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Med Surg Hesi 2025
A client is admitted to the hospital with symptoms consistent with right hemisphere stroke. With Neurovascular assessment requires immediate intervention by the nurse? - ANSWER Pupillary changes to ipsilateral dilation Achieve maximum mobility and independence for a client multiple sclerosis (MS). Which intervention is most important for the nurse to implement? - ANSWER Teach strengthing exercises The Nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendations should the nurse recommend the client to follow? - ANSWER Restrict protein intake by including meats and other high protein foods The nurse Is caring for a client with herpes zoster who reports painful blisters that align from the back along the chest curvature to the anterior chest. Which intervention is the highest priority for the nurse? - ANSWER Place the client on contact precaution A young adult who suffered a severe brain injury in an automobile collision has been mechanically ventilated for the past three days and has no spontaneous respiratory effort. After serial electroencephalograms (EEG) reveal no brain activity, the healthcare provider discusses end-of-life options with family who agree to discontinue life support. Which intervention should the nurse implement?
- ANSWER Discuss the withdrawal procedure with the family and offer support
Following a transurethral resection of the prostate (TURP), a client is discharged from the hospital with an indwelling urinary catheter. Which instruction is most important for the nurse to include in the discharge teaching plan? - ANSWER Drink 3 liters of water each day On the first postoperative day, the nurse finds an older male client disoriented and trying to climb over the bed railing. Previously he was oriented to person, place, and time on admission. Which intervention should the nurse implement first? - ANSWER Asses the client for pain Acute soft-tissue injuries (I.e. sprains, strains) provide the nurse with a variety of teaching opportunities. Which instruction should the nurse provide to a client with a soft tissue injury? - ANSWER Apply Ice intermittently for the first 24 hours A male client is admitted to the rehabilitation unit following a cerebrovascular (CVA), which resulted in paralysis of his right arm. When the nurse enters the room, he is struggling to put on a shirt, and he curses at the nurse. What is the best response from the nurse? - ANSWER Dressing must be a frustrating experience for you A client returns to unit following a craniotomy for removal of brain tumor and is obtunded but arouses to painful stimuli. Which assessment is most important for the nurse to obtain? - ANSWER Last administration of analgesia An older client who is agitated, dyspneic, orthopneic, and using accessory muscle to breathe is admitted for further treatment. Initial assessment indicates
important for the nurse to implement during the induction stage of chemotherapy?
- ANSWER Precautions to prevent infection and bleeding To reduce pulmonary complications for a client with Amyotrophic Lateral sclerosis (ALS). Which intervention should the nurse implement? (Select all that apply) - ANSWER Initiate passives engage of motion exercises Encourage use of incentive spirometer Teach the client breathing exercises A client with polycystic Kidney is admitted because of an abrupt onset of massive polyuria. The client is pale, tachycardia and female. Which serum laboratory finding requires immediate intervention by the nurse? - ANSWER Sodium 184 mEq/L A client tells the nurse, "I just received good news about my tumor, I have a neoplasm, but it is benign." How should the nurse respond? - ANSWER Ask the client if the diagnostic test indicates any secondary metastasis The Nurse is assessing a client diagnosed with medical diagnosis of a Bartholin cyst. Which physical assessment technique should the nurse use to observe the cyst? - ANSWER Place the client in lithotomy position to perform a pelvic examination The nurse is preparing to administer enoxaparin 90 mg subcutaneously daily to a client with pulmonary embolism. The pharmacy provides a prefilled syringe labeled, "Enoxaparin 100 mg/1ML "How many milliliters should the nurse administer? - ANSWER the nurse should administer 0.9 milliliters of enoxaparin?
While performing a neurovascular assessment distal to a client's fracture site, the nurse determines that the client's pulse is present, regular, and full. Which nursing action should be taken next? - ANSWER Document the neurovascular assessment as normal Magnesium hydroxide, 1.5 ounces P.O is prescribed for a client complaining of heartburn. After taking the prescribed dose 3 times today, how many mL of magnesium hydroxide has the client ingested? - ANSWER 133. milliliters? A client with renal calculus is complaining of severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority? - ANSWER Acute pain related to renal calculus Which Technique should the nurse use when assessing for early signs of rheumatoid arthritis? - ANSWER Observe the clients' fingers A client with cancer develops tumor lysis syndrome (TLS) following chemotherapy. Which nursing action has the highest priority in responding to the symptoms of this syndrome? - ANSWER Maintain intravenous therapy A client with Hepatitis A is complaining of weakness and chronic fatigue. Which intervention is most important for the nurse to implement? - ANSWER Provide liberal fluids for hydration and excretion of metabolic waste products A client who had a cast yesterday to the lower left arm comes to the clinic complaining of pain in the cast arm. Which assessment finding is most important
Which finding should the nurse document as primary manifestation of osteoporosis in an older woman? - ANSWER Loss of height over time The nurse is conducting discharge teaching for a male client with a prescription for magnesium hydroxide 15 mL one time per day. His home medication cup is ounces. How many ounces should he take each dose? - ANSWER 0. ounces Which change in lab values would indicate to the nurse that treatment for gout is successful? - ANSWER Decreased serum uric acid A client with acute renal injury (AKI) weighs 50 kg and has potassium level of 6. mEq/L (6.7 mmol/L) is admitted to the hospital. Which prescribed medication should the nurse first administer? - ANSWER Sodium polystyrene sulfonate 15 grams PO Following the administration of intravenous regular insulin to a client diagnosed with hyperkalemia, the nurse should expect which outcome to occur? - ANSWER An improvement in the cardiac conduction abnormalities An adult male who is insulin dependent diabetic. Is admitted to the hospital because of headaches. When the client stiffens and begins to seize. Which intervention is most important for the nurse to implement? - ANSWER Give the client a rapid form of glucose supplement?
A young adult is burned when wearing a shirt that was splashed with lighter fluid and caught. The shirt immediately without unbuttoning. What should the nurse implement first? - ANSWER Evaluate extremity sensation A female client returns to the clinic after being treated for chlamydia with azithromycin IM and reports that she still has symptoms. The healthcare provider obtains a swab of the discharge from the cervix for testing chlamydia. The client reports maintaining a monogamous relationship when laboratory results are positive for sexually transmitted infection. Which information should the nurse obtain to evaluate the ineffective results of treatment? - ANSWER Determine if the clients sexual partner received treatment for chlamydia The nurse implements a change in the approach to the client care after gathering evidence of a new approach. What should the nurse do first? - ANSWER Engage staff in evidence-based practice The Home Health nurse is caring for a client with Parkinson's disease who is beginning to experience swallowing difficulties. Which intervention should the nurse include for this client? - ANSWER Encourage the client and family to provide a semi-solid diet with thick liquids A client with chronic cirrhosis has esophageal varices. it is most important for the nurse to monitor the client for? - ANSWER Hematemesis The intracranial pressure of a brain-injured client who is on a ventilator has increased from 15 mm Hg to 25 mm Hg within the last 30 minutes. The client is beginning to flex all extremities intermittently. Based on these findings, which immediate action should the nurse take? - ANSWER Asses the patency of the client's artificial airway
The nurse admits a client who has a medical diagnosis of bacterial meningitis to the unit. Which intervention has the highest priority when providing care for the client? - ANSWER Obtain results of culture and sensitivity of CSF While performing assisted range of motion exercises for a client with osteoarthritis, the nurse notes joint crepitus. Which action should the nurse take? - ANSWER Continue the range of motion exercises A female client with metastatic breast cancer is admitted with shortness of breath and pleural effusion. The client has a living will and the family is requesting hospice information. Which information should the nurse provide regarding hospice? (Select all that Apply) - ANSWER Can be provided within comfort of home Provides comfort, dignity, and emotional support Family members can be involved in the plan of care
