Hesi MedSurg real exam trial Questions And Answers 2020/2021 (Complete)

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Hesi MedSurg real exam trial Questions 2021 Study Questions: Download All This Practice Questions and Much More FOR FREE Hesi Med Surg review What instruction should the nurse include in the discharge... teaching plan of a client who had a cataract extraction today? a. Sexual activities may be resumed upon return home b. Light housekeeping is permitted but avoid heavy lifting c. Use a metal eye shield on operative eye during the day d. Administer eye ointment before applying eye drops 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 b. Check his oxygen saturation level c. Administer an oral antipyretic d. Auscultate bilateral lung sound 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? a. collect a urine specimen for culture analysis b. obtain a fingerstick blood glucose level c. palpate the bladder above the symphysis pubis d. review the client fluid intake 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? a. blood ph of 7. b. glucose of 350 mg /dl c. white blood cell count of 15000mm 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? a. explain specific reason for urgent notification b. preface the report by stating the clients name and admitting diagnosis c. communicate the pre-transfusion temperatures d. optain prn prescription for acetaminophen for fever 101f 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? a. AZT therapy must be stopped when IV aerosol pentamine is being used. b. IV pentamine will be given until oral pentamine can be tolerated c. It will be necessary to continue prophylactic doses of IV or aerosol pentamine every month d. Iv pentamine may offer protection to others aids related conditions such as kaposis sarcoma A client subjective data includes dysuria, urgency, and urinary frequency. What action should the nurse implement next? a. collect a clean catch specimen b. palpate the suprapubic region c. instruct to wipe from front to back d. inquire about recent sexual activity A client tells the nurse that her biopsy results indicate that the cancer cells are well differentiated How should the nurse respond? a. offer the client reassurance that this information indicates that the clients cancer cells are benign b. explain that these tissue cells often respond more effectively to radiation than to chemotherapy c. ask the client in the healthcare provider has giving her any information about the classification of her cancer d. help the client make plans to begin inmediate treatment since her cancer is likely to spread quickly 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. monitor bp q45 minutes b. lower the head of the chair and elevate feet c. stop dialysis treatment d. administer 5%albumin IV 10.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? = 11.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 b. severe abdominal cramps and diarrhea after eating spicy foods c marked loss of weight and appetite over the last few months 19.Two days after an abscess of the chin was drained the client returns to the clinic with fever chills and a maculopapular rash with pruritis. The client has taken an oral antibiotic and cleansed the wound today with provide iodine (Betadine) solution. Which intervention should the nurse implement first? a. determine if the client has a history of diabetes b. assess airway patency and oxygen saturation c. review recent medication history and allergies ( POSSIBLE ANSWER TOO) d. obtain samples for complete blood count and cultures 20.A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the health care provider? a. low back pain and hypotension b. rhinitis and nasal stuffiness c. delayed painful rash with urticarial d. arthritic joint changes and chronic pain 21.A young adult male who has had type 2 diabetes mellitus (DM) is admitted to the intensive care unit with hyperglycemic nonketotic syndrome (HHNS). A sliding scale protocol for an isotonic IV solution with regular insulin is prescribed based on the results of a continuous blood glucose monitoring device that is attached to the client’s central venous catheter. When the client’s respirations become labored and his lungs sound indicate crackles what action should the nurse take? a. collect a specimen for a white blood cell count and cultures b. determine the clients glycosylated hemoglobin (A1C) (POSSIBLE ANSWER) c. administer insulin IV push until the clients fluid volume is adjusted d. decrease infusion rate to address fluid overload 22.When preparing to apply a fentanyl (Duragesic) transdermal patch the nurse notes that the previously applied patch is intact on the client’s upper back and the client denies pain. What action should the nurse take? a. Remove the patch and consult with the healthcare provider about the client pain resolution b. Place the patch on the clients shoulder and leave both patches in place for 12 hours c. Administer an oral analgesic and evaluate its effectiveness before applying a new patch d. Apply a new patch in a different location after removing the original patch 23.A client who had a myocardial infarction is admitted to the coronary critical care unit (CCU) with a nitroglycerin drip infusing. The clients last blood pressure measurements was 78/36.What action should the nurse implement? a. obtain blood pressure q5 minutes using duranap machine b. change the dilution of the nitroglycerin infusion c. reduce the rate of the nitroglycerin infusion d. begin dopamine infusion at 5mcg/kg per minute 24.An adolescent is admitted to the hospital because of a suicide attempt with an overdose of acetaminophen (Tylenol). Which blood values are most important for the nurse to monitor during the first 72 hours following ingestion of this overdose? a. BUN creatinine specific gravity b. White blood count, hemoglobin hematocrit c. PH,PCO2, HC d. LDH OR LD, SGOT OR ALT, SGPT OR AST 25.An elderly post-operative female client is receiving morphine sulfate via a PCA pump. Which assessment finding should prompt a nurse to administer the prescribed PRN medication naloxone? aher respiratory rate is 7 breath/minute a. her respiratory rate is 7 breath/minute b. she indicates that she feels as if she cannot get enough air to breath c. she has intercostal retractions and bilateral wheezing is auscultated d. her pulse oximeter is 89% on room air 26.Which assessment finding indicates to the nurse that the muscarinic agent bethanechol (Urecholine) is effective for a client diagnose with urinary retention? a. urinary output equal to intake b. no terminal urinary dribbling c. denies stress incontinence d. absence of xerostomia 27.Following involvement in a motor vehicle collision, a middle aged adult client is admitted to the hospital with multiple facial fractures. The client’s blood alcohol level is high on admission. Which PRN prescription should be administer if the clients begins to exhibit signs and symptoms of delirium tremens (DT s)? a. Lorazepam (Ativan) 2mg IM b. Chlorpromazine (thorazine) 50 mg IM c. Prochlorperazine (Compazine) 5 mg IM d. Hydromorphone (Dilaudid) 2 mg IM 28.Which instructions should the nurse include in the teaching plan of a client who is taking the diuretic spironolactone (Aldactone)? a. call the healthcare provider f you develop gynecomastia b. Take the medication in the morning c. Avoid caffeine and smoking d. Increase your consumption of bananas and oranges 29.A glucagon emergency kit is prescribed for a client with type 1 diabetes mellitus. When should the nurse instruct the client to take the glucagon? a. after meals to increase endogenous insulin secretion b. after insulin administration to prevent hypoglycemia c. when recognized signs of severe hypoglycemia occur d. when unable to eat during sick days 30.A client w/ hyperthyroidism is being treated w radioactive iodine (I-131). Which explanation should be included in preparing this client for this treatment? a. describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider b. explain the need for using lead shields for 2 to 3 weeks after the treatment c. describe the signs of goiter because this is a common side effects of radioactive iodine d. explain that relief of the signs/ symptoms of hyperthyroidism will occur immediately 31.A female client is being treated for tuberculosis with rifampin (rifadin) which statement indicates that further teaching is needed? a. I will take my usual contraceptive for birth control 32.A client is discharged with a prescription for warfarin (Coumadin). What discharge instructions should the nurse emphasize to the client? a. take a multi vitamin supplement daily b. use an astringent for superficial bleeding c. avoid going barefoot especially outside d. include large amounts of spinach in the diet 33.In caring for a client with diabetes insipidus who is receiving an antidiuretic hormone intranasal which serum lab test is most important for the nurse to monitor? a. osmolality b. calcium emergence of resistant bacteria what instruction should the nurse provide to the clients? a. stop taking prescribed antibiotics when symptoms decrease b. avoid using antibiotics when suffering from colds or the flu c. ask the healthcare provider to prescribe the newest antibiotic when needed d. request a prescription for first time vancomysin for a sore throat 43.A client with symptoms of influenza that started the previous day ask the clinic nurse about taking oseltamivir (Tamiflu) to treat the infection. Which response should the nurse provide? a. Advise the client once symptoms occur is too late to receive an influenza vaccination b. Refer the client to the healthcare provider at the clinic to obtain a medication prescription c. Explain to the client that antibiotics are not useful in treating viral infections such as influenza d. Instruct the client that over the counter medications are sufficient to manage influenza symptoms 44.Twenty minutes after the nurse starts a secondary IV infusion of cafepime (maxipime) 2 grams using an infusion pump to deliver the dose in one hour, the client reports feeling nauseated. What action should the nurse implement? a. stop medication infusion and notify the healthcare provider of the adverse effect b. increase the rate of the infusion to complete the dose of the medication more rapidly c. continue the infusion and administer a prn antiemetic prescription d. reassure the client that the nausea is not related to the iv infusion 45.The nurse administer donepezil hydrochloride (Aricept) to a client with Alzheimer’s disease as an intervention for which client problem? a. fluid volume excess b. disturbed thought processes c. chronic pain d. altered breathing patterns 46.To prevent deep vein thrombosis following knee replacement surgery, an adult male client is receiving enoxaparin (Lovenox) subcutaneously daily. Which laboratory finding requires immediate action by the nurse? a. blood urea nitrogen (BUN) 20mg/dl or 7.1 mmol/L (SI) b. Hematocrit 45% c. Serum creatinine 1.0 mg/dl or 88.4 mol/L (SI) d. Platelet count of 100,000/mm3 or 100x10??/ L (SI) 47.A client with type 2 diabetes mellitus is managed with metformin (Glucophage), an oral hypoglycemic agent. The primary health care provider prescribes ad additional medication injected exenatide (byetta). Which information is most important for the nurse to teach this client? a. Administer subcutaneously after meals b. Consume additional sources of potassium c. Notify the healthcare provider if anorexia occurs d. Watch for signs of jitteriness or diaphoresis ( POSSIBLE ANSWER) 48.A client is who is diagnose with schizophrenia receives a prescription for an atypical antipsychotic drug aripipazole (Abilify). Which assessment should the nurse perform to monitor for an adrenergic receptor antagonist side effect that commonly occurs atypical antipsychotic agents? a. observe the client hallucinatory behaviors b. obtain the client finger stick glucose levels c. measure the clients lying and standing blood pressure d. determine the clients abnormal involuntary movements scale (AIMS) 1- A client with pheocromocytoma reports the onset of a severe headache. The nurse observes that the client is very diaphoretic. Which assessment data should the nurse obtain first? Blood pressure 2- The drainage in the chest tube of a client with emphysema has changed from clear watery fluid. What action would be best for the nurse to take/ Maintain the current IV antibiotic schedule 3- A client is admitted with a sudden onset of right sided the nurse complete first? Observe for peripheral edema 4- When planning care for a client newly diagnose with open angle glaucoma, the nurse identifies p g y g p g g , a priority nursing diagnosis of “ Visual sensory/perceptual alterations”. This diagnosis is based on which etiology? Decreased peripheral vision 5- A client in the operating room received succinylcholine. The client is experiencing muscle rigidity and has an extremely high temperature. What action should the nurse implement? Call the PACU nurse to prepare for prolonged ventilatory support Also know that PACU is BP, Respiration and Pulse 6- A client who is receiving packed red blood cells develops nausea and vomiting. What action should the nurse take first? Stop the infusion of blood Te lo pueden poner como hemodialysis y tambien es STOP transfusion 7- A client with type 2 diabetes mellitus is admitted to the hospital for uncontrolled DM. Insulin therapy is initiated with initial dose of Humulin insulin at 8:00 at 16:00 the client complains of diaphoresis, rapid heart beat, and feeling shaky. What should the nurse do first? Determine the client current glucose level 8- After suctioning the patient with an endotracheal tube, which assessment finding indicates to the nurse that the intervention was effective? Increase in breath sounds 9- The nurse observes an increase number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). What is the best initial nursing action? Provide additional oral fluid intake Also with TURP you must know that 3l of water a day is needed 10- Which nursing diagnosis should be selected for a client who is receiving thrombolytic infusions for treatment of an acute myocardial infarction? Risk for injury related to effects of thrombolysis 11- The nurse is assessing a client who has returned from surgery following a thoracotomy. Which finding indicates the client is experiencing adequate gas exchange? The client demonstrates effective coughing and deep breathing exercises 12- When caring for a client with nephrotic syndrome which assessment is most important for the nurse to obtain? Daily Weight 13- A client who had a biliopancreatic diversion procedure (BOP) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse? Gastroccult positive emesis 43- After a computer tomography (CT) scan with intravenous contrast medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement? A. Send another nurse for an emergency tracheotomy set B. Call respiratory therapy to give a breathing treatment C. Review the client's complete list of allergies D. Prepare a dose of Epinephrine (Adrenalin 44- The nurse is reviewing blood pressure readings for a group of client's on a medical unit. Which client is at the highest risk for complications related to hypertension? A. Young adult Hispanic female who has a hemoglobin of 11 gm and drinks beer every day B. Middle-aged African-American male who has a serum creatinine level of 2.9 mg/dL C. Older Asian male who eats a diet consisiting of smoked, cured, and pickled foods. D. Post-menopausal Caucasian female who overeats and is 20% above ideal body weight Shingles Teach the pt about phantom pain Shingles Select all the apply pain bl 25.EXTERNAL FIXATION - ADMINISTER PRN MEDS 26.MULTIPLE SCLEROSIS (MS) - ADMINISTER ANTIMEDICS/ PRN AS PRESCRIBED 27.FEMALE PATIENT HOW HAVE EPIGASTRIC PAIN FOR 3 DAYS HAVE BEEN TAKIN ANTACIDS AND NO RESOLVE ARRIVE TO HOSPITAL W/HR;128 BPM, BP110/70 WHAT IS THE MOST IMPORTANT INTERVENTION FINDING IN ASSESSMENT: - ASSESS FOR RADIATING JAW PAIN. 28.Pt. W. RADIACTIVE THERAPY WHAT TO TEACH/ RECOMMEND TO PROTECT THAT PART OF THE SKIN SPECIALLY FROM THE SUN 29.Pt WITH ALS WHAT TO DO TO PREVENT RESPIRATORY COMPLICATIONS: TEACH BREATHING TECNIQUES, USES SPIROMETER, AUSCULTATE FOR BREATH OR LUNG SOUNDS. 30.PT WITH LEFT LEF ULCER: KEEP LEG ELEVATED AS MUCH AS HE CAN. 31.PT WITH AN EXTERNAL DEVICE COMPLAINING OF PAIN: ASSESS FOR PHERIPHERAL PULSES. 32.CALCULATION 1G/0.4 G = 2. 33.EXAMPLES OF DASH DIET: PEEL FRUITS AND VEGETABLES. 34.CHEST TUBE W/ A DRAINAGE CHANGING FROM CLEAR TO GREEN: KEEP IV FLUIDS. 35.PT W/ OPEN ANGLE GLAUCOMA SELECT ALL THAT APPLY: FREQUENT EYE EXAM TO ASSES FOR VISSION, USE DROPS TO DIMINSH IOP, AVOID EXTRENOUS EXERCICES LIKE JOGGING OR RUNNING ( YO PUSE SOLO ESAS 3 RESPUESTAS). 36.PT W/ HYPERTHYROIDISM DEVELOPING EXOSPHTALMUS: PRESCRIBE TEAR EYE DROPS. 37.PT VOMITING BLOOD LIKE THE PICTURE SAME AS HEMATENSIS: CHECK VITAL SIGNS ( ASI ESTA EN TODOS LOS PAPELES) AUSCULTATE LUNGS SOUNDS ( FUE LO QUE PUSO YADIRA) 38.PATIENT W/ ML FELL AND WHEN RECEIVING THE NURSE HE HAVE 2 PROJECTILE VOMITS WHAT SHE DO: PROVIDE ANTIEMETICS PRN. 39.PT W/ RAYNAUD SYNDROME WHICH WORK AS A DATA ENTRY CLERK: PROVIDE A SPACE TO WARM THE ENVIROMENT NEXT TO HER ( ALGO ASI ERA LA RESPUESTA). Y HAY OTRA RESPUESTA QUE SOLO DICE KEEP MONITORING 40.PATIENT THAT HAVE THE K= 6.7 WHAT MEDICATION PROVIDE: KAYELAXATE (TREATS HYPERKALEMIA). 41.COLON CANCER PT KAYELAXATE Med 42.RENAL INJURY KAYELAXATE MED 43.PT WITH A BRONCHOSCOPY AND DRINK A GLASS OF JUICE : DELAY THE PROCEDURE 6 HOURS 44.NEW PATIENT DIAGNOSES WITH DM TYPE IS RECEIVING TEACHING IN WHICH GLUCOMETER WILL BE THE BEST: ASSESS FOR VISUAL ACUITY AND ABILITY TO READ OR SOMETHING LIKE THAT. 45.ABG (PH 7.25 PCO2 50 SODIUM 60 TACHY AND CONFUSION/ RESPIRATORY 46.ACUTE AGN DIET: RESTRICT NA INTAKE. 47.PT W/ A EXPRESSIVE APHASIA IS ANGER WHAT SHOULD DO THE NURSE: - CVA- COMMUNICATE W/ PICTURE BOARDS. 48.NURSE IS TEACHING THE WIFE IF A PATIENT DIAGNOSED W/ SEIZURE WHAT TO DO: - TEACH HER HOW TO POSITION HIM 49.PT AFTER TTO OF SOMETHING AND WANTS TO EAT: - NURSE ASSESS FOR BOWEL MOVEMENTS. 50.SLE: - ASSESS FOR HEMATURIA 51.PATIENT ALLERGIC TO BANANA (LATEX): - CALL TO MD AND OR STAFF TO BE CHANGE EVERYTHING FOR SINTHETIC MATERIALS, 52.SUBCUT EMPHYSEMA- TORACOTOMY WAS A SELECT ALL THAT APPLY: - ASSESS FOR LUNG SOUNDS, 53.NECK DISTENTION - THINK IT WAS AND OTHER CHOICE THAT I NOT REMEMBER NOW. 54.RESTLESS LEG SYNDROME CON FEOSOL: - ASSESS FOR IRON AND FERRITIN. 55.BNP - ADMINISTRATIVE FUROSEMIDE LASIX IV 56.PARKINSON PT WALKING - REASURE THAT STEPPING ON CRACKLES IS NOT HARMFUL 57.ADDISON DISEASE - TAKE CORTICOSTEROID MEDS 58.CARPO TONIC SYNDROME - WEAR BRACE IN BOTH WRIST 59.PARKINSON AND ALZAIMERS PT - TATICARDIC AND CONFUSION 60.MID ABDOMEN BURNING PAIN - PEPTIC ULCER 61.ANTIBIOTICS - CLEAR DRAINAGE IMPROVE 62.ALLOPRINOL FOR GOUT - TAKE MEDS ALWAYS 63.BLOOD TRANSFUSION HIGH TEMPERATURE - BACK PAIN AND HYPOTENSION - ( ABO- LOW BACK PAIN AND HYPOTENSION) 64.CENTRAL FALL RISK - CARDIOVASCULAR DISEASE 65.RIGHT HIP FRACTURE - O2 SAT LEVEL 66.DESCRIBE PAIN NEUROPATHY - NERVOUS SYSTEM 67.ACUTE ABDOMINAL PAIN, NASUA, PROJECTIBLE VOMITING SEVERE HEADECHE AND PHOTO Sensitivity 68.UROLITHISIS O LITHOTRIPSY PROCEDURE RESTRICT PHYSICAL ACTION 69.UAP ( DICE EL PACIENTE QUE TIENE ABD PAIN LARGE TARRY STOOL TEST STOOL FOR OCCULT BLOOD 70.Insulin for a glucose level of 255 (Pte tmeblando despues que le pusieron insulin.) Obtain capillary glucose. 71.NGT proper tube procedure Elevate dead 60 to 90 degree.... 72.RA (rheuma) Impaired peripheral mobility relate to join pain. 73.Finger stick glucose finding 50 OC Level of conscious A. Case management and screening for clients with HIV. B. Regional relocation center for earthquake victims. C. Vitamin supplements for high-risk pregnant women. D. Lead screening for children in low-income housing. Critical Care/Geriatrics/Medical Surgical-Renal-Acute Tubular Necrosis -GERI Diabetic,renal no function,decrease urine or not urine, septic shock, check urine specific Gravity and osmolarity urine. Acute Renal Failure: Low Protein Chronic Renal Failure: NOT Protein at all Asw possible:Urine claude and check input and output Critical Care/Medical Surgical-Cardiovascular? Immune/Hematology/Integumentary/Respiratory-MODS-central line placement NOTE: The Multiple Organ Dysfunction Syndrome (MODS) can be defined as the development of potentially reversible physiologic derangement involving two or more organ systems not involved in the disorder that resulted in ICU admission, and arising in the wake of a potentially life-threatening physiologic insult. Answer: Shock Critical Care/Medical Surgical-Respiratory-Chest tube-tension pneumothorax A client who is admitted to the intensive care unit with a right chest tube attached to a THORA-SEAL chest drainage unit becomes increasingly ......... and complains of difficulty breathing. The nurse determines the client is tachypnea with absent breath sounds in the client’s right lung fields. Which additional finding indicates that the client has developed a tension pneumothorax? a. Continuous bubbling in the water- seal chamber. b. Decreased bright red bloody drainage. c. Tachypnea with difficulty breathing. d. Tracheal deviation toward the left lung. Critical Care/Medical Surgical-Respiratory/Trauma/Emergency-tension Pneumothorax s/s disnea tatycardia hbp chest pain Tension pneumothorax : insert 14 gage large bore needle or a chest tube insert. This procedure aloud immediate realizes of air plural space. Because is to air in a plural space and the lung collapsed Fundamentals-Basic Nursing Skills-Aphasia A patient with aphasia trying to say something to the RN “I want....” But she doesn’t finish the sentence, what the nurse need to do A- Give extra time to finish the sentence B- Ask the pt if she want to go to the bathroom Fundamentals-Basic Nursing Skills/Elimination-Catheterize A client is unable to void following a procedure, so the nurse obtains a prescription to perform a straight catheterization. After inserting the catheter, the nurse observes that the client has an immediate output of 500 ml of clear yellow urine. What action should the nurse implement next? A) Remove the catheter and palpate the client’s bladder for residual distention. B) Remove the catheter and replace with an indwelling catheter C) Allow the bladder to empty completely or up to 1,000 ml of urine D) Clamp the catheter for thirty minutes and then resume draining. Fundamentals-Basic Nursing Skills/Mobility-Skin pressure point Catheter in the skin is red: a. Document b. Evaluate (Check) every 30 minutes M c. Massaging d. Leave on open air and monitor 14. Fundamentals-Basic Nursing Skills/Mobility-Trapeze use *Answer: Check for upper strength extremities 15. Fundamentals-Basic Nursing Skills/Nutrition-Determine BMI *Answer: HEIGHT AND WEIGHT 16. Fundamentals-Basic Nursing Skills/Safety-Apply PPE ISOLATION PRECAUTIONS (ORDER): WASH HANDS PUT ON AN ISOLATION GOWN APPLY A SURGICAL MASK DON GLOVES Fundamentals-Basic Nursing Skills/Safety-Electrical shock care A toddler bit through an electrical cord and received a burn to the mouth and tongue region. The client’s parents bring the child to the nearest emergency department. Which action should the nurse take at this time? A. Provide the client with an ice pack to apply to the mouth. B. Encourage the client to suck on ice chips while waiting for the physician. C. Stabilize the client and prepare for transport to a hospital with a burns center. D. Monitor the client’s vital signs and reassure the parents that the client will recover. NOTE: Electrical cord in floor: Check the pulse Fundamentals-Basic Nursing Skills/Safety-Restrains-mittens THE NURSE IS PLANNING CARE FOR A CHILD WHO IS COMPLAINING OF PERSISTENT ITCHING DUE TO SCABIES. WHICH MEASURE SHOULD THE NURSE IMPLEMENT TO MINIMIZE THE CLIEDS RISK FOR COMPLICATION? A. KEEP THE CHILDS NAILS SHORT AND ENCOURAGE USE OF HAND MITTENS. B. MONITOR FOR DESQUAMATION AND NORMAL FLORA OVERGROWTH C. SHAVE THE BODY HAIR BEFORE APPLYING THE SCABICIDE LOTION D. WAS SKIN BETWEEN APPLICATION OF TOPICAL ANTI PARASITIC DOSIS? NOTE: WHEN YOU SEE MITTEN THAT IS THE ANSWER Fundamentals-Med Administration-Aspirate-2 vials Medicine: 1- Check Label 2- Put air in both 3- Take A 4- Take B Insulin: Air into B vial (cloudy) Air into A vial (clear/regular) Aspirate into the A, And then aspirate the B Fundamentals-Med Administration-IV sites IV LEFT FOREARM INFILTRATED (SELECT ALL THAT APPLY): A -LEFT HAND B -LEFT SUBCLAVIAN C -RIGHT HAND D -RIGHT FOREARM E -RIGHT SUBCLAVIAN NOTE: NEVER USE SUBCLAVIAN FOR IV AND WHEN SOMETHING IS WRONG WITH THE ARM USE THE OTHER ONE Fundamentals-Med Administration-Med error A postoperative client has three different PRN analgesics prescribed for different levels. The nurse inadvertently administers a dose that is not within the prescribed parameters. What action should the nurse take first? A. Administer a prescribed antidote. A- Give food to the patient in the mouth B- Indicate to the patient where is the tray ( reorient ) C- Look how the patient eat D- Finger food 30. Fundamentals/Medical Surgical-Basic Nursing Skills/Safety-Huntington’s chorea *ANSWER: padding on the side rail Or llevarlo a la cafeteria 31. Fundamentals/Medical Surgical-Basic Nursing Skills/Safety-Hyperglycemia-vomiting TYPE 1 DIABETES MELLITUS BLOOD GLUCOSE 420 BEGINS VOMIT: A- TURN THE CLIENT TO A LATERAL position B- OBTAIN A FINGER STICK GLUCOSE 32. Fundamentals/Medical Surgical-Basic Nursing Skills/Safety-MRI A PATIENT SCHEDULED MRI AND SAID THAT HAS A METAL TOOTH. WHAT THE RN NEED TO DO? A- ASSESS PT FEAR TO THE TEST B- CONSULTS RADIOLOGY C- SEND PT TO X-RAY INSTEAD D- CANCEL THE TEST. 33. Fundamentals/Medical Surgical-Integumentary/Operative-JP drain full POSTOPERATIVE DRESSING: ABDOMINAL WOUND WITH JACKSON PRATT DRAIN. WHAT THE NURSE DO FIRST? (PICTURE) A- ASSESS THE SURGICAL WOUND B- SQUEEZE C- EMPTY 34. Fundamentals/Medical Surgical-Med Administration-IV-gravity infusion flow rate (Question with 4 pictures) Overflow: A- ARM B- ARM AND FOREARM C- IV DRIP D- IV REGULATION 35. Fundamentals/Medical Surgical-Med Administration/Math-IV-Heparin-units HEPARIN SODIUM 25000 IN 5% 500 ml Answer: 36 36. Fundamentals/Medical Surgical-Renal-Diuretic & daily weight Discharge teaching to a patient with heart failure what parameter is most important for weight monitoring *Answer: Weight the patient at the same time, Same Scale, same cloth type) The nurse is preparing a teaching plan for a client taking a prescribed diuretic for edema in the lower extremities. What instruction should the nurse include in this teaching plan? A- Stop taking the medication when the edema in the lower extremities subsides. B- Take the diuretic every day, regardless of weight loss or muscle weakness. C- Limit fluid intake while taking the diuretic to reduce fluid retention. D- Weight yourself daily at the same time and report excessive weight loss. 37. Fundamentals/Pathophysiology-Basic Nursing Skills/Hygiene/Safety-Handwashing HAND WASHING: A- Reduces spread of microorganism. Bio..... B- Lock virus C- Lock in human virus 38. Fundamentals/Pathophysiology/Professional Issues/Medical Surgical-Basic Nursing Skills/Nutrition/Teaching-DM2 and CKD-diet Ketoacidosis Diet A- Banana, whole bread... B- Oatmeal B Oatmeal...... C- 6 oz Coffee, strawberry, artificial sweetening D-Egg, butter 39. Fundamentals/Pediatrics-Basic Nursing Skills/Nutrition-infant weight-1-month AT THE 1 MONTH OLD CLINIC VISIT, AN INFANTS NUDE WEIGHT IS 600 GRAM MORE THAT AT BIRTH. WHICH INTERVENTION SHOULD THE NURSE IMPLEMENT? A. ENCOURAGE GIVING 2 OUNCES OF WATER BETWEEN FEEDINGS. B. RECOMMENDED ADING KARO SYRUP TO EACH FORMA FEEDING C. DOCUMENT INFANT’S WEIGHT ON GROWTH CHART D. CHECK THE INFANT’S WEIGHT USING A METRIC SCALE. NOTE: ANSWER: 600 grams 40. Fundamentals/Pediatrics-Med Administration-Oral susp-resisting-PEDI A child that resists taking the medication: a. Parents help the nurse holding him b. Provide the child juice with the medication c. Explain to the child that if he doesn’t take the medication, he won’t feel better. 41. Fundamentals/Pediatrics-Med Administration/Math-Calculation-PO dose-3x/wk/BSA The healthcare provider prescribes methotrexate 7.5 mg PO weekly, in 3 divided doses for a child with rheumatoid arthritis whose body surface area (BSA) is 0.6 m2. The therapeutic dosage of methotrexate PO is 5 to 15 mg/m2/week. How many mg should the nurse administer in each of the three doses given week? Answer: 2. 42. Fundamentals/Pediatrics-Med Administration/Math-IV-ml/hour-PEDI Vanco 400 mg 6 hours, 100 ml one and half hour Answer: 67 43. Fundamentals/Pediatrics/Professional Issues/Medical Surgical-Basic Nursing Skills/Safety/Leadership-Airborne precautions Un Nino que los Padres lo llevaron al ER A. Mandarlo a la casa B. RN ponerse el precaution C. Ponerle una mascara al nino. B *(Isolated room) Airborne precautions: Diseases a. Measles b. Chickenpox (varicella) c. Disseminated varicella zoster d. Tuberculosis Barrier protection a. Single room is maintained under negative pressure; door remains closed except upon entering and exiting. b. Negative airflow pressure is used in the room, with a minimum of 6 to 12 air exchanges p hour depending on health care agency protocol. c. Ultraviolet germicide irradiation or high-efficiency particulate air filter is used in the room d. Health care workers wear mask or personal respiratory protection device. e. Mask placed on client when client is out of the room; client leaves the room only if necessary. Fundamentals/Professional Issues-Basic Nursing Skills/Nutrition/Cultural/Spiritual-Hindu diet A Hindu patient... what can the nurse do? A- REMOVE BEEF FROM PT MEAL TRAIL B- ENCOURAGE FAMILY TO BRING FOOD FROM HOME C- SHOW THE CARDIAC MENU TO THE PATIENT D- GIVE TO THE PATIENT WHAT HE WANTS Fundamentals/Professional Issues-Med Administration/Documentation-Bar code scan-med administration Maternity – Postpartum – Hemorrhage postpartum Possible asw: Check for clots and lochia Maternity – Postpartum – Priority management-postpartum After receiving shift report, the nurse working on a postpartum unit should assessment first? A) Vaginal birth today whose infant is refusing to breastfeed. B) Cesarean birth of twin today who is new complaining of pain. C) Post-cesarean birth today with fundus at the umbilicus. D- Multipara vaginal birth yesterday saturating two pads hours. Maternity/Medical Surgical – Antepartum – Barbiturates & pregnancy The nurse is evaluating medication teaching. Which statement by a female who takes a barbiturate for sleep indicates she understands the teaching? a) “I should ensure that I do not become pregnant while taking this medication.” b) “I must take my birth control pill in the morning and my sleeping pill at night.” c) “I will increase the amount I take in small doses if I can’t sleep through the night.” d) “I should take my anxiety pill, alprazolam, only when I really need it.” Maternity/Medical Surgical –Postpartum –Post vaginal delivery-diaphragm Patient that had a vaginal birth, diaphragm. What teaching the nurse need to give to the patient? A- 2 or 6 hours before intercourse B- Re-adapt C- Resisted diaphragm D- Is no anticoncertive Maternity/Professional Issues-Antepartum/Cultural/Spiritual-Pregnancy-cultural awareness Pregnant women first prenatal visit at 12 weeks A - Concern about delivery B - Parenting C - Complication during pregnancy D - CHILDHOOD Maternity/Professional Issues-Antepartum/Leadership-BPP-fetal well-being Four clients arrive on the labor and delivery unit at the same time. Which client should the nurse assess first? a) A 41-week multigravida who is scheduled induction of labor today. b) A 38-week primagravida who reports contractions occurring every 10 minutes. c) A 36-week multigravida with a prescription for serial blood pressure. d) A 39-week primigravida with biophysical profile score of 5 out of 8 Medical Surgical-Cardiovascular-Angina-exercise A male client with angina pectoris is being discharged from the hospital. What instructions should the nurse plan to include to the discharge teaching? a. Engage in physical exercise immediately after eating to help decrease cholesterol levels. b. Walk briskly in cold weather to increase cardiac output. c. Keep nitroglycerin in a light-colored plastic bottle and readily available. d. Avoid all isometric exercises, but walk regularly. Medical Surgical-Cardiovascular-Arterial sheath Saunder 791 Arterial sheath : Pedal pulses and colour, warmth movement and sensation of affected leg & foot Asses insertion site for bleeding, pain, tenderness, swelling or haematoma. No levantarse hasta despues de 8 hrs A patient recovering left femoral atrial sheath. What finding requires immediate intervention (Select all that apply?) A. Tenderness on insertion site B. Left groin egg size C. Quarter size of drainage D. Unrelieved back, flank pain E. Cool/pale left foot The nurse in the outpatient unit is caring for a client who had a right femoral cardiac cauterization two hours ago .What assessment findings requires immediate intervention? A. The client wants assistance walking to the bathroom B. Clients pulse oximeter is 98% C. The client right feed is warn to touch D. The client B/P is 110/70 and pulse 90 OJO CON ESTA NO SALIO PERO HAY QUE VERLA 61. Medical Surgical-Cardiovascular-Atenolol The healthcare provider prescribes atenolol 50 mg PO daily for a client with angina pectoris. Which finding should the nurse report to the healthcare provider before administering the medication? a) Chest pain. b) Urinary frequency. c) Tachycardia. d) Irregular pulse. 62. Medical Surgical-Cardiovascular-Atrial fibrillation-assess Atrial fibrillation, or A-Fib, is the most common heart rhythm disorder in the United States. It’s a condition in which the electrical impulses that control muscle contractions in the upper chambers of the heart become rapid and chaotic. About 160,000 new cases of A-Fib are diagnosed in the U.S. each year–but physicians believe that many people who have A-Fib have not been diagnosed. The likelihood of developing A-Fib increases with age. The majority of people diagnosed with A-Fib are 55 or older. Between three and five percent of people over age 65 and nine percent of people over the age of 80 have A-Fib. Diagnosing and treating A-Fib are important because, left untreated, it can lead to a number of serious heart conditions. Patients with A-Fib are also five times more likely to suffer a stroke. (Although you should see a doctor to diagnose A-Fib, one way to help asses your risk is to take your pulse. Click here for a step-by-step guide–or watch Archie Manning show how it’s done.) One complicating factor is that the signs and symptoms of A-Fib can vary greatly from patient to patient. Some people experience a sudden heart flutter or tremor, or feel their heart “speed up” suddenly; other patients with A-Fib may not feel anything at all. Other symptoms can include: Shortness of breath Fatigue Weakness or difficulty exercising Chest pain Sweating Dizziness Fainting A-Fib is not an emergency–but it is a serious condition. If you suspect you have A-Fib you should see your doctor immediately. Contact your primary care doctor–or find a St.Vincent doctor near you. Or make an appointment to see an A-Fib specialist at the St.Vincent A-Fib Center of Excellence. We can discuss the many treatment options available to treat and cure A-Fib–and help choose the one that’s right for you. 63. Medical Surgical-Cardiovascular-BP-variance in arms *Change the arm or wait 5 min and change the arm 64. Medical Surgical-Cardiovascular-High BP-vasoconstriction A patient is diagnosed with MALIGNANT HYPERTENSION, patient likes skiing and asks if is ok to continue: A. “COLD WEATHER MAY CONSTRICT YOUR BLOOD VESSELS AND INCREASE BP” B. “SKIING MIGHT PRODUCE TOO MUCH EXERTION” C. “SHOULD BE OK AS SOON AS YOU CONFINE SKIING D. “GO FOR IT IS A TERRIFIC WORKOUT [Show More]

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