HESI RN MED SURG

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HESI RN MED SURG 1. A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the best initial nursing action? Answer: Administer the first dose of prescribed antibiotic therapy 2. A client is brought to the Emergency Department by ambulation in cardiac arrest with cardiopulmonary resuscitation (CPR) in progress. The client isintubated and receiving 100% oxygen per self‐inflating (ambu) bag. The nurse determines that the client is cyanotic, cold, and diaphoretic. Which assessment is most important for the nurse to obtain? Answer: deep tendon reflexes. 3. After hospitalization for Syndrome of Inappropriate Antidiuretic hormone (SIADH), a client develops myelinolysis. Which intervention should the nurse implement first? Answer: Reorient client to hisroom. 4. A male client with heart failure (HF) calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain? Answer: Has his weight changed in the lastseveral days? 5. An older adult woman with a long history of COPD is admitted with progressive shortness of breath and a persistent cough. She is anxious and is complaining of a dry mouth. Which intervention should the nurse implement? Answer: Apply a high‐flow venturi mask. 6. A client with a history of asthma and bronchitis arrives at the clinic with SOB, productive cough with thickened, tenacious mucous, and the inability to walk up flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self‐care? Answer: Increase the daily intake of oral fluids to liquefy secretions. 7. A cardiac catheterization of a client with heart disease indicates the following blockages: 95% LAD, 99% proximal circumflex, and 95% proximal RCA. The client later asks the nurse “what does all that mean for me?” Answer: Three main arteries have major blockage with only 1 to 5% of the blood flow getting through to the heart muscle. 8. A client who weighs 175 pounds is receiving an IV bolus dose of heparin 80 units/kg. The heparin is available in a 2 mL vial, labeled 10,000 units/mL. How many mL should the nurse administer? (enter numeric value only. If rounding, round to nearest tenth.) Answer: 1.3 mL after calculations: the calculator willshow 1.272727272727273, but you must round to the nearest tenth. So, the answer is 1.3 mL. 9. What information should the nurse include in the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD)? 2 | P a g e Answer: minimize symptoms by wearing loose, comfortable clothing. 10. The nurse is caring for a client with a lower left lobe pulmonary abscess. Which position should the nurse instruct the client to maintain? Answer: Left Lateral. 11. A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider? Answer: Yellow Sclera 12. While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse? Answer: Increasing anxiety. 13. The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft to promote burn healing. Which information should the nurse provide this client? Answer: The xenograft is taken from nonhuman sources.

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