LATEST Med-Surg HESI Remediation TEST VERIFIED SOLUTION 100% CORRECT ANSWERS

Ibuprofen is a non-steroidal anti-inflammatory drugs (NSAIDS) which is commonly used for muscle strains and aches. Which should the nurse recognize as a serious side effect of ibuprofen? A: Nephrotoxicity. B: Xerostomia. C: Hallucination. D: Convulsions. - ANSWER A: Nephrotoxicity Rationale: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) used to treat pain and inflammation. NSAIDs have nephrotoxic effects and should be avoided in patients with kidney disease. The emergency department nurse triages a twelve-year-old client with a history of a bike accident approximately 2 hours ago. The client is now reporting seeing dark floating spots in the right eye. The nurse notes that the sclera is white and there is bruising and swelling with a small deep jagged laceration on the outer aspect of the right orbital socket. The client is not reporting eye pain or headache. Which condition is consistent with the nurse's assessment? A: Hordeolum. B: Corneal abrasion. C: Retinal detachment. D: Macular degeneration. - ANSWER C: Retinal detachment Rationale: A history of a bike accident and the presence of bruising, swelling and laceration indicate that the client experienced an accelerated force against the right orbital socket. These signs, accompanied with the complaint of report of seeing dark floating spots in the field of vision would be indicative of a retinal hole or tear which is now starting to detach the retina from the back of the eyeball. Retinal detachments are typically painless. An unlicensed assistant personnel (UAP) is providing a bed bath to a client who is 48 hours post radical neck dissection due to oral cancer. Upon turning the client to the side, the UAP notices the client's neck dressing start to ooze bright red blood. The UAP immediately applies pressure to the neck dressing and calls the nurse. What should the nurse do first? A: Raise the head of the client's bed to 45° and flex the client's knees. B: Switch out their gloved hand for the UAP's non -gloved hand. C: Instruct the UAP to gently take their hand off the client's dressing. D: Maintain direct pressure on dressing and transport client to the operating room. - ANSWER C: Instruct the UAP to gently take their hand off the client's dressing Rationale: The oozing blood indicates a leak of the carotid artery rather than a rupture. A client who is status post radical neck dissection should be monitor for the development of carotid artery leakage or rupture. A ruptured artery will appear as large amounts of bright red blood spurting quickly. A carotid artery with a leak will appear as oozing of bright red blood. If a carotid leakage is suspected, do not touch the area because additional pressure could cause immediate rupture; instead call the Rapid Response Team. The UAP should stop applying pressure. Direct pressure is only applied to a ruptured carotid artery. A female client has had a scleral buckling with the use of silicone oil for repair of partial retinal detachment of her right eye. The client is transferred to the surgical floor. The client is lying on her left side with her head in the midline position during the nurse's assessment. A protective shield is covering the client's right eye. Which is the most important nursing intervention the nurse should implement post-operatively? A: Offer pain medication continuously around the clock. B: Keep both of the eyes covered with protective eye shields. C: Ensure the client remains on her left side with her head midline. D: Administer topical corticosteroids and immunosuppressants. - ANSWER C: Ensure the client remain on her left side with her head midline Rationale: The most important nursing intervention for a client following retinal detachment repair in which gas or silicone oil placed in the eye to promote retinal attachment is to maintain the client's head in the same position the surgeon has placed it. The gas or oil bubble is used to float up against the retina to hold the retina in place until it heals in place. The client's lower extremity has an ulcer present. Which assessment findings would indicate to the nurse that the ulcer is the result of peripheral arterial disease? (SATA) A: The ulcer is located on the great toe. B: The lower extremities pulses are bounding. C: The area where the ulcer is located is edematous. D: The ulcer site is painful and tender when manipulated. E: Dependent rubor is present in the extremity with the ulcer. - ANSWER A: The ulcer is located on the great toe. D: The ulcer site is painful and tender when manipulated. E: Dependent rubor is present in the extremity with the ulcer. Rationale: Arterial ulcers are located at the end of toes and/or between them. The great toe is often the site affected. Pain is present at the ulcer site. These ulcers are often deep in appearance, pale wound bed, with well-defined and even edges present. The extremity is often cold or cool to the touch, pulses are either decreased or absence. The extremity affected by the peripheral arterial disease and the extremity is pale when elevated and demonstrates dependent rubor when lowered. When counseling a family about a loved-one diagnosed with dementia, it is most important that the nurse address which concern with the family prior to discharge? A: Ineffective thermoregulation. B: Suicidal thoughts. C: Impaired skin integrity. D: Self-care deficit. - ANSWER D: Self-care deficit Rationale: Dementia is a progressive disease with multiple effects, including memory loss and decreased cognitive skills. This results in the client being unable to safely perform activities of daily living and make safe and sound decisions. The nurse is assigned a client who was admitted for a basilar fracture. Which finding is indicative of a complication that should be reported to the healthcare provider immediately? A: The client's report of some neck stiffness. B: The presence of new onset of post nasal drip. C: Client's request for acetaminophen for a headache.