LATEST 2024 HESI Med Surg Practice VERIFIED SOLUTION 100% CORRECT ANSWERS

A client is caring for a client with diabetes insipidus (DI). What data warrants the MOST immediate intervention by the nurse? a. serum sodium of 185 mEq/L (185 mmol/L) b. dry skin with inelastic tugor c. apical rate of 110 beats per minute d. polyuria and excessive thirst - ANSWER a. serum sodium of 185 mEq/L (185 mmol/L) 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. frequent use of chewable and liquid antacids for indigestion b. severe abdominal cramps and diarrhea after eating spicy foods c. upper mid-abdominal pain described as gnawing and burning d. marked loss of weight and appetite over the last 3 or 4 months - ANSWER c. upper mid-abdominal pain described as gnawing and burning The nurse assesses a client who is newly diagnosed with hyperthyroidism and observes that the client's eyeballs are protuberant, causing a wide-eyed appearance and eye discomfort. Based on this finding, which action should the nurse include in this client's plan of care? a. assess for signs of increased intracranial pressure b. prepare to administer levothyroxine c. review the client's serum electrolyte values d. obtain a prescription for artificial tear drops - ANSWER d. obtain a prescription for artificial tear drops To reduce the risk for pulmonary complication for a patient with Amyotrophic Lateral Sclerosis (ALS), which interventions should the nurse implement? (Select all that apply.) a. perform chest physiotherapy b. teach the client breathing exercises c. initiate passive range of motion exercises d. establish a regular bladder routine e. encourage use of incentive spirometer - ANSWER a. perform chest physiotherapy b. teach the client breathing exercises e. encourage use of incentive spirometer A client is hospitalized with heart failure (HF). Which intervention should the nurse implement to improve ventilation and reduce venous return? a. perform passive range of motion b. place the client in a high Fowler position c. administer oxygen per nasal cannula d. increase the client's activity level - ANSWER b. place the client in a high Fowler position A client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that the client's distal pulses are diminished in the left foot. Which interventions should the nurse implement? (Select all that apply.) a. verify pedal pulses using a doppler pulse device b. evaluate the application of the splint to the left leg c. offer ice chips and oral clear liquids d. monitor left leg for pain, pallor, paresthesia, paralysis, pressure e. administer oral antispasmodics and narcotic analgesics - ANSWER a. verify pedal pulses using a doppler pulse device b. evaluate the application of the splint to the left leg d. monitor left leg for pain, pallor, paresthesia, paralysis, pressure The healthcare provider prescribes diagnostic tests for a client whose chest xray indicates pneumonia. Which diagnostic test should the nurse review for implementation in the MOST therapeutic treatment of the pneumonia? a. sputum culture and sensitivity b. blood cultures c. arterial blood gases (ABGs) d. computerized tomography (CT) of the chest - ANSWER a. sputum culture and sensitivity A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened, tenacious mucous, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is MOST important for the nurse to instruct the client about self-care? a. call the clinic if undesirable side effects of medication occur b. avoid crowded enclosed areas to reduce pathogen exposure c. increase the daily intake of oral fluids to liquefy secretions d. teach anxiety reduction methods for feelings of suffocation - ANSWER c. increase the daily intake of oral fluids to liquefy secretions 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 instruction should the nurse provide? (Please view the video to select the option that applies. To review the video, click the play button again.) a. select a different injection site b. continue with the insulin injection c. keep the skin flat rather than bunched d. lie down flat for better skin exposure - ANSWER b. continue with the insulin injection The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a trans-urethral resection of the prostate (TURP). What is the BEST initial nursing action? a. provide additional oral fluid intake b. measure the client's intake and output c. increase the flow of the bladder irrigation d. administer a PRN dose of an antispasmodic agent - ANSWER c. increase the flow of the bladder irrigation Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first? a. elevate the extremities on pillows b. evaluate edema for pitting c. assess pulses with a vascular doppler d. wrap the feet with warmed blankets - ANSWER c. assess pulses with a vascular doppler