HESI Med-Surg 2021

HESI Med-Surg 2023 What instruction should the nurse include in the discharge teaching plan of a client who had a cataract extraction today? Ans- Light housekeeping is permitted but avoid heavy lifting. A male adult comes to the urgent care clinic 5 days after being diagnosed with influenza. He is short of breath, febrile, and coughing green colored sputum. Which intervention should the nurse implement first? Ans- Obtain a sputum sample for culture. An elder male client tells the nurse that he is loosing sleep because he has to get up several times at night to go to the bathroom that he has trouble starting his urinary stream and that he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement? Ans- Palpate the bladder above the symphysis pubis. An adult client is admitted with diabetic keto acidosis (DKA) and a urinary tract infection (UTI). Prescriptions for IV ABX and insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse? Ans- Potassium of 2.5 mEq/L A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed RBC. When notifying the HCP what information should the nurse provide first using the SBAR communication process? Ans- explain specific reason for urgent notification. An adult male client is admitted for pneumocystis carinil pneumonia (PCP) secondary to AIDS. While hospitalized he receives IV pentamidine isethionate therapy. In preparing this client for discharge, what important aspect regarding his medication therapy should the nurse explain? Ans- It will be necessary to continue prophylactic doses of IV or aerosol pentane every month. A client subjective data includes dysuria, urgency, and urinary frequency. Which action should the nurse implement next? Ans- Collect a clean catch specimen. A client tells the nurse that her biopsy results indicate that the cancer cells are well differentiated. How should the nurse respond? Ans- ask the client if the HCP has given her any information about the classification of her cancer. A client with CKD is treated on hemodialysis. During the first treatment, clients blood pressure drops form 150/90 to 80/30. Which action should the nurse take first? Ans- stop dialysis treatment A client with a DVT is receiving a continuous infusion of heparin sodium 25,000 unit in 5% dextrose injection 250 mL. The prescription indicates the dosage should be increased to 900 units/hr. The nurse should program the infusion pump to deliver how many mL/hr? Ans- 9 mL/hr 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 diagnosis? Ans- upper mid abdominal gnawing and boring pain. The nurse is providing preoperative education for a jewish client scheduled to receive a xenograft to promote burn healing. Which information should the nurse provide this client? Ans- xenograft is taken from nonhuman sources. A client who took a camping vacation two weeks ago in a country with tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse to report? Ans- jaundice sclera During a home visit the nurse assesses the skin of a client with eczema who reports an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms? Ans- a grandson and his new dog recently visited. When explaining dietary guidelines to a client with acute glomerulonephritis (AGN) which instruction should the nurse include in the dietary teaching? Ans- restrict sodium intake. A male client who is 24 hours postop for an exploratory laparotomy complains that he is starving because he has no real food since before surgery. Prior to advancing his diet, which intervention should the nurse implement? Ans- Auscultate bowel sounds in all four quadrants A client diagnosed with stable angina secondary to ischemic heart disease has a prescription for sublingual (SL) nitroglycerin (NTG). The nurse should tell the client to follow which instructions if chest pain is not relieved after taking 3 NTG tablets 5 minutes apart? Ans- call 911 if pain is unreleased and chew a tablet of ASA 325mg. After taking orlistat (Xenical) for one week a female client tells the home health nurse that she is experiencing increasingly frequent oily stools and flatus. Which action should the nurse take? Ans- ask the client to describe her dietary intake history for the last several days. Two days after an abscess of the chin was drained, the client returns to the clinic with fever, chills, and a maculopapular rash with pruitis. The client has taken an oral ABX and cleansed the wound today with provided iodine (Betadine) solution. Which intervention should the nurse implement first? Ans- assess airway potency and oxygen saturation. A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the HCP? Ans- low back pain and hypotension. A young adult male who has DM2 is admitted to ICU with hyperglycemia nonketotic syndrome (HHNS). A sliding scale protocol for an isotonic IV solution with regular insulin is prescribed based on the results of a continuous blood glucose monitoring device that is attached to the clients central venous catheter. When the clients respirations become labored and his lung sounds indicates crackles what action should the nurse take? Ans- decrease infusion rate to address fluid overload. When preparing to apply a fentanyl transdermal patch the nurse notes that the previously applied patch is intact on the clients upper back and the client denies pain. What action should the nurse take? Ansapply a new patch in a different location after removing the original patch. A client who had a myocardial infarction is admitted to the CCU with a nitroglycerin drip infusing. The clients last BP measurements with 78/36. What action should the nurse implement? Ans- reduce the rate of the nitroglycerin infusion. An adolescent is admitted to the hospital because of a suicide attempt with an overdose of acetaminophen. Which blood values are most important for the nurse to monitor during the first 72 hours following ingestion of this overdose? Ans- LDH or LD. SGOT or ALT. SGPT or AST. An elderly post operative female client is receiving morphine sulfate via a PCA pump. Which assessment finding should prompt a nurse to administer the prescribed PRN medication naloxone? Ans- Her respiratory rate is 7 breaths per minute. Which assessment finding indicates to the nurse that the muscarinic agent bethanechol is effective for a client diagnosed with urinary retention? Ans- urinary output equal to intake. Following involvement in a MVA, a middle aged adult client is admitted to the hospital with multiple facial fractures. The clients blood alcohol level is high on admission. Which PRN prescription should be administered fi the client begins to exhibit signs and symptoms of delirium tremens? Ans- Lorazepam (Ativan) 2 mg IM Which instructions should the nurse include in the teaching plan of a client who is taking the diuretic spironolactone (Aldactone)? Ans- take the medication in the morning. A glucagon emergency kit is prescribed for a client with DM1. When should the nurse instruct the client to take the glucagon? Ans- when recognized signs/ symptoms of severe hypoglycemia occur. A client with hyperthyroidism is being treated with radioactive iodine. Which explanation should be included in preparing this client for this treatment? Ans- describe radioactive iodine as a tasteless, colorless medication administered by the HCP. A female client is being treated for tuberculosis with rifampin. Which statement indicates that further teaching is needed? Ans- I will take my usual contraceptive for birth control A client is discharged with a prescription of warfarin. What discharge instructions should the nurse emphasize to the client? Ans- avoid going barefoot, especially outside. In caring for a client with diabetes insipid who is receiving an antidiuretic hormone intranasally, which serum lab test is most important to monitor? Ans- osmolarit