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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 af... ter 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? 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? 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? several days 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 client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the health care provider? A young adult male who has had type 2 diabetes mellitus (DM) is admitted to the intensive care unit with hyperglycemic nonketotic symdrome (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 clients central venous catheter. When the clients respirations become labored and his lungs sound indicate crackles what action should the nurse take? d. decrease infusion rate to address fluid overload When preparing to apply a fentanyl (Duragesic) transdermal patch the nurse notes that the previously applied patch is intact on the clients upper back and the client denies pain. What action should the nurse take? d. Apply a new patch in a different location after removing the original patch 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? c. reduce the rate of the nitroglycerin infusion 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? 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? Which assessment finding indicates to the nurse that the muscarinic agent bethanechol (Urecholine) is effective for a client diagnose with urinary retention? Following involvement in a motor vehicle collision, a middle aged adult client is admitted to the hospital with multiple facial fractures. The clients 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 Which instructions should the nurse include in the teaching plan of a client who is taking the diuretic spironolactone (Aldactone)? b. Take the medication in the morning 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? c. when recognized signs of severe hypoglycemia occur A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for this treatment? medication administered by the healthcare provider A female client is being treated for tuberculosis with rifampin (rifadin) Which statement indicates that futher teaching is needed? d- I will take my usual contraceptive for birth control A client is discharged with a prescription for warfarin ( Coumadin). What discharge instructions should the nurse emphasize to the client? c. avoid going barefoot especially outside In caring for a client with diabetes insipidus who is receiving an antidiuretic hormone intranasally which serum lab test is most important for the nurse to monitor? After administering dihydroergotamine (Migranal) 1 mg subcutaneously to a client with a severe migraine headache the nurse should explain that relief can be expected within what time frame? d. 15 minutes A client with hypertension who has been taking labetalol for two weeks, reports a five pound (2.2 kg) weight gain. Which follow up assessment is most important for the nurse to obtain? d.breath sounds A male client is receiving pilocarpine hydrochloride (Isopto Carpine) ophthalmic drops for glaucoma. He calls the clinic and ask the nurse why he has difficulty seeing at night. What explanation should the nurse provide? a. The eye drops slow pupil response to accommodate for darkness A client who is taking and oral dose of tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline? a. toasted wheat bread and jelly The therapeutic effect of insulin in treating type 1 diabetes mellitus is based on which physiologic action? The health care provider prescribe a medication for an older adult client who is complaining of insomnia. And instructs the client to return in 2 weeks. The nurse should question which prescription? A male client reports to the nurse that he is experiencing GI distress from high dose of a corticosteroid and is planning to stop taking the medication. In response to the clients statement what nursing action is most important for the nurse to take? gradually rather than abruptly. Fifteen minutes after receiving sulfa athenozole . A male client report a burning sensation over his abdomen chest and groin. Which intervention is most important for the nurse to implement? Antibiotic resistant organism are a major infection control problems. To help minimize the emergence of resistant bacteria what instruction should the nurse provide to the clients? 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? obtain a medication prescription 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? prescription The nurse administer donepezil hydrochloride (Aricept) to a client with Alzheimers disease as an intervention for which client problem? 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 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 client is who is diagnose with schizophrenia receives a prescription for a 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 client with eczema is using an OTC topical product with urea 10% OTC (Aqua Care Cream) to the affected skin areas. Which finding reflects the expected therapeutic response. Hydration of affected dry skin areas A male client with a primary lung cancer was told by his healthcare provider that he now has a secondary tumor. After the healthcare provider leaves, the client asks the nurse what "secondary tumor" means. What response would be best for the nurse to provide. Let me call your health care provider back to explain the meaning of secondary tumors. The UAP reports to the nurse that a client who was admitted with abdominal pain has just had a large black tarry stool. What intervention should the nurse implement first. Test the stool for occult blood Which action is most important for the nurse to implement to reduce the risk for DVT in a post op client. Advise the client to perform leg exercises regularly A male tells the clinic nurse that he is experiencing burning on urination, and assessment reveals that he had sexual intercourse four days ago with a woman he casually met. Which action should the nurse implement. Obtain a specimen of urethral drainage for culture The nurse is planning care for a pt with CKD who is a resident at a long term care facility. The pt is anuric and has hemodialysis 3x per week. Which intervention should the nurse include in the pt's plan of care? record strict urinary output A male client who reports feeling chronically fatigued has a hemoglobin of 11.0 grams/dl (110 mmol/L or SI), hematocrit of 34% and microcytic and hypochromic red blood cells. Based on the findings, which dinner selection should the nurse suggest for the patient? Beef steak with steam broccoli and orange slices The nurse is preparing a client for a bronchoscopy. While obtaining consent, the client complaints of thirst and admits to drinking a small amount of orange juice two hours ago. What action should the nurse take? Delay procedure for 6 hours. A client uses triamcinolone (Kenalog), a corticosteroid ointment, to manage pruritus caused by a chronic skin rash. The client calls the clinic nurse to report increased erythema with purulent exudate at the site. What action should the nurse implement? . Schedule an appointment for the client to see the healthcare provider. The nurse learns in changes of shift report that x-ray report for newly admitted client indicates consolidation in the left lower lung. What action should the nurse take? Administer a PRN dose of a bronchodilator. The nurse is planning care for a client with chronic kidney disease who is a resident at a long-term nursing facility. The client is anuric and has hemodialysis 3 times a week. Which intervention should the nurse include in the client's plan of care D records strict urinary output Following an ileal conduit urinary diversion, a male client voices several complaint. Which complaint indicates to the nurse that he is experiencing a complication? A dark purplish colored stoma. A male client is admitted to the emergency department with vomiting of dark brown, foul-smelling emesis. He reports he had surgical repair of a recurrent inguinal hernia one week ago and complains of intense abdominal pain. After assessing that his bowel sounds are hyperactive, which prescription should the nurse implement first. Insert a nasogastric tube (NTG) and attach to low intermittent suction. The nurse is monitoring capillary glucose, q4 hours, of a adult woman admitted with diabetic ketoacidosis. Two hours after receiving 10 units of regular insulin for a glucose level of 255 mg/dL, the client is perspiring and complaining of shakiness. What interventions should the nurse implement Obtain another capillary glucose level. The nurse is planning care for an older adult male who experienced a cerebrovascular accident several weeks ago. Because of his expressive aphasia, the client often becomes frustrated with the nursing staff. Which intervention should the nurse implement? Encourage client in use of picture charts. A client with an arterial ischemic leg ulcer is being discharged from the hospital. Which instruction is most important for the nurse to include in this client’s discharge teaching plan? Inspect feet daily for skin breakdown. The chest x-ray for a client who is admitted for pneumonia shows pleural effusion with decreased air flow in the entire left upper lobe. What breath sounds that verify the x-ray finding should the nurse document after auscultation of the left upper lobe. Diminished breath sounds. Which group of foods is best for the nurse to recommend for clients with a strong family history of colon and rectal cancers? Oatmeal raisin and fruit with skin Which food is most important for the nurse to encourage a male client with ostemalacia to include in this daily diet? B)- Fortified milk and cereals. A male client with esophageal varices who has been NPO since admission to the intensive care unit is requesting something to eat. He has not had a bleeding episode in three days, and he has a prescription for diet as tolerated. Which snack is best for the nurse to provide the client? D)- Luke warm broth, iced tea, and a lemon popsicle. A client who has a history of long standing back pain treated with methadone (Dolophine), is admitted to the surgical unit following urological surgery. What modifications in the plan of care should the nurse make for this client’s pain management during the postoperative period? Maintain client’s methadone, and medicate surgical pain based on pain rating. A male client with laryngectomy frequently expectorates copious amounts of purulent secretions. When changing the ties of the tracheostomy tube. Which action is most important for the nurse to take? Leave the old one to place until the new ones are secure during spring break, a young adult present at the urgent care clinic and report a stiff neck, fever for the past 6 hours, and headaches. Which intervention is more important for the nurse to implement? Initiate insolation precautions. A client with hypothyroidism report difficulty falling asleep because of feeling of depression which action should the nurse implement? Encourage increased exercise and activity during the day. A client receives a prescription for warfarin (Coumadin) 2 mg IM daily. The pharmacy delivers a vial. The instruction reads, reconstitute with 2.7 ml of sterile water for injection to yield 2 mg/ml. How many ml should the nurse administer? (Enter the numerical value only). R/ 2.5 After being transferred from the emergency department to a medical unit, a client vomits into an emesis basin. The nurse observes the emesis as seen in the picture. What assessment should the nurse complete first? Obtain current vitals signs. An older adult woman is seen in the clinic 3 months following her diagnosis of types 2 diabetes mellitus (DM) She tells the nurse that she has had a difficult time keeping her blood sugar in control. The nurse reviews the client s current fingerstick and daily log of blood glucose levels. Which intervention is most important for the nurse to implement? Review the client glycose ated hemoglobin (ALC) level. Two day following a nephrectomy, the client reports abdominal pressure and nausea. Which intervention should the nurse implement? Auscultate bowels sounds. an adult female client is diagnosed with restless leg syndrome and is referred to the sleep clinic. The healthcare provider prescribes ferrous sulfate (Feosol) 325mg PO daily. Which laboratory values should the nurse monitor? Serum iron and ferritin. To reduce the risk for pulmonary complication for a client with Amyotrophic Lateral Sclerosis (ALS), what intervention should the nurse implement? (Select all apply) Perform chest physiotherapy. Encourage use of incentive spirometer. Teach the client breathing exercises. The nurse is evaluating a male client s understanding of diet teaching about the DASH (Dietary Approaches to stop hypertension) eating plan. Which behavior indicate that the client is adhering to the eating plan? Enjoys fat free yogurt an occasional snack food. The nurse is taking a client’s blood pressure and observe carpal spams after the sphygmomanometer cuff is inflated. What action should the nurse implement next? Asses the client’s recent serum calcium level A male client is recovering from an episode of urinary tract calculi. During discharge teaching the client asks about the dietary restrictions he should follow. In discussing fluid intake, the nurse should include which type of fluid limitation? Tea and hot chocolate. During preoperative teaching for a male client scheduled for repair of an inguinal hernia, the client tells the nurse that he has had several surgeries and understands the need to perform coughing and deep breathing exercises after surgery. How should the nurse respond? Ask for a demonstration of these exercises A client with chronic obstructive pulmonary disease (COPD) is somnolent and having periods of apnea. The client oxygen saturations 88% while receiving humidified oxygen at 6L/nasal cannula(NC). Which intervención should the nurse implementa? Change oxygen to 40% per face mask. A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client plan of care? Continuous cardiac monitoring. 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 povidone-iodine (betadine) solution. Which intervention should the nurse implement first? b. Assess airway patency and oxygen saturation The Health Care Provider prescribes an IV solution of regular insulin (Humulin) 100 units in 250 ml of 0.45% saline to infuse at 12 units/hour. The nurse should program the infusion pump to deliver how many ml/hours. (Enter numeric value only) l/h After 3 days of persistent epigastric pain, a female client presents to the clinic she has been taking oral antacids without relief. Her vital signs are HR 122 beats/minute, respirations 16 breaths/minute, oxygen saturation 96% and blood pressure 116/70. The nurse obtains a 12-lead ECG. Which assessment finding is most critical? ST elevation in three leads The clinic nurse is reviewing strategies for blood glucose monitoring with a client who is newly diagnosed with diabetes mellitus. In helping the client select a blood glucose meter, which client assessments should the nurse complete. D. Manual dexterity and visual acuity. An older adult man who is legally blind in both eyes and is taking diuretics requests assistance to the bathroom. Which intervention should the nurse implement? D. Assist the client to the bathroom After teaching a female client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Elimination of which food choices by the client indicates teaching is successful C. Whole milk and daily ice cream servings The nurse applies an automatic external defibrillator (AED) to a client who collapse din an exam room at a community clinic. What action should the nurse take next. B. Determine the defibrillator reading A homeless adult male with a history of chronic alcoholism is admitted with signs of hepatic encephalopathy. Two days after receiving a prescription for lactulose, the client has three diarrhea stools within 4 hours. Which intervention is most important for the nurse include in the client's plan of care? a. Provide meticulous perineal care with a skin barrier. A male client with an external fixation device for a fractured left femur is complaining of left foot pain. Which intervention should the nurse implement first? C. Assess peripheral pulses A client with acute renal injury (AKI) who weighs 50 kg and has a potassium level of 6.7 mEq/L is admitted to the hospital. Which prescribed medication should the nurse administer B. Sodium polystyrene (Kayexalate) 15 grams PO What goal has the highest priority when planning nursing care for a client with acute sinusitis b. expresses knowledge of causative factors. A client is recovering from a transurethral prostatectomy. Which activity should be limited until after the first postoperative visit with his healthcare provider? D. Driving a car. The nurse is assessing a client who is one day post parathyroidectomy and finds that the client is experiencing stridor. After notifying the healthcare provider, the nurse should prepare for which procedure. A. Tracheostomy placemen Two days following abdominal surgery a client begins to complain of cramping abdominal pain, and the nurse's inspection of the abdomen indicates slight distention. Which action should the nurse implement first? D. Auscultate the client’s abdomen A fair-skinned female client who is an avid runner is diagnosed with malignant melanoma, which is located on the lateral surface of the lower leg. After wide margin resection, the nurse provides discharge teaching. It is most important for the nurse to emphasize the need to observe for changes in which characteristic. Appearance of any mole A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider? Low back pain and hypotension The nurse plans to administer naloxone (Narcan) 1mg .the label of the 10 ml vial indicates that the drug concentration is 0.4 mg/mL how many ml should the nurse administer R/ 2.5 Ml Which nursing problem has the highest priority when planning care for a client whit ostemalacia? Rick for injury The nurse is providing preoperative educationfor a Jewish client schedule to receive a xenograft to promote burn healing .Which information should the nurse provide this client? The xenograft is taken from nonhuman sources A client with pheochromocytoma reports the onset of a severe headache The nurse observe that the client is very diaphoretic. Which assessment data should the nurse obtain next? Blood pressure A client develops subcutaneous emphysema following a thoracotomy. To evaluate the progression of subcutaneous emphysema,which assements should the nurse make select all that apply Palpate skin around the chest tube Auscultate breath sounds bilaterally Observe appearance of the neck The drainage in the chest tube of a client with emphysema has changed from viscous green to clear watery fluid. what action would be best for the nurse to take? B Maintain the current IV antibiotic schedule Which action is most important for the nurse to implant to reduce the risk for deep vein thrombosis in a postoperative client? C Advise the client to perform leg exercise regular An adult female whit multiple sclerosis (MS) fell while walking to the bathroom. On transfer to the intensive care unit ,she is confused and has projectile vomiting twice Which intervention should the nurse implemented first? D Complete head -to toe neurological assessment A Fame client whit chronic syndrome of inappropriate ant – diuretic hormone (SIADH) report to the nurse that she is constantly thirsty. What action should the nurse take ? Encourage the client to use hard candy frequently to help relieve her thirst The nurse is assessing a group of older adults. What factor in a male clients history puts him at greatest risk for developing colon cancer? C- Has intestinal polyps The nurse should include which information in the teaching plan for a client recently diagnosed whit primary open -angle glaucoma? SELECT ALL THE APPLY A -Limit salt intake to reduce increased intraocular pressure (iop) B -Regular eye examine are necessary tomonitor IOP and visual field C -Daily eye medication is instilled to lower intraocular pressure A client with stage IV bone cancer is admitted to the hospital for pain control the client verbalizes continuous severe pain 8 on a 1 to 10 scale which intervention should the nurse implement B – Admitter opioid and no opioid medication simultaneously The nurse completes the admission assessment of female client whit systemic lupus erythematosus Which finding requires the most immediate follow -up assessment by the nurse ? Hematuria What instruction should the nurse include in the discharge teaching plan of a client who had a cataract extraction today? Light housekeeping is permitted. but avoid heavy lifting A client who has been takin finasteride (proscar) an enzyme ( 5 alpha reductase) inhibitor used to shrink the gland , is admitted because of continuing begin prostatic hypertrophy(BPH0 symptoms when planning care which nursing problem should the nurse plan to address first? Risk for infection [Show More]

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