Hesi Final Study Questions: Med Surg II

Hesi Final Study Questions: Med Surg II A nurse is caring for a client who is learning how to take care of a newly created colostomy. When observing a return demonstration of the colostomy irrigation, the nurse evaluates that more teaching is required when the client: Ans- Hangs the irrigation bag on the door clothes hook during fluid insertion Following surgery, a client asks the nurse if he or she can help measure intake and output. What is the best nursing response? Ans- Assess the client's ability to measure the intake and output A client with cancer of the pancreas has a pancreaticoduodenectomy (Whipple procedure). The nurse expects that the client will have which tube after surgery? Ans- Nasogastric A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, the nurse expects the client to state: Ans- "I have trouble breathing when I walk rapidly." A client with a spontaneous pneumothorax asks, "Why did they put this tube into my chest?" The nurse explains that the purpose of the chest tube is to: Ans- Remove air from the pleural space Following surgery in the inguinal area, the client complains of pain on the right side of the chest, becomes dyspneic, and begins to cough violently. The nurse suspects that a pulmonary embolus has occurred. What is the priority nursing action? Ans- Elevate the head of the bed As an acute episode of rheumatoid arthritis subsides, active and passive range-of-motion exercises are taught to the client's spouse. The nurse should teach that direct pressure should not be applied to the client's joints because this may precipitate: Ans- Pain A client is admitted to the hospital with the diagnosis of cancer of the thyroid and a thyroidectomy is scheduled. What is important for the nurse to consider when caring for this client during the postoperative period? Ans- Hoarseness and airway obstruction may result from laryngeal nerve damage. A client is scheduled to have a cardiac catheterization via the femoral approach. The nurse teaches the client about post-procedure interventions that protect the catheter insertion site. The nurse instructs the client that the leg used for catheter insertion will be: Ans- Kept extended while on bed rest A female client who has recurrent urinary tract infections (UTIs) is inquiring about the prevention of future UTIs. What information should the nurse include when teaching the client? (Select all that apply.) Ans- -Drink 8 to 10 glasses of water each day -Urinate immediately after sexual intercourse A client is diagnosed with Cushing syndrome. Which clinical manifestation does the nurse expect to increase in a client with Cushing syndrome? Ans- Glucose level A client with hepatic cirrhosis begins to develop slurred speech, confusion, drowsiness, and a flapping tremor. With this evidence of impending hepatic coma, which diet can the nurse expect will be prescribed for this client? Ans- 20 g of protein, 2000 calories A nurse concludes that the anemia that accompanies chronic kidney disease should be treated because it contributes to: Ans- Chronic fatigue A client is scheduled to receive general anesthesia during an upcoming surgery. The nurse provides education about common side effects of general anesthesia. The nurse concludes that the teaching has been effective when the client states, "Immediately after surgery I may experience: Ans- A sore throat." A client has surgery for the creation of burr holes after sustaining head trauma. An early clinical manifestation of meningeal irritation for which the nurse assesses the client is: Ans- Kernig's sign What therapeutic effect should the nurse identify as the reason for administration of neomycin sulfate to a client before colon surgery? Ans- Destroy intestinal bacteria A client newly diagnosed with myasthenia gravis is concerned about fluctuations in physical condition and generalized weakness. When caring for this client it is most important for the nurse to plan to: AnsSpace activities throughout the day A client is diagnosed with myasthenia gravis, and the anticholinesterase medication pyridostigmine (Mestinon) is prescribed. When teaching the client about this medication, the nurse explains that the desired effect is to increase: Ans- Contraction of skeletal muscles A client with a history of a pulmonary embolus is to receive 3 mg of warfarin (Coumadin) daily. The client has blood drawn twice weekly to ascertain that the international normalized ratio (INR) stays within a therapeutic range. The nurse provides dietary teaching. Which food selected by the client indicates that further teaching is necessary? Ans- Spinach salad A client with advanced bone cancer is experiencing cachexia. The nurse discusses the nutritional aspect of palliative care with the family. Why is it important to explain these nutritional interventions to the family? Ans- Enhance the quality of the client's life When providing discharge teaching to a client who had a total hip replacement, the nurse should instruct the client to avoid: Ans- Sitting in a low chair A client comes to the clinic for a physical and asks to be tested for acquired immunodeficiency syndrome (AIDS). Which test should the nurse explain will be used for the initial screening for AIDS? Ans- Enzymelinked immunosorbent assay (ELISA) A nurse is caring for a client who is receiving total parenteral nutrition. Which responses indicate that the client is experiencing hyperglycemia? (Select all that apply.) Ans- -Polyuria -Polydipsia Tuberculosis is confirmed and isoniazid (INH), rifampin (Rifadin), and pyridoxine (vitamin B6) are prescribed for a client. The client says, "I've never had to take so many medicines for an infection before." What is the nurse's best reply? Ans- "This type of organism is difficult to destroy." A nurse in a rehabilitation center teaches clients with quadriplegia to use an adaptive wheelchair. Why is it important that the nurse provide this instruction? Ans- It is unlikely that the client will regain the ability to walk. A male client has discharge from his penis. Gonorrhea is suspected. To obtain a specimen for a culture, the nurse should: Ans- Swab the drainage directly from the urethra to obtain a specimen A nurse teaches the signs of organ rejection to a client who had a kidney transplant. What should be included in the education? Ans- Elevated blood pressure Which relationship does the nurse consider reflective of the relationship of naloxone (Narcan) to morphine sulfate? Ans- Protamine sulfate to parenteral heparin On the first postoperative day following a thyroidectomy, a client tolerates a full-fluid diet. This is changed to a soft diet on the second postoperative day. The client reports having a sore throat when swallowing. What should the nurse do first? Ans- Administer analgesics as prescribed before meals When caring for an anxious patient, the nurse should monitor for which signs of hyperventilation? AnsRespiratory alkalosis A nurse obtains daily stool specimens for a client with chronic bowel inflammation. The nurse concludes that these stool examinations were prescribed to determine: Ans- Occult blood. Which clinical indicator is the nurse most likely to identify when assessing a client with a ruptured cerebral aneurysm? Ans- Sudden severe headache A nurse is evaluating a client's response to fluid replacement therapy. Which clinical finding indicates adequate tissue perfusion to vital organs? Ans- Urinary output of 30 mL in an hour In response to a client's question, the nurse explains the difference between partial-thickness (seconddegree) burns and full-thickness (third-degree) burns. What information about partial-thickness burns should the nurse include in the discussion? Ans- They are painful, reddened, and have blisters A client with acute kidney failure is to receive peritoneal dialysis and asks why the procedure is necessary. The nurse's best response is, "It: Ans- Helps perform some of the work usually done by the kidneys." A client has a closed chest drainage system in place. To determine the amount of chest tube drainage, the nurse should: Ans- Refer to the date and time markings on the outside of the collection chamber A farmer seeks medical care for a large crusty patch of skin on the cheek. The client states that even after using different remedies, it still bleeds easily and has not gotten better. From the client's history, the nurse suspects skin cancer because the major precipitating factor associated with skin cancer is: AnsExposure to radiation A nurse determines that a client in the acute phase of burns has eaten only a small portion of each meal. Considering this finding, the nurse should assess the client for: Ans- Prolonged w