Hesi rn medical surgical nursing

Question 1: View

An older adult client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement?

A. Encourage deep breathing and coughing exercises. B. Teach a family member to administer eye drops. C. Provide an eye shield to be worn while sleeping D. Obtain vital signs every 2 hours during hospitalization.

Explanation

A. Deep breathing and coughing are important for general postoperative care but they are not specifically indicated for immediate postoperative cataract surgery. These exercises can increase intraocular pressure and potentially disrupt the healing process.
B. While it's important to educate caregivers about medication administration, this is not the priority in the immediate postoperative period. The patient should be stable and comfortable before teaching begins.
C. An eye shield is crucial to protect the operated eye from accidental injury during sleep. It prevents rubbing and potential complications.
D. Monitoring vital signs is essential for postoperative care. However, the frequency of every 2 hours is excessive for cataract surgery. Vital signs can be monitored less frequently, depending on the patient's condition.

Question 2: View

A client with pancreatitis is receiving 0.9% normal saline, and the prescribed IV infusion rate was increased from 100 mL/hour to 150 mL/hour. Which assessment finding indicates to the nurse that the prescription has a therapeutic outcome?

Reference Range:

Blood glucose (70 to 110 mg/dL (less than 6.1 mmol/L)] Amylase [60 to 120 units/dL (30 to 220 units/L)]

Blood urea nitrogen (BUN) [10 to 20 mg/dL (3.6 to 7.1 mmol/L)]

Hematocrit (HCT) [42% to 52% (0.42 to 0.52 volume fraction)]

A. An increase in the hematocrit (HCT) from 42% (0.42 volume fraction) to 52% (0.52 volume fraction). B. An increase in the blood glucose level from 130 mg/dl. (7.22 mmol/L). C. A decrease in blood urea nitrogen (BUN) from 36 mg/dL (12.9 mmol/L) to 23 mg/dL (8.21 mmol/L). D. A decrease in serum amylase from 24 units/dl (240 units) to 12 units/dl. (120 units/L);

Explanation

A. This would indicate fluid volume deficit, not improvement. Increasing IV fluids should lead to a decrease in hematocrit, not an increase.
B. This is not a desired outcome for a patient with pancreatitis, as hyperglycemia is a common complication. The focus should be on maintaining stable blood glucose levels.
C. BUN is a marker of kidney function and hydration status. A decrease in BUN indicates improved renal perfusion, which is a therapeutic outcome of increasing IV fluids.
D. While a decrease in amylase is generally a good sign for pancreatitis, it is not a direct result of increasing IV fluids. Amylase levels decrease as the pancreatitis improves.

Question 3: View

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

A. Neutrophil count. B. C-reactive protein level. C. Platelet count. D. Serum potassium and sodium levels.

Explanation

A. While neutrophils are involved in the immune response and wound healing, they are more indicative of an acute infection. An increased wound size suggests a worsening chronic condition rather than an acute infection.
B. C-reactive protein (CRP) is a sensitive marker of inflammation. An increase in CRP often accompanies worsening inflammation, such as an increase in wound size. Evaluating CRP levels would provide valuable information about the overall inflammatory state of the client.
C. Platelets are involved in blood clotting and wound healing, but they are not directly related to the overall inflammatory process or wound size.
D. These electrolytes are important for overall health, but they are not directly related to wound healing or inflammation.

Question 4: View

The nurse is preparing a teaching plan for a client taking a prescribed diuretic for edema in the lower extremities. Which instruction should the nurse include in this teaching plan?

A. Take the diuretic every day, regardless of weight loss or muscle weakness. B. Weigh yourself daily at the same time and report excessive weight loss. C. Limit fluid intake while taking the diuretic to reduce fluid retention. D. Stop taking the medication when the edema in the lower extremities subsides.

Explanation

A. Diuretics can cause electrolyte imbalances and dehydration, leading to muscle weakness. The patient should report any signs of muscle weakness to the healthcare provider.
B. Weight is a good indicator of fluid loss. Monitoring daily weight and reporting excessive weight loss helps to evaluate the effectiveness of the diuretic and detect potential complications.
C. Limiting fluid intake while on a diuretic can lead to dehydration and electrolyte imbalances. Adequate fluid intake is essential.
D. Diuretics are often prescribed for long-term management of edema. The patient should not stop taking the medication without consulting the healthcare provider.

Question 5: View

The nurse is evaluating a client's symptoms, and formulates the nursing problem, "High risk for injury due to potential urinary tract infection." Which symptoms indicate the need for this nursing problem?

A. Straining on urination and nocturia B. Azotemia and anorexia. C. Hematuria and proteinuria. D. Fever and dysuria.

Explanation

A. These symptoms indicate a urinary tract issue but do not necessarily indicate a high risk for injury. While they are uncomfortable, they do not typically lead to physical harm.
B. Azotemia is the build-up of waste products in the blood, and anorexia is a loss of appetite. These symptoms indicate a more severe kidney problem and do not specifically point to an increased risk of injury due to a potential UTI.
C. These symptoms suggest kidney involvement but do not necessarily indicate an imminent risk of injury. While they are important to address, they do not warrant the nursing problem of "high risk for injury due to potential urinary tract infection."

D. Fever and dysuria are classic symptoms of a urinary tract infection (UTI). A UTI can progress to a more serious infection, such as pyelonephritis, which can lead to sepsis and potentially life-threatening complications. Therefore, these symptoms indicate a high risk for injury due to the potential for a UTI to worsen.

Question 6: View

The healthcare provider prescribes cefazolin 800 mg IM every six hours. The available vial is labeled, "Cefazolin 1 gram," and the instructions for reconstitution state, For IM use add 2.5 mL sterile water for Injection to provide a total volume of 3.0 mL. After reconstitution, the solution contains how many mg/mL? Enter numeric value only. If rounding is required, round to the nearest whole number.)

Explanation

One gram is equivalent to 1000 mg. If you add 2.5 mL of sterile water to the vial as instructed, the total volume of the solution becomes 3.0 mL.

Therefore, the concentration of the solution is 1000 mg divided by 3 mL, which equals approximately 333.33 mg/mL.

Question 7: View

The nurse is assessing a client who is newly diagnosed with hypothyroidism. Which assessment finding requires immediate intervention?

A. Weight gain. B. Hypoventilation. C. Cold intolerance. D. Lethargy

Explanation

A. Weight gain is a common symptom of hypothyroidism but it is not an immediate threat to life. It can be managed with diet and medication.
B. Hypoventilation, or decreased respiratory rate, can lead to hypoxemia (low oxygen levels in the blood) and hypercapnia (increased carbon dioxide levels in the blood). These conditions can rapidly deteriorate into a respiratory crisis and require immediate intervention.
C. Cold intolerance is a common symptom of hypothyroidism but is not an immediate threat to life. It can be managed with warm clothing and a warm environment.
D. Lethargy is another common symptom of hypothyroidism but is not an immediate threat to life. It can be managed with medication and lifestyle changes.
8. The nurse reviews discharge instructions with a client

Question 8: View

The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?

A. Minimize intake of spicy foods. B. Remain upright following meals. C. Avoid wearing tight fitting clothes. D. Begin a smoking cessation program.

Explanation

A. Spicy foods can exacerbate GERD symptoms by irritating the esophagus and increasing acid production. While minimizing spicy foods is important, it is one of several dietary changes that can help manage GERD. It’s beneficial but may not be the single most critical instruction compared to other lifestyle modifications.
B. Remaining upright after meals is crucial for managing GERD. Lying down or reclining too soon after eating can allow stomach acid to flow back into the esophagus, worsening symptoms. Staying upright helps to facilitate digestion and reduce acid reflux, making this practice highly important for symptom control and prevention of reflux.
C. Tight-fitting clothes can increase abdominal pressure, which may contribute to the occurrence of acid reflux. While this is a helpful instruction to prevent exacerbation of symptoms, it may not be as directly impactful as remaining upright after meals.
D. Smoking can weaken the lower esophageal sphincter (LES), making it easier for stomach acid to reflux into the esophagus. However, while important, this instruction might be considered a secondary priority compared to immediate practical strategies like maintaining an upright position after eating.

Question 9: View

An adult client is admitted to the medical unit due to rectal bleeding after a colonoscopy in which a polyp was biopsied and cauterized. Which Intervention should the nurse do first?

A. Palpate all peripheral pulses in the extremities. B. Encourage cough and deep breathing exercises. C. Complete a focused assessment of the abdomen. D. Initiate measurement of fluid intake and output.

Explanation

A. While assessing peripheral pulses is important, it's not the priority in this situation. The primary concern is the rectal bleeding.
B. These exercises are important to prevent postoperative complications like pneumonia, but they are not the immediate priority when a patient is experiencing rectal bleeding.
C. Assessing the abdomen will help determine the severity of the bleeding, identify any signs of abdominal distention or tenderness, and provide crucial information for further interventions.
D. Monitoring fluid intake and output is important for any patient, but it's not the initial priority when a patient is actively bleeding.

Question 10: View

While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?

A. Stone fragments are collected when straining the client's urine. B. Client denies urinary frequency, urgency, or dysuria. C. Urine is pale pink with no observable blood clots. D. Serum creatinine and blood urea nitrogen (BUN) levels are within normal limits.

Explanation

A. This directly indicates that the lithotripsy procedure was successful in breaking down the stone into smaller fragments that can be passed through the urinary tract.
B. While the absence of these symptoms is a positive sign, it does not directly confirm the success of the lithotripsy procedure. These symptoms can be present even if the stone has been broken down.
C. Pale pink urine is expected after lithotripsy due to minor bleeding. The absence of blood clots is also a good sign, but it doesn't definitively confirm the procedure's success.
D. Serum creatinine and blood urea nitrogen (BUN) levels are within normal limits. These lab values are important indicators of kidney function but do not directly relate to the success of the lithotripsy procedure itself.