Nur 240 Hesi Med Surg Exam Questions And Answers With
Rationales A+ Graded
• A .client .is .being .discharged .following .radioactive .seed .implantation .for
prostate .cancer. .What .is .the .most .important .information .that .the .nurse
.
should .provide .to .this .client’s .family?
.
A. Follow .exposure .precautions.
B. Encourage .regular .meals.
C. Collect .all .urine.
D. Avoid .touching .the .client.
Rationale:
Clients .being .treated .for .prostate .cancer .with .radioactive .seed .implants .should .be
. instructed .regarding .the .amount .of .time .and .distance .needed .to .prevent .excessive
exposure .that .would .pose .a .hazard .to .others. .Option .B .is .a .good .suggestion .to
.
promote .adequate .nutrition .but .is .not .as .important .as .option .A. .Option .C .is
.
unnecessary. .Contact .with .the .client .is .permitted .but .should .be .brief .to .limit
.
radiation .exposure.
.
• In .assessing .a .client .with .an .arteriovenous .(AV) .shunt .who .is .scheduled
.for .dialysis .today, .the .nurse .notes .the .absence .of .a .thrill .or .bruit .at .the
.shunt .site.
,What .action .should .the .nurse .take?
A. Advise .the .client .that .the .shunt .is .intact
and .ready .for .dialysis .as .scheduled.
.
B. Encourage .the .client .to .keep .the .shunt .site
elevated .above .the .level .of .the .heart.
.
, C. Notify .the .health .care .provider .of .the .findings .immediately.
D. Flush .the .site .at .least .once .with .a .heparinized .saline .solution.
Rationale:
Absence .of .a .thrill .or .bruit .indicates .that .the .shunt .may .be .obstructed. .The .nurse
should .notify .the .health .care .provider .so .that .intervention .can .be .initiated .to
.
restore .function .of .the .shunt. .Option .A .is .incorrect. .Option .B .will .not .resolve .the
.
obstruction. .An .AV .shunt .is .internal .and .cannot .be .flushed .without .access .using
.
special .needles.
.
• The .nurse .is .concerned .about .infection .for .a .client .after .an
.esophagogastrostomy .for .esophageal .cancer. .Which .actions .should
.the .nurse
include .in .the .client’s .plan .of .care? .(Select .all .that .apply.)
A. Frequent .oral .care .every .2 .hours .while .awake.
B. Use .incentive .spirometer .every .2 .hours.
C. Empty .contents .from .NG .tube .every .8 .hours.
D. Ambulate .within .1 .hour .of .return .from .the .PACU.
E. Limit .visitors .until .postoperative .day .2.
Rationale:
One .hour .post .op .is .too .soon .to .ambulate .for .this .client. .Visitors .help .support .the
patient .and .are .encouraged .to .visit. .Oral .care .is .necessary .as .the .client .will .be
.
NPO. .To .decrease .the .risk .of .infection .post .operatively, .implement
.
, routine .pulmonary .exercises. .The .client .will .have .an .NG .tube .in .place, .likely .to
. intermittent .suction, .to .decompress .the .stomach .post .surgery.
• The .nurse .notes .that .the .client’s .drainage .has .decreased .from .50 .to .5 .mL/hr
12 .hours .after .chest .tube .insertion .for .hemothorax. .What .is .the .best .initial
.
action .for .the .nurse .to .take?
.
A. Document .this .expected .decrease .in .drainage.
B. Clamp .the .chest .tube .while .assessing .for .air .leaks.
C. Milk .the .tube .to .remove .any .excessive .blood .clot .buildup.
D. Assess .for .kinks .or .dependent .loops .in .the .tubing.
Rationale:
The .least .invasive .nursing .action .should .be .performed .first .to .determine .why .the
drainage .has .diminished. .Option .A .is .completed .after .assessing .for .any .problems
.
causing .the .decrease .in .drainage. .Option .B .is .no .longer .considered .standard
.
protocol .because .the .increase .in .pressure .may .be .harmful .to .the .client. .Option .C
.
is .an .appropriate .nursing .action .after .the .tube .has .been .assessed .for .kinks .or
.
dependent .loops.
.
• A .client .on .telemetry .has .a .pattern .of .uncontrolled .atrial .fibrillation .with .a
rapid .ventricular .response. .Based .on .this .finding, .the .nurse .anticipates
.
assisting .the .physician .with .which .treatment?
.
A. Administer .lidocaine, .75 .mg .intravenous .push.
Rationales A+ Graded
• A .client .is .being .discharged .following .radioactive .seed .implantation .for
prostate .cancer. .What .is .the .most .important .information .that .the .nurse
.
should .provide .to .this .client’s .family?
.
A. Follow .exposure .precautions.
B. Encourage .regular .meals.
C. Collect .all .urine.
D. Avoid .touching .the .client.
Rationale:
Clients .being .treated .for .prostate .cancer .with .radioactive .seed .implants .should .be
. instructed .regarding .the .amount .of .time .and .distance .needed .to .prevent .excessive
exposure .that .would .pose .a .hazard .to .others. .Option .B .is .a .good .suggestion .to
.
promote .adequate .nutrition .but .is .not .as .important .as .option .A. .Option .C .is
.
unnecessary. .Contact .with .the .client .is .permitted .but .should .be .brief .to .limit
.
radiation .exposure.
.
• In .assessing .a .client .with .an .arteriovenous .(AV) .shunt .who .is .scheduled
.for .dialysis .today, .the .nurse .notes .the .absence .of .a .thrill .or .bruit .at .the
.shunt .site.
,What .action .should .the .nurse .take?
A. Advise .the .client .that .the .shunt .is .intact
and .ready .for .dialysis .as .scheduled.
.
B. Encourage .the .client .to .keep .the .shunt .site
elevated .above .the .level .of .the .heart.
.
, C. Notify .the .health .care .provider .of .the .findings .immediately.
D. Flush .the .site .at .least .once .with .a .heparinized .saline .solution.
Rationale:
Absence .of .a .thrill .or .bruit .indicates .that .the .shunt .may .be .obstructed. .The .nurse
should .notify .the .health .care .provider .so .that .intervention .can .be .initiated .to
.
restore .function .of .the .shunt. .Option .A .is .incorrect. .Option .B .will .not .resolve .the
.
obstruction. .An .AV .shunt .is .internal .and .cannot .be .flushed .without .access .using
.
special .needles.
.
• The .nurse .is .concerned .about .infection .for .a .client .after .an
.esophagogastrostomy .for .esophageal .cancer. .Which .actions .should
.the .nurse
include .in .the .client’s .plan .of .care? .(Select .all .that .apply.)
A. Frequent .oral .care .every .2 .hours .while .awake.
B. Use .incentive .spirometer .every .2 .hours.
C. Empty .contents .from .NG .tube .every .8 .hours.
D. Ambulate .within .1 .hour .of .return .from .the .PACU.
E. Limit .visitors .until .postoperative .day .2.
Rationale:
One .hour .post .op .is .too .soon .to .ambulate .for .this .client. .Visitors .help .support .the
patient .and .are .encouraged .to .visit. .Oral .care .is .necessary .as .the .client .will .be
.
NPO. .To .decrease .the .risk .of .infection .post .operatively, .implement
.
, routine .pulmonary .exercises. .The .client .will .have .an .NG .tube .in .place, .likely .to
. intermittent .suction, .to .decompress .the .stomach .post .surgery.
• The .nurse .notes .that .the .client’s .drainage .has .decreased .from .50 .to .5 .mL/hr
12 .hours .after .chest .tube .insertion .for .hemothorax. .What .is .the .best .initial
.
action .for .the .nurse .to .take?
.
A. Document .this .expected .decrease .in .drainage.
B. Clamp .the .chest .tube .while .assessing .for .air .leaks.
C. Milk .the .tube .to .remove .any .excessive .blood .clot .buildup.
D. Assess .for .kinks .or .dependent .loops .in .the .tubing.
Rationale:
The .least .invasive .nursing .action .should .be .performed .first .to .determine .why .the
drainage .has .diminished. .Option .A .is .completed .after .assessing .for .any .problems
.
causing .the .decrease .in .drainage. .Option .B .is .no .longer .considered .standard
.
protocol .because .the .increase .in .pressure .may .be .harmful .to .the .client. .Option .C
.
is .an .appropriate .nursing .action .after .the .tube .has .been .assessed .for .kinks .or
.
dependent .loops.
.
• A .client .on .telemetry .has .a .pattern .of .uncontrolled .atrial .fibrillation .with .a
rapid .ventricular .response. .Based .on .this .finding, .the .nurse .anticipates
.
assisting .the .physician .with .which .treatment?
.
A. Administer .lidocaine, .75 .mg .intravenous .push.
