HESI Med-Surg

What instruction should the nurse include in the discharge teaching plan of a client who

had a cataract extraction today?

A male adult comes to the urgent care clinic 5 days after being diagnose with influenza.

He is short of breath, febrile, and coughing green colored sputum. Which intervention

should the nurse implement first?

a. Obtain a sputum sample for culture

An elder male client tells the nurse that he is loosing sleep because he has to get up

several times at night to go to the bathroom that he has trouble starting his urinary

stream and that he does not feel like his bladder is ever completely empty. Which

intervention should the nurse implement?

c. palpate the bladder above the symphysis pubis

An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection

(UTI) Prescriptions for intravenous antibiotics and insulin infusion are initiated. Which

serum laboratory value warrants the most immediate intervention by the nurse?

d. potassium of 2.5 meq/l

A client with sickle cell anemia develops a fever during the last hour of administration of

a unit of packed red blood cell. When notifying the healthcare provider what information

should the nurse provide first using the SBAR communication process?

An adult male client is admitted for pneumocystis carinil pneumonia (PCP) secondary to

aids. While hospitalize he receives IV pentamidine isethionate therapy. In preparing this

client for discharge what important aspect regarding his medication therapy should the

nurse explain?

b. Light housekeeping is permitted but avoid heavy lifting

a. explain specific reason for urgent notification

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c. It will be necessary to continue prophylactic doses of IV or aerosol pentamine every

month

A client subjective data includes dysuria, urgency, and urinary frequency. What action

should the nurse implement next?

a.collect a clean catch specimen

A client tells the nurse that her biopsy results indicate that the cancer cells are well

differentiated How should the nurse respond?

b. ask the client in the healthcare provider has giving her any information

about the classification of her cancer

c.

A client with a chronic kidney disease is treated on hemodialysis. During the 1 treatment

clients blood pressure drops from 150/90 to 80/30 Which action should the nurse take

first?

A client with deep vain thrombosis (DVT) is receiving a continues infusion of heparin

sodium 25,000 unit in 5% dextrose injection 250ml. The prescription indicates the

dosage should be increase 900 units/hr. The nurse should program the infusion pump to

deliver how many ml/hr?

9

The nurse is obtaining the admission history for a client with suspected peptic ulcer

disease (PUD). Which subjective data reported by the client supports this diagnosis?

a. upper mid abdominal gnawing and burning pain

The nurse is providing preoperative education for a jewish client schedule to receive a

xenograft graft to promote burn healing. Which information should the nurse provide this

client?

c. stop dialysis treatment

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a.the xenograft is taken from nonhuman source

A client who took a camping vacation two weeks ago in a country with a tropical climate

comes to the clinic describing vague symptoms and diarrhea for the past week. Which

finding is most important for the nurse to report?

a. jaundice sclera

During a home visit the nurse assesses the skin of a client with eczema who reports

than an exacerbation of symptoms has occurred during the last week. Which

information is most useful in determining the possible cause of the symptoms?

d. a grandson and his new dog recently visited

When explaining dietary guidelines to a client with acute glomerulonephritis (AGN)

which instruction should the nurse include in the dietary teaching?

b. restrict sodium intake

A male client who is 24hr post operative for an exploratory laparoctomy complains that

he is starving because he has had no real food since before surgery. Prior to advancing

his diet which intervention should the nurse implememt?

d. Auscultate bowel sound in all four quadrants

e.

A client diagnose with stable angina secondary to ischemic heart disease has a

prescription for sublingual (SL) nitroglycerin (NTG). The nurse should tell the client to

follow which instructions if chest pain is not relieved after taking 3 NTG tables 5 min

apart?

d. call 911 pain is unrelieved and chew a tablet of aspirin 325mg

After taking orlistat (Xenical) for one week a femela client tells the home health nurse

that she is experiencing increasingly frequent oily stools and flatus. What action should

the nurse take?

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