HESI MED SURG 1 FOR RN 2021
1. On the third postoperative day, a client who has had a hip replacement surgery becomes anxious and diaphoretic, and begins to experience auditory hallucinations. The client denies having a
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HESI MED SURG 1 FOR RN 2021
1. On the third postoperative day, a client who has had a hip replacement surgery becomes anxious and diaphoretic, and begins to experience auditory hallucinations. The client denies having any pain. The client’s vital signs and pulse rate is 125beats/minute, respiratory rate is 36 breaths per minute, and blood pressure is 166/88mmHg. Which Nursing interventions should the nurse implement ? (Select all that apply)
A. Apply soft wrist restraints bilaterally
‘ B. Turn the television on for distraction.
C. Reorient to day and time frequently.
D. Present a calm, supportive demeanor
E. Administer a PRN dose of LorazepamQ
a.
.
2. A female client who recently married returns to the clinic with recurrent cystitis
and urethritis. The client presents with pain on urinating, urinary frequency and
urgency which additional information should the nurse obtain
a. review a recent urinalysis for calcium oxalate precipitants
b. Ask if she has recently had a streptococcus infection c. inquire about her hygiene practices after sexual intercouse
d. Examine clients history for any genetic renal disease
3. which long term outcome is most important for the nurse to include in the plan of
care for an older adult client with chronic pyelonephritis
a. Manges activities of daily living independently
b. Restricts fluid intake to 1L/day
c. Measures oral temperature daily d. maintains blood pressure within normal limits
4. The nurse is providing discharge instruction to a client who is receiving
prednisone 5mg PO daily for a rash due to contact with poison ivy. Which
symptom should the nurse tell the client to report to the healthcare provider?
a, Abdominal Striae
b. Rapid weight gain
c. Gastric irritation ….
d. Moon facies
5. A young adult male client has a cast following an open reduction for a fracture
tibia. He is in skeletal traction with 10 lbs of weight. Approximately two hours after
returning to the unit, he reports severe pain in the affected extremity, and the
the nurse observes that the limb is blue and blanched, what should the nurse do first?
a. Administer PRN pain medication routinely as prescribed
b. Notify the health care provider of the assessment finding
c. Release the traction and notify the healthcare provider
d. Record the observation and check the limb q15 minutes
6. AN adult client who was admitted yesterday with bilateral pneumonia has
congested breath sounds, an oxygen saturation of 94% and a temperature of
100 degree F(37.8c). He has a weak cough effort and is using his accessory
muscles to breathe. Which intervention should the nurse implement first?
a. Administer a prescribed antipyretic
b. Obtain arterial blood gases c. suction to clear secretion from airways
d. offer a prescribed PRN analgesic
7. which nursing problem has the highest priority when planning care for a client
with Meniere disease
a. alteration in comfort related to pain in the ear
b. alteration in body temperature related to decreased hypothalamic function c. potential for injury related to vertigo
d. impaired skin integrity related to immobility
8. A home-bound client with severe, end -stage chronic obstructive pulmonary
disease (COPD) is being visited by the home-health nurse. which instruction
should the nurse include in the client’s teaching plan?
a. use oxygen continuously, at the lowest dose possible
b. cluster activities together, first thing in the morning
c. use the beta-agonist inhalers q2h, around the clock
d. use pursed lip breathing techniques continually, around the clock
9. An obese client with emphysema who smokes at least a pack of cigarettes daily
is admitted after experiencing a sudden increase in dyspnea and activity
intolerance. Oxygen therapy is initiated and it is determined that the client will be
discharged with oxygen. which information will be MOST important for the nurse
to emphasize in the discharge teaching plan?
a. Methods for weight loss b. Guidelines for oxygen use
c. strategies for smoking cessation
d. Approaches to conserve energy
10. An adult male with hypertension cannot control his blood pressure with oral
medication, so he is admitted to the hospital for antihypertensive management
and further evaluation. Laboratory finding include an elevated blood urea
nitrogen (BUN), serum creatinine and white blood cell count. when the client
becomes dyspneic and reports palpitations, his heart rate is 150 beats/minutes
Which intervention should the nurse implement?
a. Obtain blood sample for troponin levels
b. collect sputum for culture and sensitivity
c. insert an indwelling urinary catheter d. Initiate telemetry and supplemental O2
11. A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which intervention of this finding should the nurse make?
A. Representative of a decline in the client’s condition.
B. Evidence of a spread of the disease to the kidney C. Confirmation of the autoimmune disease process
D. indication of the onset of joint degeneration
12. The nurse is planning care for a client with a direct (sliding) hiatal hernia. Nursing actions should be planned to meet which goal?
A. increase intestinal peristalsis
B. promote effective swallowing C. prevent esophageal reflux
D. maintain intact oral mucosa
13. The nurse is planning care for an older adult male who experienced his cerebrovascular accident several weeks ago. Because of his expressive aphasia, the client often becomes frustrated with the nursing staff. Which intervention should the nurse implement?
A. speak slowly to the client
B. teach the client use of basic sign language C. encourage client’s use of picture charts
D. Ask the client simple questions
14.which instruction should the nurse include in the discharge teaching for a client who has gastroesophageal reflux?
A. Encourage the client to lie down and rest after meals
B. Instruct the client to use antacids only as a last resort C. teach the client to elevate the head of the bed on blocks
D. remind the client to avoid high-fiber foods
15. A client arrives by car to the emergency department and tells the nurse of being stung by a bee on the neck while gardening.the client informs the nurse that the prescribed epinephrine pen had expired. Which assessment finding warrants immediate intervention by the nurse? A. Audible Upper airway stridor
B. Complaint of chest heaviness
C. O2 saturation 88% on room air
D. Raised whelps over chest area
16. A client who fractured the right femur from a fall at home is placed in skeletal traction while awaiting surgery. when the client tells the nurse the need to urinate, which intervention should the nurse implement?
A. insert an indwelling urinary catheter preoperatively .
B. Release the traction so the client can use a bedpan
C. log roll the client and the place adult disposable briefs beneath the client D. maintain traction while the client uses a female urinal
17. A client is transferred to the AZT area from the postanesthesia care unit(PACU). After obtaining the client’s vital signs, what should the nurse assess next?
A. Urine output in the bedside drainage unit B. Airway patency and tidal volume
C. Neurological and pain assessment
D. Intravenous fluid infusion rate.
18. Which outcome should the nurse use to evaluate the effects of Buck’s traction for a client with a fractured left hip?
A. Decreased peripheral pulses and capillary refill >3 seconds in the left foot B. A palpable left dorsalis pedal pulse and the left foot is warm to touch
C. A burning, tingling sensation under the foam boot on the left leg.
D. A positive Homan’s sign and tenderness in the left posterior calf
19. Following an ileal conduit urinary diversion, a client voices several concerns. which finding indicates the nurse that the client is experiencing a complication?
A. A small amount of bleeding at the stoma site
B. A bright red, moist ostomy site
C. Amber colored urine coming out of the stoma D. A dark purplish colored stoma
20. A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision, and palpitations, which finding is most important for the nurse to assess in the client? A. Obtain a list of medications taken for cardiac history
B. Determine the client’s level of orientation and cognition
C. Assess distal pulses and signs of peripheral edema
D. Ask client about exposure to environment heat
21. During the spring break, a young adult presents to the urgent care clinic and reports a stiff neck, a fever for the past 6 hours, and a headache. Which intervention is most important for the nurse to implement
a. Administer an antipyretic
b. prepare for a lumbar puncture
c. Draw a blood culture d. Initiate isolation precaution
22. A male client with acquired immune deficiency syndrome (AIDS) and pneumocystis carinii pneumonia has a CD4+ t cell count of 200 cells/microliter. the client asks the nurse why he keeps getting massive infections. Which pathophysiologic mechanism should the nurse describe in response to the client’s questions?
a inadequate numbers of T lymphocytes are available to initiate cellular immunity and macrophages
B. The humoral immune response lacks B cells that form antibodies and opportunistic infections result
c. Exposure to multiple environmental infections agents overburdens the immune systems until it fails
d Bone marrow suppression of white blood cells causes insufficient cells to phagocytize the organism.
23. The healthcare provider prescribes a liter of normal saline 0.9% to be infused over 9 hours for clients who are NPO. The nurse should program the infusion pump to deliver how many mL/hour?
1litre --------9hrs
1000ml-----9hrs
9hrs=1000ml
1hr=1000/9=111.1ml/hr
nearest whole number: 111ml/hr ( correct answer)
24. The nurse assists a client with Parkinson's disease (PD) to ambulate in the hallway. The client appears to “freezes” and then carefully lifts one leg and steps forward. The client tells the nurse of pretending to step over a crack on the floor. How should the nurse respond? A. Confirm that this is an effective technique to help with ambulation
B. Reorient the client to his present location and circumstances
C. Assist the client to a carpeted area where he can walk more easily
D. plan to assess the client’s cognition after returning to his room
25. The nurse is monitoring the capillary glucose, every 4 hours, of an adult woman admitted with diabetic ketoacidosis (DKA). Two hours after receiving 10 units of regular insulin for a glucose level of 255 mg/dL, the client is perspiring and complaining of shakiness. Which intervention should the nurse implement?
a. Administer an additional dose of insulin b. obtain another capillary glucose level
c. Reevaluate client’s symptoms in an hour
d. give the client 8 ounces of orange
26. A hospitalized client with peripheral arteries disease (PAD) is instructed regarding leg and foot care. Which statement by the client indicates to the nurse that learning has occurred?
a. “I will try to keep moving if leg pain promotes good circulation.” b. “I can use a mirror to check the bottoms of my feet for any signs of breakdown.’
c. Whenever i am sitting in a chair i will keep my legs up to reduce swelling”
d. “I will use my swimming pool early in the day while the water is still very cool”
27. An older female client experiences an exacerbation of her heart failure after eating Asian food at a restaurant with her family. The telephone triage nurse should encourage the family to bring the client to the emergency room immediately for which
a. Headache
b. 1+ edema of her feet and hands c. dizziness and confusion
d. watery diarrhea
28. The nurse is planning to conduct a glaucoma screening program. Which setting serves the population at highest risk for glaucoma?
a. Health fair at a suburban muslim temple
b. Seniors daycare center in a predominantly Caucasian suburb c. Senior Nutrition Center in an African-American community
d. urban community garden used by the Asian-american families
29. A young client who is being taught to use an inhaler for symptoms of asthma tells the nurse the intention to use the inhaler but plans to continue smoking cigarettes. on evaluating the client's response, what is the best initial action by the nurse?
a. explain that denial of illness can interfere with the treatment regimen b. Revise the plan of care based on the clients plans to continue smoking
c. Review factors surrounding clients beliefs about smoking cessation
d. inform the health care provider of the statement made by the client
30. During the admission assessment, the nurse identifies multiple bruises at various stages of healing on a male client recently diagnosed with aplastic anemia. The nurse reviews his stat serum laboratory values which reveals platelets 50,000/mm3 (5 x 10/L), white blood cells 3,000/mm3 ( 3 x10/L) and red blood cells 2.5 million/mm3 ( 2.5 x 10/12/L). Which actions should the nurse implement? (select all that apply)
A. Initiate sepsis protocols
B. Implement contact precautions C. Monitor for signs of bleeding D. Infuse blood products as prescribed E. Provide a soft- bristle toothbrush
31.A client in skeletal traction tells the nurse of being frustrated because of needing help to be reposition in bed.Which intervention should the nurse implement?
A-Administer an intravenous PRN anti-anxiety medication B- Provide an overhead trapeze to the bed for the client to use
C- Place a draw sheet under the client to assist with positioning
D- inform the client that it is the nurses responsibility to repositioning
32.During an office visit with his primary healthcare provider, a middle aged adult male describes having symptoms of angina pectoris when doing chores in his yard.
A- A complete 7 day diet history of clients oral intake B- A description of the chest pain when client is at rest
C-The client blood pressure sitting and standing
D-A demonstration of the activity that precipitates pain
33- A client who is training for a first marathon arrives at the clinic reporting an increase in the frequency of leg cramps. Which recommendation should the nurse provide to help decrease the frequency of leg cramps.
A- Avoid drinking alcohol forty-eight hours before training.
B- Drink a liter of water during and after running.
C- Eat a high carbohydrate meal after running . D-Consume a sport drink before and after doing training.
34- An older adult recently DX with type 2 D/M suddenly becomes confused and weak with cool , clammy skin . The client is unable to remember what to do for such symptoms and is taken to a near-by urgent care facility by a neighbor. Which nursing interventions should the nurse implement?(select all that applies) A-Check a blood sample for glucose level B-Prepare to administer regular insulin. C-Observe respiratory rate and pattern
D-Palpate for bladder pain and distention.
E-Report any changes in blood pressure.
35-When providing care for an unconscious client who has seizures .Which nursing intervention is most essential. A-Ensure oral suction is available
B-Maintain client in a semi-fowler's position.
C-Keep the room at a comfortable temperature
D-Provide frequent mouth care.
36-The nurse provides dietary instructions about iron rich foods to a client with iron deficiency anemia.Which food selection made by the client indicates a need for additional instructions?
A-Liver
B- Kidney beans
C-Leafy green vegetables D-Oranges
37-A female college student comes to the school health clinic complaining of urinary frequency and burning with right lower back pain which intervention should the nurse implement first. A-Measure her temperature and pulse rate.
B-Palpate the right flank for tenderness
C-Evaluate the urine for a strong odor
D-Test her urine for the presence of hematuria.
38-Which information should the nurse include when giving discharge instructions to a client following a left eye cataract extraction with lens implants?
A-Sleep flat in a supine position
B-Turn ,cough, and deep breath every 2 hours C-Observe pupil response of the right eye
D-Administer a stool softener.
39. During a home visit, the nurse should evaluate the effectiveness of a client’s treatment for chronic obstructive pulmonary disease( COPD) by assessing for which primary symptoms?
A. Dyspnea B. Unilateral diminished breath sounds
C. Edema of the ankles
D. Tachycardia
40. Five months following treatment for herpes zoster (shingles), an older adult client tells the home health nurse of continuing to experience pain where the rash occurred . Which action should the nurse implement?
A. Teach the client about phantom pain symptoms B. Complete an assessment of the client's pain
C. Perform a complete mental status warm
D. Determine if the client has had a shingle vaccination
41. An adult male who was recently diagnosed with glaucoma tells the nurse that he feels like he is driving through a tunnel. The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client? A. Maintain prescribed eye drop regimen
B. Eat a diet high in calorie
C. Wear prescription glasses
D. Avoid frequent eye pressure measurements
42. Following a motorcycle collision, a young adult’s fractured left tibia was surgically repaired and a long- leg cast was applied. For the past two days, the client reports increased weakness in both forearms. Which action should the nurse take?
A. Demonstrate arm strengthening exercises
B. Encourage additional rest periods.
C. Measure the blood pressure in both arms D. Watch client while crutch walking
43. Which action should the nurse ask a client with systemic lupus erythematosus (SLE) in order to determine if the client is experiencing an impending disease exacerbation?
A. Has the amount or color of your urine changed?
B. Are you experiencing respiratory distress? C. Have you had a fever in the past few weeks?
D. Are you having any trouble swallowing?
44. Following discharge teaching, a male client with a duodenal ulcer tells the nurse that he will drink plenty of dairy products, such as milk to help coat and protect his ulcer. Which is the best follow up action by the nurse?
A. Suggest that the client also plan to eat frequent small meals to reduce discomfort
B. Reinforce this teaching by asking the client to list diary foods that he might select C. Review with the client the need to avoid foods that are rich in milk and cream
D. Remind the client that it is also important to switch to decaffeinated coffee and tea
45. A health care worker with no known exposure to tuberculosis has received a Mantoux tuberculin skin test . The nurse’s assessment of the test after 62 hours indicates 5mm of erythema without induration. Which is the best initial nursing action? A. Document negative results in the client's medical record
B. Refer client to a healthcare provider for isoniazid (INH) therapy
C. Review client’s history for possible exposure to TB
D. Instruct the client to return for a repeat test in 1 week
46. A client with pernicious anemia takes supplemental folate acid and self administers monthly vitamin B12 injections. the clients report feeling increasingly fatigued. Which laboratory value should the nurse review?
A. Liver enzymes B. Complete blood count
C. Serum electrolytes
D. Platelet Count
47. A Client newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for captopril 50mg PO BID. The client has NO history of hypertension, and the baseline blood pressure (BP) is 132/78mm HG. which action should the nurse implement? A. Withhold the medication if BP is within normal range
B. Assess the client for signs any symptoms of hypertension …….I think its B
C. Administer antihypertensive medication as prescribed
D. Examine the medical history for hypertensive risk factors
48. A client uses triamcinolone, a corticosteroid ointment, to manage pruritus caused by a chronic skin rash. The client calls the clinic nurse to report increased erythema with purulent exudate at the site. Which action should the nurse implement?
A. Explain that the client needs to complete all prescribed doses of the medication.
B. Advise the client to apply plastic wrap over the ointment to promote healing.
C. Instruct the client to continue the ointment until all erythema is relieved.
D. Schedule an appointment for the client to see the healthcare provider.
49. During preoperative teaching for a 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?
A. Document the client’s understanding of teaching.
B. Ask for demonstration of these exercises.
C. Explain that coughing should be avoided.
D. Review the client’s previous surgical history.
50. Which intervention by the community health nurse is an example of the secondary level of prevention.
A. Providing a needle exchange program at a community mental health clinic.
B. Developing an educational program for clients with diabetes mellitus.
C. Administering influenza vaccines to members of a nursing home.
D. Initiating contact notification for sexual partners of an HIV-positive client.
51. A nurse receives a report on a client who is four hours post-total abdominal hysterectomy. The previous nurse reports that it was necessary to change the client’s perineal pad hourly, and that it is again saturated. The previous nurse also reports that the client’s urinary output has decreased. Which action should the nurse implement first?
A. Assess for weakness or dizziness
B. Change the perineal pad
C. Evaluate the skin turgor
D. Measure the urinary output.
52. A client is currently receiving an infusion labeled , 5% Dextrose injection 500ml with heparin sodium 25,000 Units at 14ml/hour per pump. A prescription is received to change the rate of the infusion to heparin 1,000 units/hour. How many mL/hour should the nurse program the infusion pump?( Enter numeric value only.)
ml/hr = 500/25000 * 1000units/1hr = 20
20
53. Which intervention should the nurse include in the teaching plan for a client with pruritus?
A. Encourage the client to keep a warm sleeping environment.
B. Explain the importance of not taking any type of tub bath.
C. Discourage the use of any type of skin lubricant.
D. Instruct the client to keep fingernails trimmed short.
55. A client who has been taking Finasteride , an enzyme ( 5 alpha reductase) inhibitor used to shrink the prostate gland , is admitted because of continuing benign prostatic hypertrophy ( BPH) symptoms. When planning care, which nursing problem should the nurse address first?
A. Risk for Infection.
B. Chronic Pain
C. Urinary retention
D. Disturbed sleep pattern
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