MED-SURG HESI Practice Questions

MED-SURG HESI practice questions from the Saunders book The nurse is preparing to assist a client with a cuffed tracheostomy tube to eat. What intervention is the priority before the client is permitted to drink or eat? Inflate the cuff Rationale: If a client with a tracheostomy is allowed to eat and the tracheostomy has a cuff, the nurse should inflate the cuff to prevent aspiration of food or fluids. The cuff would not be deflated because of the risk of aspiration. The nurse has implemented a bowel maintenance program for an unconscious client. The nurse would evaluate the plan as best meeting the needs of the client if which method was successful in stimulating a bowel movement? Glycerin suppository Rationale: The least amount of invasiveness needed to produce a bowel movement is best. Use of glycerin suppositories is the least invasive method and usually stimulates bowel evacuation within a half-hour. A client is readmitted to the hospital with dehydration after surgery for creation of an ileostomy. The nurse assesses that the client has lost 3 lb of weight, has poor skin turgor, and has concentrated urine. The nurse interprets the client's clinical picture as correlating most closely with recent intake of which medication, which is contraindicated for the ileostomy client? Biscodyl Rationale: The client with an ileostomy is prone to dehydration because of the location of the ostomy in the gastrointestinal tract and should not take laxatives. The client is complaining of skin irritation from the edges of a cast applied the previous day. Which action should the nurse take? The nurse petals the edges of the cast with tape Rationale: minimize skin irritation. The nurse is taking a health history for a client with hyperparathyroidism. Which question would elicit information about this client's condition? "Are you experiencing pain in your joints?" Rationale: Hyperparathyroidism is associated with over secretion of parathyroid hormone (PTH), which causes excessive osteoblast growth and activity within the bones. When bone reabsorption is increased, calcium is released from the bones into the blood, causing hypercalcemia. The bones suffer demineralization as a result of calcium loss, leading to bone and joint pain A client with type 2 diabetes mellitus has a blood glucose level greater than 600 mg/dL (34.3 mmol/L) and is complaining of polydipsia, polyuria, weight loss, and weakness. The nurse reviews the health care provider's documentation and expects to note which diagnosis? Hyperosmolar hyperglycemic syndrome (HHS) Rationale: HHS is seen primarily in clients with type 2 diabetes mellitus, who experience a relative deficiency of insulin. The onset of signs and symptoms may be gradual. Manifestations may include polyuria, polydipsia, dehydration, mental status alterations, weight loss, and weakness. The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse develops the plan, expecting that the health care provider (HCP) will most likely prescribe which option? ---Maintain activity level as prescribed. Rationale: Standard management for the client with DVT includes maintaining the activity level as prescribed by the health care provider; limb elevation; relief of discomfort with warm, moist heat; and analgesics as needed. Recent research is showing that ambulation, as previously thought, does not cause pulmonary embolism and does not cause the existing DVT to worsen. Therefore, the nurse should maintain the prescribed activity level, which could be bed rest or ambulation. Opioid analgesics are not required to relieve pain, and pain normally is relieved with acetaminophen.re provider (HCP) will most likely prescribe which option? Maintain activity level as prescribed. A client has had surgery to repair a fractured left hip. When repositioning the client from side to side in the bed, what should the nurse plan to use as the most important item for this maneuver? ----- Abductor splint Rationale: After surgery to repair a fractured hip, an abductor splint is used to maintain the affected extremity in good alignment. A bed pillow and an overhead trapeze also are used, but neither is the priority item to be used in repositioning the client from side to side. The nurse is preparing to care for a client who had a supratentorial craniotomy. The nurse should plan to place the client in which position? Semi Fowler's Rationale: you know why A client with an external arteriovenous shunt in place for hemodialysis is at risk for bleeding. Which is the priority nursing intervention? -Ensure that small clamps are attached to the arteriovenous shunt dressing. Rationale: An external arteriovenous shunt is a less common form of access site but carries a risk for bleeding when it is used because 2 ends of an external cannula are tunneled subcutaneously into an artery and a vein, and the ends of the cannula are joined. If accidental disconnection occurs, the client could lose blood rapidly. For this reason, small clamps are attached to the dressing that covers the insertion site for use if needed. The shunt site also should be assessed at least every 4 hours. Checking the shunt for the presence of bruit and thrill relates to patency of the shunt. Although checking the results of the prothrombin time is important, it is not the priority nursing action. A client is admitted to the hospital emergency department after receiving a burn injury in a house fire. The skin on the client's trunk is tan, dry, and hard. It is edematous but not very painful. The nurse determines that this client's burn should be classified as which type? Full-thickness Rationale: Full-thickness burns involve the epidermis, the full dermis, and some of the subcutaneous fat layer. The burn appears to be a tan or fawn color, with skin that is hard, dry, and inelastic. Edema is severe, and the accumulated fluid compresses tissue underneath because of eschar formation. Some nerve endings have been damaged, and the area may be insensitive to touch, with little or no pain. The nurse is assessing a client with a duodenal ulcer. The nurse interprets that which sign or symptom is most consistent with the typical presentation of duodenal ulcer? Pain that is relieved by food intake Rationale: The most typical finding with duodenal ulcer is pain that is relieved by food intake. The pain is often described as a burning, heavy, sharp, or "hunger pang" pain that often localizes in the mid-epigastric area. The nurse is developing a plan of care for a client with Cushing's syndrome. The nurse documents a client problem of excess fluid volume. Which nursing actions should be included in the care plan for this client? Select all that apply. Monitor daily weight. Monitor intake and output. Assess extremities for edema Rationale: The client with Cushing's syndrome and a problem of excess fluid volume should be on daily weights and intake and output and have extremities assessed for edema. He or she should be maintained on a high-potassium, low-sodium diet. A client with a history of ear problems is going on vacation by aircraft. The nurse advises the client to include which activities to prevent barotrauma during ascent and descent of the airplane? Select all that apply: Yawning- Swallowing - Chewing gum - Sucking on a hard c ( its not what your thinking ) Rationale: Clients who are prone to barotrauma should perform any of a variety of mouth movements to equalize pressure between the ear and the atmosphere, particularly during ascent and descent of an aircraft. These can include yawning, swallowing, drinking, chewing, and sucking on hard candy. Valsalva maneuver also may be helpful. The client should avoid sitting with the mouth motionless during this time because the resulting lack of pressure change in the ear will contribute to pressure buildup behind the tympanic membrane. The nurse is assessing a client with an abdominal aortic aneurysm. Which assessment finding by the nurse is unrelated to the aneurysm? B A. Pulsatile abdominal mass B. Hyperactive bowel sounds in the area C. Systolic bruit over the area of the mass D. Subjective sensation of "heart beating" in the abdomen Rationale: Hyperactive bowel sounds are not related specifically to an abdominal aortic aneurysm. Not all clients with abdominal aortic aneurysm exhibit symptoms. Those who do may describe a feeling of the "heart beating" in the abdomen when supine or being able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be auscultated over the mass. The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective? A rise in blood pressure Following pericardiocentesis, the client usually expresses immediate relief. Heart sounds are no longer muffled or distant and blood pressure increases. The nurse is creating a plan of care for a client with a diagnosis of nephrotic syndrome whose glomerular filtration rate (GFR) is normal. Which interventions should the nurse include in the plan of care? Select all that apply. All of these Monitor daily weight. Maintain sodium restrictions. Monitor intake and output (I&O). Maintain bed rest when edema is severe. Rationale:Controlling edema is a critical aspect of therapeutic management of nephrotic syndrome. If the GFR is normal, dietary intake of proteins is needed to restore normal plasma oncotic pressure and thereby decrease edema. Daily measurement of weight and abdominal girth, and careful monitoring of I&O will determine whether weight loss is caused by diuresis or protein loss. Dietary modifications may include salt restriction and fluid restriction and are based on the client's symptoms. Bed rest is prescribed to promote diuresis when edema is severe. The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal compartment. Which is the most appropriate action? Document the findings Rationale: Bubbling in the water seal compartment is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. Therefore, it is unnecessary to call the HCP or change the chest tube drainage system. Continuous bubbling during inspiration and expiration indicates an air leak. If this occurs, it must be corrected. The nurse is preparing for removal of an endotracheal (ET) tube from a client. In assisting the health care provider with this procedure, which is the initial nursing action? She had betta: Suction the ET tube. Rationale: Once the client has been weaned successfully and has achieved an acceptable level of consciousness to sustain spontaneous respiration, an ET tube may be removed. The ET tube is suctioned first, and then the cuff is deflated and the tube is removed. The nurse determines that a client with a tracheostomy tube needs suctioning if which finding is noted? Rhonchi are auscultated. Rationale: When you auscultate that rhonchi, it is an indication that there are secretions in the large airways. The client requires suctioning if the client cannot expectorate them. A pulse oximetry reading of 96% is an acceptable reading. A pleural friction rub is indicative of inflamed pleural surfaces. Fine crackles are indicative of air moving into previously deflated alveoli. The nursing student is assigned to care for a client with a diagnosis of acute kidney injury (AKI), diuretic phase. The nursing instructor asks the student about the primary goal of the treatment plan for this client. Which goal, if stated by the nursing student, indicates an adequate understanding of the treatment plan for this client? Prevent loss of electrolytes. Rationale: In the diuretic phase, fluids and electrolytes are lost in the urine. As a result, the plan of care focuses on fluid and electrolyte replacement and monitoring. The nurse has been caring for a client who required a Sengstaken-Blakemore tube because other treatment measures for esophageal varices were unsuccessful. The health care provider (HCP) arrives on the nursing unit and deflates the esophageal balloon. Which assessment finding by the nurse is the most important and should be reported to the HCP immediately? Hematemesis Rationale: A Sengstaken-Blakemore tube may be inserted in a client with a diagnosis of cirrhosis with bleeding esophageal varices. It has both an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated, the client may begin to bleed again from the esophageal varices, manifested as vomiting of blood (hematemesis). The nurse is planning discharge teaching for a client diagnosed and treated for compartment syndrome. Which information should the nurse include in the teaching? "Bleeding and swelling caused increased pressure in an area that couldn't expand." Rationale: Compartment syndrome is caused by bleeding and swelling within a tissue compartment that is lined by fascia, which does not expand. The bleeding and swelling put pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms. The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply. Head midline Neck in neutral position Head of bed elevated 30 to 45 degrees Rationale:Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure from elevating. The head of the client at risk for or with increased intracranial pressure should be positioned so that it is in a neutral, midline position. The head of the bed should be raised to 30 to 45 degrees. The nurse should avoid flexing or extending the client's neck or turning the client's head from side to side. The nurse is caring for a postoperative pneumonectomy client. Which finding on assessment of the client is an adverse sign or symptom indicating pulmonary edema? Lung crackles in the remaining lung Rationale: The client with pulmonary edema that developed after pneumonectomy demonstrates dyspnea, cough, frothy sputum, crackles, and possibly cyanosis. A client is scheduled for surgical creation of an internal arteriovenous (AV) fistula on the following day. The client says to the nurse, "I'll be so happy when the fistula is made tomorrow. This means I can have that other hemodialysis catheter pulled right out." Which interpretation should the nurse make based on the client's statement? The client does not understand that the site needs to mature or develop for 1 to 2 weeks before use. Rationale: An AV fistula is the internal creation of an arterial-to-venous anastomosis. This causes engorgement of the vein, allowing both the artery and the vein to be easily cannulated for hemodialysis. Fistulas take 1 to 2 weeks to mature (engorgement) or develop before they can be used for dialysis, so the current method of access must remain in place to be used during that period. A client is admitted with suspected diabetic ketoacidosis (DKA). Which clinical manifestations best support a diagnosis of DKA? 1.Blood glucose 500 mg/dL (27.8 mmol/L); arterial blood gases: pH 7.30, PaCo2 50, HCO3– 26. 2.Blood glucose 400 mg/dL (22.2 mmol/L); arterial blood gases: pH 7.38, PaCo2 40, HCO3– 22. 3.Blood glucose 450 mg/dL (25.0 mmol/L); arterial blood gases: pH 7.48, PaCo2 39, HCO3– 29. 4.Blood glucose 350 mg/dL (19.4 mmol/L); arterial blood gases: pH 7.28, PaCo2 30, HCO3– 14. Rationale: DKA is caused by a profound deficiency of insulin and is characterized by hyperglycemia (blood glucose level greater than or equal to 250 mg/dL [13.9 mmol/L]), ketosis (ketones in urine or serum), metabolic acidosis, and dehydration. The correct option is 4, as it represents an elevated blood glucose and the arterial blood gases (ABGs) indicate metabolic acidosis. Option 1 is incorrect, as the ABGs indicate respiratory acidosis; option 2 is incorrect, as the ABG values are within normal; and option 3 is incorrect, as the ABGs indicate metabolic alkalosis. A client with ulcerative colitis has a prescription to begin a salicylate compound medication to reduce inflammation. What instruction should the nurse give the client regarding when to take this medication? After meals Rationale: The medication needs to be taken after meals to reduce gastrointestinal irritation A client with chronic kidney disease who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril. When should the nurse plan to administer this medication? On return from dialysis Rationale: Antihypertensive medications such as enalapril are given to the client following hemodialysis. This prevents the client from becoming hypotensive during dialysis and from having the medication removed from the bloodstream by dialysis. The nurse is monitoring the function of a client's chest tube that is attached to a drainage system. The nurse notes that the fluid in the water seal chamber rises with inspiration and falls with expiration. The nurse determines that which is occurring? Tidaling is present. ( it supposed to happen) Rationale: When the chest tube is patent, the fluid in the water seal chamber rises with inspiration and falls with expiration. This is referred to as tidaling and indicates proper function of the system. A client with acute ulcerative colitis requests a snack. Which is the most appropriate snack for this client? 1.Carrots and ranch dip 2.Whole-grain cereal and milk 3.A cup of popcorn and a cola drink 4.Applesauce and a graham cracker Rationale: The diet for the client with ulcerative colitis should be low fiber (low residue). The nurse should avoid providing foods such as whole-wheat grains, nuts, and fresh fruits or vegetables. Typically, lactosecontaining foods also are poorly tolerated. The client also should avoid caffeine, pepper, and alcohol. The nurse is planning to teach a client with peripheral arterial disease about measures to limit disease progression. Which items should the nurse include on a list of suggestions for the client? Select all that apply. (2,4,5) 1.Soak the feet in hot water daily. 2.Be careful not to injure the legs or feet. 3.Use a heating pad on the legs to aid vasodilation. 4.Walk each day to increase circulation to the legs. 5.Cut down on the amount of fats consumed in the diet. Rationale: Long-term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise), promote vasodilation (warmth), relieve pain, and maintain tissue integrity (foot care and nutrition). Soaking the feet in hot water and application of a heating pad to the extremity are contraindicated. The affected extremity may have decreased sensitivity and is at risk for burns. Also, the affected tissue does not obtain adequate circulation at rest. Direct application of heat raises oxygen and nutritional requirements of the tissue even further. A client who has undergone gastric surgery has a nasogastric (NG) tube connected to low intermittent suction that is not draining properly. Which action should the nurse take initially? (3) 1.call the surgeon to report the problem. 2.Reposition the NG tube to the proper location. 3.Check the suction device to make sure it is working. 4.Irrigate the NG tube with saline to remove the obstruction. Rationale: After gastric surgery, the client will have an NG tube in place until bowel function returns. It is important for the NG tube to drain properly to prevent abdominal distention and vomiting. The nurse must ensure that the NG tube is attached to suction at the level prescribed and that the suction device is working correctly. The tip of the NG tube may be placed near the suture line. Because of this possibility, the nurse should never reposition the NG tube or irrigate it. If the NG tube needs to be repositioned, the nurse should call the surgeon, who would do this repositioning under fluoroscopy The community health nurse is visiting a homeless shelter and is assessing the clients in the shelter for the presence of scabies. Which assessment finding should the nurse expect to note if scabies is present? Brown-red macules with scales Pustules on the trunk of the body White patches noted on the elbows and knees Multiple straight or wavy threadlike lines underneath the skin Rationale: Scabies can be identified by the multiple straight or wavy threadlike lines beneath the skin. The skin lesions are caused by the female, which burrows beneath the skin to lay its eggs. The eggs hatch in a few days, and the baby mites find their way to the skin surface, where they mate and complete the life cycle. Options 1, 2, and 3 are not characteristics of scabies. The registered nurse is precepting a new nurse who is caring for a client with pernicious anemia as a result of gastrectomy. Which statement made by the new nurse indicates understanding of this diagnosis? "Decreased production of intrinsic factor by the stomach affects absorption of vitamin B12 in the small intestine." Rationale: Intrinsic factor is produced in the stomach but is used to aid in the absorption of vitamin B12 in the small intestine. The nurse has a prescription to obtain a urinalysis specimen from a client with an indwelling urinary catheter. Which actions should the nurse include in performing this procedure? Select all that apply. (1,2,3,5) 1.Explaining the procedure to the client 2.Clamping the tubing of the drainage bag 3.Aspirating a sample from the port on the drainage tubing 4.Obtaining the specimen from the urinary drainage bag 5.Wiping the port with an alcohol swab before inserting the syringe Rationale: A urine specimen is not taken from the urinary drainage bag. Urine undergoes chemical changes while sitting in the bag, so its properties do not necessarily reflect current client status. In addition, it may become contaminated with bacteria from opening the system. The remaining options are correct interventions for obtaining the specimen.