HESI Med Surg V1 Correct answers and Rationales Study guide

Hesi Med Surg V1 Correct answers and Rationales 1. Guaiac Occult Test. What lab is most important? 2. Patient had BDP 3 months ago with dehydration. What would warrant the nurse immediate intervention? 3. A patient with Parkinson’s. “Freezes.” Pretends there is a crack on the floor and Carefully lifts leg and steps over. 4. Patient had Atrial Fibrillation and then AED was used. One minute later, Patient sudden goes in to ventricular Tachycardia. What should the nurse do? 5. Heart failure acute exacerbation. How to Reduce Cardiac Workload? 6. External Fixation Device- What should the nurse do first? 7. COPD patient is experience shortness of breath. 8. Client with CVA (stroke). Has only eaten half of their food. Family is concern about nutrition. What should the nurse tell the family? 9. A male client with asthma has bronchoconstriction and mucous production due to exercising. What should the nurse do? 10. A client with liver abscess and drainage of abscess. Which lab value? 11. Suprapubic prostatectomy. Three-way catheter. Which assessment? 12. A client with ulcerative colitis. UAP report what finding? 13. Flank pain and acute pyelonephritis. Priority nursing action. 14. Long-standing pulmonary infection. Assess for hypoxia. Select All That Apply. 15. Traction applied, but client is frustrated because client keeps calling nurse for help with repositioning. 16. Multiple Sclerosis and urinary retention. 17. Client works as a data desk job with Raynaud’s syndrome. What to do to prevent wrist injury? 18. C.K.D. Lab to report. 19. Client withy Gullian Barre is not blinking. 20. Taking prednisone PO 5mg. What symptom? 21. Succinylcholine. High Temperature. 22. The nurse drops a sterile package of supplies on the floor in the operating room (OR) suite. The … impervious wrapper. Which action should the nurse implement? 23. Client with Acute Glomerulonephritis. 24. Client ask about biopsy results from cancer cells well differentiated. What response? 25. Right cataract and lens implant. Which intervention should the nurse first? 26. The unlicensed assistive personnel (UAP) reports to the nurse that a client who was admitted with abdominal pain has just had a large black tarry stool. What intervention should the nurse implement first? 27. Which action is most important for the nurse to implement to reduce the risk for deep vein thrombosis in a postoperative client? 28. The nurse is preparing a client for a bronchoscopy. While obtaining consent, the client complains of thirst and admits to drinking a small amount of orange juice two hours ago. What action should the nurse take? 29. A client uses triamcinolone (kenalog), a corticosteroid ointment, to manage pruritis caused by a chronic skin rash. The client calls the clinic nurse to report increased erythema with purulent exudate at the site. What action should the nurse implement? 30. The nurse learns in change of shift report that the x-ray report for a newly admitted client indicates consolidation in the left lower lung. What action should the nurse take? 31. The nurse is monitoring the glucose q4h of an adult woman admitted with DKA. Two hours after receiving 10 units of regular insulin for glucose of 255, the client is perspiring and complaining of shakiness. What intervention should the nurse implement? 32. The chest x-ray for a client who is admitted for pneumonia shows pleural effusion with decreased air flow in the entire left upper lobe. What breath sounds that verify the x-ray findings should the nurse document after auscultation of the left upper lobe? 33. Which food is most important for the nurse to encourage a male patient with osteomalacia to include in his daily diet? 34. An older adult woman is seen in the clinic 3 months following her diagnosis of type 2 diabetes mellitus (DM). She tells the nurse that she has had a difficult time keeping her blood sugar in control. The nurse reviews the client's current finger-stick and daily log of blood glucose levels. Which intervention is most important for the nurse to implement? 35. The nurse is taking a client's blood pressure and observes carpal spasm after the sphygmomanometer cuff is inflated. What action should the nurse implement next? 36. A male client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about the dietary restriction he should follow. In discussing fluid intake, the nurse should include which type of fluid limitation? 37. During preoperative teaching for a male client scheduled for repair of an inguinal hernia, the client tells the nurse that he has had several surgeries and understands the need to perform coughing and deep breathing exercises after surgery. How should the nurse respond? 38. A pt suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this pt's plan of care? 39. After 3 days of persistent epigastric pain, a female pt presents to the clinic. She has been taking oral antacids w/o relief. Her vital signs are HR 122 beats/min, respirations 16 breaths/min, O2 96% and BP 116/70. The nurse obtains a 12-lead ECG. Which assessment finding is most critical? 40. A male client with an external fixation device for a fractured left femur is complaining of left foot pain. Which intervention should the nurse implement first? 41. Two days following abdominal surgery a client begins to complain of cramping abdominal pain, and the nurse's inspection of the abdomen indicates slight distention. Which action should the nurse implement first? 42. A fair-skinned female client who is an avid runner is diagnosed with malignant melanoma, which is located on the lateral surface of the lower leg. After wide margin resection, the nurse provides discharge teaching. it is most important for the nurse to emphasize the need to observe for changes in which characteristic? 43. Math question: Order of 8,200 units. Each 1mL of solution contains 10,000 units of alfa. How many mL? (If Rounding is necessary, then round to the nearest tenth). Simply, divide 8200 and 10,000, which equals 44. What instruction should the nurse include in the discharge teaching plan of a client who had a cataract extraction today? 45. When a nurse is caring for a client with acute hypothyroidism, which serum laboratory value requires immediate intervention? 46. A potential donor of corneal tissue for the eye bank has just died. The nurse enters the room prescribed antibiotic eye drops. What action should the nurse take next? 47. 3 months following her diagnosis of type II diabetes…had a difficult time keeping her blood sugar is centered. The nurse reviews that..blood glucose levels. Which interventions in most important for the nurse to implement? 48. Retinal Tear. What to do to avoid risk of retina damage? 49. 2-year old boy is having health assessment. Which further assessment by nurse?