure is hypertensive. Initially flaccid
paralysis occurs, resulting in hyporefkexic deep tendon reflexes. Bowel sounds are not
indicative of a brain attack.
Which clinical manifestation further supports an assessment of a left-sided brain
attack?
A) Visual field deficit on the left side.
B) Spatial-perceptual deficits.
C) Paresthesia of the left side.
D) Global aphasia.
D) Global aphasia.
Rationale: Global aphasia refers to difficulty speaking, listening, and understanding, as
well as difficulty reading and writing. Symptoms vary from person to person. Aphasia
may occur secondary to any brain injury involving the left hemisphere. Visual field
deficits, spatial-perceptual deficits, and paresthsia of the left side usually occur with
right-sided brain attack.
When preparing a patient for a noncontrast computed tomography (CT) scan STAT,
what nursing intervention should the nurse implement?
A) Determine if the client has any allergies to iodine
B) Explain that the client will not be able to move her head throughout the CT scan.
C) Premedicate the client to decrease pain prior to having the procedure.
D) Provide an explanation of relaxation exercises prior to the procedure.
B) Explain that the client will not be able to move her head throughout the CT scan.
Rationale: Because head motion will distort the images, Nancy will have to remain still
throughout the procedure. Allergies to iodine is important if contrast dye is being used
for the CT scan. Premedicating the client to decrease pain prior to the procedure is
unnecessary because CT scanning is a noninvasive and painless procedure. Providing
an explanation of relaxation exercises prior to the procedure is a worthwhile
intervention to decrease anxiety but is not of highest priority.
A neurologist prescribes a magnetic resonance imaging (MRI) of the head STAT for a
patient. Which data warrants immediate intervention by the nurse concerning this
diagnostic test?
A) Elevated blood pressure.
B) Allergy to shell fish.
C) Right hip replacement.
D) History of atrial fibrillation.
C) Right hip replacement.
The magnetic field generated by the MRI is so strong that metal-containing items are
strongly attracted to the magnet. Because the hip joint is made of metal, a lead shield
must be used during the procedure. Elevated blood pressure, an allergy to shell fish,
and a history of atrial fibrillation would not affect the MRI.
A client's daughter is sitting by her mother's bedside who was recently transferred to
the Intermediate Care Unit. She states "I don't understand what a brain attack is.
The healthcare provider told me my mother is in serious condition and they are going
to run several tests. I just don't know what is going on. What happened to my
mother?" What is the best response by the nurse?
A) "I am sorry, but according to the Health Insurance Portability and Accounting Act
(HIPAA), I cannot give you any information."
B) "Your mother has had a stroke, and the blood supply to the brain has been
blocked."
C) "How do you feel about what the healthcare provider said?"
D) "I will call the healthcare provider so he/she can talk to you about your mother's
serious condition."
B) "Your mother has had a stroke, and the blood supply to the brain has been blocked."
Rationale: The nurse can discuss what a diagnosis means. Nancy is unable to make
,hesi med surg exam
decisions, so the next of kin, her daughter, Gail, needs sufficient information to make
informed decisions. The nurse has the knowledge, and the responsibility, to explain
Nancy's condition to Gail. The nurse should give facts first, and then address her
feelings after the information is provided.
What is the normal range for cardiac output?
The normal range for cardiac output to ensure cerebral blood flow and oxygen delivery
is 4 to 8 L/min.
A client was admitted with the diagnosis of a brain attack. Their symptoms began 24
hours before being admitted. Why would this client not be a candidate for for
thrombolytic therapy?
Thrombolytic therapy is contraindicated in clients with symptom onset longer than 3
hours prior to admission. This client had symptoms for 24 hours before being brought
to the medical center
What are plate guards?
Plate guards prevent food from being pushed off the plate. Using plate guards and
other assistive devices will encourage independence in a client with a self-care deficit.
Which condition is considered a non-modifiable risk factor for a brain attack?
A) High cholesterol levels.
B) Obesity.
C) History of atrial fibrillation.
D) Advanced age.
D) Advanced age.
Rationale: People over age 55 are a high-risk group for a brain attack because the
incidence of stroke more than doubles in each successive decade of life. Non-
modifiable means the client cannot do anything to change the risk factor. All the other
options are modifiable risk factors.
A client is experiencing homonymous hemianopsia as the result of a brain attack.
Which nursing intervention would the nurse implement to address this condition?
A) Turn Nancy every two hours and perform active range of motion exercises.
B) Place the objects Nancy needs for activities of daily living on the left side of the
table.
C) Speak slowly and clearly to assist Nancy in forming sounds to words.
D) Request that the dietary department thicken all liquids on Nancy's meal and snack
trays.
B) Place the objects Nancy needs for activities of daily living on the left side of the
table.
Rationale: Homonymous hemianopsia is loss of the visual field on the same side as the
paralyzed side. This results in the client neglecting that side of the body, so it is
beneficial to place objects on that side. Nancy had a left-hemisphere brain attack so
her right side is the weak side. Speaking slowly and clearly would address the client's
verbal deficits due to aphasia. Requesting all liquids to be thickened would address
dysphagia. Turning the client every 2 hours and performing active range of motion
exercises would address the client's risk for immobility due to paralysis.
A physical therapist (PT) places a gait belt on a client and is assisting them with
ambulation from the bed to the chair. As they get up out of the bed, they report being
dizzy and begin to fall. The PT carefully allows them to fall back to the bed and
notifies the primary nurse. Which written documentation should the nurse put in the
client's record?
A) Client experienced orthostatic hypotension when getting out of bed.
B) PT reported client complained of dizziness when getting out of bed, and gait belt
was used to allow client to fall back onto the bed.
C) PT notified the primary nurse that the client could not ambulate at this time
because of dizziness.
D) Client had difficulty ambulating from the bed to the chair when accompanied by
the PT, variance report completed.
B) PT reported client complained of dizziness when getting out of bed, and gait belt
was used to allow client to fall back onto the bed.
Rationale: This documentation provides the factual data of the events that occurred.
A)The nurse is making an assumption that the dizziness was caused by orthostatic
hypotension. C) Not all the pertinent facts are included in this documentation.
D) A variance report should never be documented in the client's record.
,hesi med surg exam
A new nurse graduate is caring for a postoperative client with the following arterial
blood gases (ABGs): pH, 7.30; PCO2, 60 mm Hg; PO2, 80 mm Hg; bicarbonate, 24
mEq/L; and O2 saturation, 96%. Which of these actions by the new graduate is
indicated?
A) Encourage the client to use the incentive spirometer and to cough.
B) Administer oxygen by nasal cannula.
C) Request a prescription for sodium bicarbonate from the health care provider.
D) Inform the charge nurse that no changes in therapy are needed.
A) Encourage the client to use the incentive spirometer and to cough.
Rationale: Respiratory acidosis is caused by CO2 retention and impaired chest
expansion secondary to anesthesia. The nurse takes steps to promote CO2 elimination,
including maintaining a patent airway and expanding the lungs through breathing
techniques. O2 is not indicated because Po2 and oxygen saturation are within the
normal range. Sodium bicarbonate is not indicated because the bicarbonate level is in
the normal range; promoting excretion of respiratory acids is the priority in respiratory
acidosis. Post anesthesia, the client will need interventions as described in A above or
may progress to a state of somnolence and unresponsiveness.
The nurse is providing dietary instructions to a 68-year-old client who is at high risk
for development of coronary heart disease (CHD). Which information should the
nurse include?
A) Limit dietary selection of cholesterol to 300 mg per day
B) Increase intake of soluble fiber to 10 to 25 grams per day.
C) Decrease plant stanols and sterols to less than 2 grams/day.
D) Ensure saturated fat is less than 30% of total caloric intake.
B) Increase intake of soluble fiber to 10 to 25 grams per day.
Rationale: To reduce risk factors associated with coronary heart disease, the daily
intake of soluble fiber (B) should be increased to between 10 and 25 gm. Cholesterol
intake (A) should be limited to 180 mg/day or less. Intake of plant stanols and sterols is
recommended at 2 g/day (C). Saturated fat (D) intake should be limited to 7% of total
daily calories.
A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which
statement by the nurse provides the most accurate explanation for use of the splints?
A) Prevention of deformities.
B) Avoidance of joint trauma.
C) Relief of joint inflammation.
D) Improvement in joint strength.
A) Prevention of deformities.
Rationale: Splints may be used at night by clients with rheumatoid arthritis to prevent
deformities (A) caused by muscle spasms and contractures. Splints are not used for (B).
(C) is usually treated with medications, particularly those classified as non-steroidal
antiinflammatory drugs (NSAIDs). For (D), a prescribed exercise program is indicated.
A 32-year-old female client complains of severe abdominal pain each month before
her menstrual period, painful intercourse, and painful defecation. Which
additional history should the nurse obtain that is consistent with the client's
complaints?
A) Frequent urinary tract infections.
B) Inability to get pregnant.
C) Premenstrual syndrome.
D) Chronic use of laxatives.
B) Inability to get pregnant.
Rationale: Dysmenorrhea, dyspareunia, and difficulty or painful defecation are
common symptoms of endometriosis, which is the abnormal displacement of
endometrial tissue in the dependent areas of the pelvic peritoneum. A history of
infertility (B) is another common finding associated with endometriosis. Although (A,
C, and D) are common, nonspecific gynecological complaints, the most common
complaints of the client with endometriosis are pain and infertility.
A client with a 16-year history of diabetes mellitus is having renal function tests
because of recent fatigue, weakness, elevated blood urea nitrogen, and serum
creatinine levels. Which finding should the nurse conclude as an early symptom of
renal insufficiency?
A) Dyspnea.
B) Nocturia.
C) Confusion.
D) Stomatitis.
B) Nocturia.
Rationale: As the glomerular filtration rate decreases in early renal insufficiency,
, hesi med surg exam
metabolic waste products, including urea, creatinine, and other substances, such
phenols, hormones, electrolytes, accumulate in the blood. In the early stage of renal
insufficiency, polyuria results from the inability of the kidneys to concentrate urine and
contribute to nocturia (B). (A, C, and D) are more common in the later stages of renal
failure.
A client with heart disease is on a continuous telemetry monitor and has developed
sinus bradycardia. In determining the possible cause of the bradycardia, the nurse
assesses the client's medication record. Which medication is most likely the cause of
the bradycardia?
A) Propanolol (Inderal).
B) Captopril (Capoten).
C) Furosemide (Lasix).
D) Dobutamine (Dobutrex).
A) Propanolol (Inderal).
Rationale: Inderal (A) is a beta adrenergic blocking agent, which causes decreased
heart rate and decreased contractility. Neither (B), an ACE inhibitor, nor (C), a loop
diuretic, causes bradycardia. (D) is a sympathomimetic, direct acting cardiac stimulant,
which would increase the heart rate.
A client has been taking oral corticosteroids for the past five days because of
seasonal allergies. Which assessment finding is of most concern to the nurse?
A) White blood count of 10,000 mm3.
B) Serum glucose of 115 mg/dl.
C) Purulent sputum.
D) Excessive hunger.
C) Purulent sputum.
Rationale: Steroids cause immunosuppression, and a purulent sputum (C) is an
indication of infection, so this symptom is of greatest concern. Oral steroids may
increase (A) and often cause (D). (B) may remain normal, borderline, or increase while
taking oral steroids.
A female client receiving IV vasopressin (Pitressin) for esophageal varice rupture
reports to the nurse that she feels substernal tightness and pressure across her
chest. Which PRN protocol should the nurse initiate?
A) Start an IV nitroglycerin infusion.
B) Nasogastric lavage with cool saline.
C) Increase the vasopressin infusion.
D) Prepare for endotracheal intubation.
A) Start an IV nitroglycerin infusion.
Rationale: Vasopressin is used to promote vasoconstriction, thereby reducing bleeding.
Vasoconstriction of the coronary arteries can lead to angina and myocardial infarction,
and should be counteracted by IV nitroglycerin per prescribed protocol (A). (B) will not
resolve the cardiac problem. (C) will worsen the problem. Endotracheal intubation may
be needed if respiratory distress occurs (D).
A client with gastroesophageal reflux disease (GERD) has been experiencing severe
reflux during sleep. Which recommendation by the nurse is most effective to assist
the client?
A) Losing weight.
B) Decreasing caffeine intake.
C) Avoiding large meals.
D) Raising the head of the bed on blocks.
D) Raising the head of the bed on blocks.
Rationale: Raising the head of the bed on blocks (D) (reverse Trendelenburg position)
to reduce reflux and subsequent aspiration is the most effective recommendation for a
client experiencing severe gastroesophageal reflux during sleep. (A, B and C) may be
effective recommendations but raising the head of the bed is more effective for relief
during sleep.
The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone
(SIADH), which is manifested by which symptoms?
A) Loss of thirst, weight gain.
B) Dependent edema, fever.
C) Polydipsia, polyuria.
D) Hypernatremia, tachypnea.
A) Loss of thirst, weight gain.
Rationale: SIADH occurs when the posterior pituitary gland releases too much ADH,
causing water retention, a urine output of less than 20 ml/hour, and dilutional
An ER nurse is completing an assessment on a patient that is alert but struggles to
answer questions. When she attempts to talk, she slurs her speech and appears very
frightened. What additional clinical manifestation does the nurse expect to find if
nacy's sysmptoms have been caused by a brain attack (stroke)?
A. A carotid bruit
B. A hypotensive blood pressure
C. hyperreflexic deep tendon relexes.
D. Decreased bowel sounds
A) A carotid bruit.
Rationale: the carotid artery (artery to the brain) is narrowed in clients with a brain
attack. A bruit is an abnormal sound heard on auscultation resulting from interference
with normal blood flow. Usually the blood pressure is hypertensive. Initially flaccid
paralysis occurs, resulting in hyporefkexic deep tendon reflexes. Bowel sounds are not
indicative of a brain attack.
Which clinical manifestation further supports an assessment of a left-sided brain
attack?
A) Visual field deficit on the left side.
B) Spatial-perceptual deficits.
C) Paresthesia of the left side.
D) Global aphasia.
D) Global aphasia.
Rationale: Global aphasia refers to difficulty speaking, listening, and understanding, as
well as difficulty reading and writing. Symptoms vary from person to person. Aphasia
may occur secondary to any brain injury involving the left hemisphere. Visual field
deficits, spatial-perceptual deficits, and paresthsia of the left side usually occur with
right-sided brain attack.
When preparing a patient for a noncontrast computed tomography (CT) scan STAT,
what nursing intervention should the nurse implement?
A) Determine if the client has any allergies to iodine
B) Explain that the client will not be able to move her head throughout the CT scan.
C) Premedicate the client to decrease pain prior to having the procedure.
D) Provide an explanation of relaxation exercises prior to the procedure.
B) Explain that the client will not be able to move her head throughout the CT scan.
Rationale: Because head motion will distort the images, Nancy will have to remain still
throughout the procedure. Allergies to iodine is important if contrast dye is being used
for the CT scan. Premedicating the client to decrease pain prior to the procedure is
unnecessary because CT scanning is a noninvasive and painless procedure. Providing
an explanation of relaxation exercises prior to the procedure is a worthwhile
intervention to decrease anxiety but is not of highest priority.
A neurologist prescribes a magnetic resonance imaging (MRI) of the head STAT for a
patient. Which data warrants immediate intervention by the nurse concerning this
diagnostic test?
A) Elevated blood pressure.
B) Allergy to shell fish.
C) Right hip replacement.
D) History of atrial fibrillation.
C) Right hip replacement.
The magnetic field generated by the MRI is so strong that metal-containing items are
strongly attracted to the magnet. Because the hip joint is made of metal, a lead shield
must be used during the procedure. Elevated blood pressure, an allergy to shell fish,
and a history of atrial fibrillation would not affect the MRI.
A client's daughter is sitting by her mother's bedside who was recently transferred to
the Intermediate Care Unit. She states "I don't understand what a brain attack is.
The healthcare provider told me my mother is in serious condition and they are going
to run several tests. I just don't know what is going on. What happened to my
mother?" What is the best response by the nurse?
A) "I am sorry, but according to the Health Insurance Portability and Accounting Act
(HIPAA), I cannot give you any information."
B) "Your mother has had a stroke, and the blood supply to the brain has been
blocked."
C) "How do you feel about what the healthcare provider said?"
D) "I will call the healthcare provider so he/she can talk to you about your mother's
serious condition."
B) "Your mother has had a stroke, and the blood supply to the brain has been blocked."
Rationale: The nurse can discuss what a diagnosis means. Nancy is unable to make
,hesi med surg exam
decisions, so the next of kin, her daughter, Gail, needs sufficient information to make
informed decisions. The nurse has the knowledge, and the responsibility, to explain
Nancy's condition to Gail. The nurse should give facts first, and then address her
feelings after the information is provided.
What is the normal range for cardiac output?
The normal range for cardiac output to ensure cerebral blood flow and oxygen delivery
is 4 to 8 L/min.
A client was admitted with the diagnosis of a brain attack. Their symptoms began 24
hours before being admitted. Why would this client not be a candidate for for
thrombolytic therapy?
Thrombolytic therapy is contraindicated in clients with symptom onset longer than 3
hours prior to admission. This client had symptoms for 24 hours before being brought
to the medical center
What are plate guards?
Plate guards prevent food from being pushed off the plate. Using plate guards and
other assistive devices will encourage independence in a client with a self-care deficit.
Which condition is considered a non-modifiable risk factor for a brain attack?
A) High cholesterol levels.
B) Obesity.
C) History of atrial fibrillation.
D) Advanced age.
D) Advanced age.
Rationale: People over age 55 are a high-risk group for a brain attack because the
incidence of stroke more than doubles in each successive decade of life. Non-
modifiable means the client cannot do anything to change the risk factor. All the other
options are modifiable risk factors.
A client is experiencing homonymous hemianopsia as the result of a brain attack.
Which nursing intervention would the nurse implement to address this condition?
A) Turn Nancy every two hours and perform active range of motion exercises.
B) Place the objects Nancy needs for activities of daily living on the left side of the
table.
C) Speak slowly and clearly to assist Nancy in forming sounds to words.
D) Request that the dietary department thicken all liquids on Nancy's meal and snack
trays.
B) Place the objects Nancy needs for activities of daily living on the left side of the
table.
Rationale: Homonymous hemianopsia is loss of the visual field on the same side as the
paralyzed side. This results in the client neglecting that side of the body, so it is
beneficial to place objects on that side. Nancy had a left-hemisphere brain attack so
her right side is the weak side. Speaking slowly and clearly would address the client's
verbal deficits due to aphasia. Requesting all liquids to be thickened would address
dysphagia. Turning the client every 2 hours and performing active range of motion
exercises would address the client's risk for immobility due to paralysis.
A physical therapist (PT) places a gait belt on a client and is assisting them with
ambulation from the bed to the chair. As they get up out of the bed, they report being
dizzy and begin to fall. The PT carefully allows them to fall back to the bed and
notifies the primary nurse. Which written documentation should the nurse put in the
client's record?
A) Client experienced orthostatic hypotension when getting out of bed.
B) PT reported client complained of dizziness when getting out of bed, and gait belt
was used to allow client to fall back onto the bed.
C) PT notified the primary nurse that the client could not ambulate at this time
because of dizziness.
D) Client had difficulty ambulating from the bed to the chair when accompanied by
the PT, variance report completed.
B) PT reported client complained of dizziness when getting out of bed, and gait belt
was used to allow client to fall back onto the bed.
Rationale: This documentation provides the factual data of the events that occurred.
A)The nurse is making an assumption that the dizziness was caused by orthostatic
hypotension. C) Not all the pertinent facts are included in this documentation.
D) A variance report should never be documented in the client's record.
,hesi med surg exam
A new nurse graduate is caring for a postoperative client with the following arterial
blood gases (ABGs): pH, 7.30; PCO2, 60 mm Hg; PO2, 80 mm Hg; bicarbonate, 24
mEq/L; and O2 saturation, 96%. Which of these actions by the new graduate is
indicated?
A) Encourage the client to use the incentive spirometer and to cough.
B) Administer oxygen by nasal cannula.
C) Request a prescription for sodium bicarbonate from the health care provider.
D) Inform the charge nurse that no changes in therapy are needed.
A) Encourage the client to use the incentive spirometer and to cough.
Rationale: Respiratory acidosis is caused by CO2 retention and impaired chest
expansion secondary to anesthesia. The nurse takes steps to promote CO2 elimination,
including maintaining a patent airway and expanding the lungs through breathing
techniques. O2 is not indicated because Po2 and oxygen saturation are within the
normal range. Sodium bicarbonate is not indicated because the bicarbonate level is in
the normal range; promoting excretion of respiratory acids is the priority in respiratory
acidosis. Post anesthesia, the client will need interventions as described in A above or
may progress to a state of somnolence and unresponsiveness.
The nurse is providing dietary instructions to a 68-year-old client who is at high risk
for development of coronary heart disease (CHD). Which information should the
nurse include?
A) Limit dietary selection of cholesterol to 300 mg per day
B) Increase intake of soluble fiber to 10 to 25 grams per day.
C) Decrease plant stanols and sterols to less than 2 grams/day.
D) Ensure saturated fat is less than 30% of total caloric intake.
B) Increase intake of soluble fiber to 10 to 25 grams per day.
Rationale: To reduce risk factors associated with coronary heart disease, the daily
intake of soluble fiber (B) should be increased to between 10 and 25 gm. Cholesterol
intake (A) should be limited to 180 mg/day or less. Intake of plant stanols and sterols is
recommended at 2 g/day (C). Saturated fat (D) intake should be limited to 7% of total
daily calories.
A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which
statement by the nurse provides the most accurate explanation for use of the splints?
A) Prevention of deformities.
B) Avoidance of joint trauma.
C) Relief of joint inflammation.
D) Improvement in joint strength.
A) Prevention of deformities.
Rationale: Splints may be used at night by clients with rheumatoid arthritis to prevent
deformities (A) caused by muscle spasms and contractures. Splints are not used for (B).
(C) is usually treated with medications, particularly those classified as non-steroidal
antiinflammatory drugs (NSAIDs). For (D), a prescribed exercise program is indicated.
A 32-year-old female client complains of severe abdominal pain each month before
her menstrual period, painful intercourse, and painful defecation. Which
additional history should the nurse obtain that is consistent with the client's
complaints?
A) Frequent urinary tract infections.
B) Inability to get pregnant.
C) Premenstrual syndrome.
D) Chronic use of laxatives.
B) Inability to get pregnant.
Rationale: Dysmenorrhea, dyspareunia, and difficulty or painful defecation are
common symptoms of endometriosis, which is the abnormal displacement of
endometrial tissue in the dependent areas of the pelvic peritoneum. A history of
infertility (B) is another common finding associated with endometriosis. Although (A,
C, and D) are common, nonspecific gynecological complaints, the most common
complaints of the client with endometriosis are pain and infertility.
A client with a 16-year history of diabetes mellitus is having renal function tests
because of recent fatigue, weakness, elevated blood urea nitrogen, and serum
creatinine levels. Which finding should the nurse conclude as an early symptom of
renal insufficiency?
A) Dyspnea.
B) Nocturia.
C) Confusion.
D) Stomatitis.
B) Nocturia.
Rationale: As the glomerular filtration rate decreases in early renal insufficiency,
, hesi med surg exam
metabolic waste products, including urea, creatinine, and other substances, such
phenols, hormones, electrolytes, accumulate in the blood. In the early stage of renal
insufficiency, polyuria results from the inability of the kidneys to concentrate urine and
contribute to nocturia (B). (A, C, and D) are more common in the later stages of renal
failure.
A client with heart disease is on a continuous telemetry monitor and has developed
sinus bradycardia. In determining the possible cause of the bradycardia, the nurse
assesses the client's medication record. Which medication is most likely the cause of
the bradycardia?
A) Propanolol (Inderal).
B) Captopril (Capoten).
C) Furosemide (Lasix).
D) Dobutamine (Dobutrex).
A) Propanolol (Inderal).
Rationale: Inderal (A) is a beta adrenergic blocking agent, which causes decreased
heart rate and decreased contractility. Neither (B), an ACE inhibitor, nor (C), a loop
diuretic, causes bradycardia. (D) is a sympathomimetic, direct acting cardiac stimulant,
which would increase the heart rate.
A client has been taking oral corticosteroids for the past five days because of
seasonal allergies. Which assessment finding is of most concern to the nurse?
A) White blood count of 10,000 mm3.
B) Serum glucose of 115 mg/dl.
C) Purulent sputum.
D) Excessive hunger.
C) Purulent sputum.
Rationale: Steroids cause immunosuppression, and a purulent sputum (C) is an
indication of infection, so this symptom is of greatest concern. Oral steroids may
increase (A) and often cause (D). (B) may remain normal, borderline, or increase while
taking oral steroids.
A female client receiving IV vasopressin (Pitressin) for esophageal varice rupture
reports to the nurse that she feels substernal tightness and pressure across her
chest. Which PRN protocol should the nurse initiate?
A) Start an IV nitroglycerin infusion.
B) Nasogastric lavage with cool saline.
C) Increase the vasopressin infusion.
D) Prepare for endotracheal intubation.
A) Start an IV nitroglycerin infusion.
Rationale: Vasopressin is used to promote vasoconstriction, thereby reducing bleeding.
Vasoconstriction of the coronary arteries can lead to angina and myocardial infarction,
and should be counteracted by IV nitroglycerin per prescribed protocol (A). (B) will not
resolve the cardiac problem. (C) will worsen the problem. Endotracheal intubation may
be needed if respiratory distress occurs (D).
A client with gastroesophageal reflux disease (GERD) has been experiencing severe
reflux during sleep. Which recommendation by the nurse is most effective to assist
the client?
A) Losing weight.
B) Decreasing caffeine intake.
C) Avoiding large meals.
D) Raising the head of the bed on blocks.
D) Raising the head of the bed on blocks.
Rationale: Raising the head of the bed on blocks (D) (reverse Trendelenburg position)
to reduce reflux and subsequent aspiration is the most effective recommendation for a
client experiencing severe gastroesophageal reflux during sleep. (A, B and C) may be
effective recommendations but raising the head of the bed is more effective for relief
during sleep.
The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone
(SIADH), which is manifested by which symptoms?
A) Loss of thirst, weight gain.
B) Dependent edema, fever.
C) Polydipsia, polyuria.
D) Hypernatremia, tachypnea.
A) Loss of thirst, weight gain.
Rationale: SIADH occurs when the posterior pituitary gland releases too much ADH,
causing water retention, a urine output of less than 20 ml/hour, and dilutional
