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50 hesi questions.docx.pdf med surg

The document from Med-Surg discusses prioritizing assessments and medi...
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Med-Surg (NURS 1111)

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Academic year: 2021/2022
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Our Lady of Lourdes School of Nursing

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1 nurse on the cardiac unit has received the shift report from the outgoing nurse. Which client should the nurse assess first?

  1. The client who has just been brought to the unit from the emergency department (ED) with no report of complaints.
  2. The client who received pain medication 30 minutes ago for chest pain that was a level 3 on a 1-to-10 pain scale.
  3. The client who had a cardiac catheterization in the morning and has palpable pedal pulses bilaterally.
  4. The client who has been turning on the call light frequently and stating her care has been neglected.
  5. The nurse on the cardiac unit is preparing to administer medications after receiving the morning change-of-shift report. Which medication should the nurse administer first?
  6. The cardiac glycoside to the client who has an apical pulse of 58.
  7. The loop diuretic to a client with a serum K+ level of 3 mEq/L.
  8. The antidysrhythmic to the client in ventricular fibrillation.
  9. The calcium-channel blocker who has a blood pressure of 110/68.
  10. Which client should the telemetry nurse assess first after receiving the a. shift report?
  11. The client diagnosed with deep vein thrombosis who has an edematous right calf.
  12. The client diagnosed with mitral valve stenosis who has heart palpitations.
  13. The client diagnosed with arterial occlusive disease who has intermittent claudication.
  14. The client diagnosed with congestive heart failure who has pink frothy sputum.
  15. The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse?
  16. The 44-year-old client diagnosed with a myocardial infarction.
  17. The 65-year-old client admitted with unstable angina.
  18. The 75-year-old client scheduled for a cardiac catheterization.
  19. The 50-year-old client complaining of chest pain.
    1. The charge nurse is making assignments for a 30-bed cardiac unit staffed with three registered nurses (RNs), three licensed practical nurses (LPNs), and three unlicensed assistive personnel (UAPs). Which assignment is most appropriate by the charge nurse?
  20. Assign an RN to perform all sterile procedures.
  21. Assign an LPN to give all IV medications.
  22. Assign an UAP to complete the a. care.
  23. Assign an LPN to write the care plans.
  24. The nurse on a cardiac unit is discussing a client with the case manager. Which information should the nurse share with the case manager?

This study source was downloaded by 100000848403111 from CourseHero on 06-28-2022 12:13:18 GMT -05:

  1. Discuss personal information the client shared with the nurse in confidence.
  2. Provide the case manager with any information that is required for continuity of care.
  3. Explain that client confidentiality prevents the nurse from disclosing information.
  4. Ask the case manager to get the client’s permission before sharing information.
  5. The nurse assesses erratic electrical activity on the telemetry reading while the client is talking to the nurse on the intercom system. Which task should the nurse instruct the UAP to implement?
  6. Call a Code Blue immediately.
  7. Check the client’s telemetry leads.
  8. Find the nurse to check the client.
  9. Remove the telemetry monitor.
  10. The charge nurse on the cardiac unit has to float a nurse to the emergency department for the shift. Which nurse should be floated to the emergency department?
  11. The nurse who has 4 years of experience on the cardiac unit.
  12. The nurse who just transferred from critical care to the cardiac unit.
  13. The nurse with 1 year of experience on the cardiac unit who has been on a week’s sick leave.
  14. The nurse who has worked in the operating room for 2 years and in the cardiac unit for 3 years.
  15. The charge nurse in the cardiac critical care unit is making rounds. Which client should the nurse see first?
  16. The client with coronary artery disease who is complaining that the nurses are being rude and won’t answer the call lights.
  17. The client diagnosed with an acute myocardial infarction who has an elevated creatinine phosphokinase-cardiac muscle (CPK-MB) level.
  18. The client diagnosed with atrial fibrillation on an oral anticoagulant who has an International Normalized Ratio (INR) of 2.
  19. The client 2 days’ postoperative coronary artery bypass who is being transferred to the cardiac unit.
  20. A client was admitted to the intensive care unit 36 hours ago following extensive pulmonary trauma. Which clinical manifestation would first alert the nurse that the client is experiencing adult respiratory distress syndrome (ARDS)?
  21. Blood-tinged, frothy sputum
  22. Dense pulmonary infiltrates with a “whited-out” appearance
  23. A n increase in respiratory rate
  24. Increasing hypoxemia
  25. A client with a history of asthma presents in the physician’s office with complaints of difficulty breathing. While performing the initial assessment, the nurse becomes concerned that the client’s respiratory status has worsened based on which of the following?

This study source was downloaded by 100000848403111 from CourseHero on 06-28-2022 12:13:18 GMT -05:

  1. Instruct a client on a bronchoscopy
  2. Administer a purified protein derivative (PPD) to a client
  3. The nurse has just received orders to provide chest physiotherapy for a client two times per day. The nurse evaluates which schedule to be most therapeutic?
  4. 7:00 a. and 1:00 p.
  5. 6:00 a. and 4:00 p.
  6. 9:00 a. and 5:00 p.
  7. 8:00 a. and 8:00 p.
  8. The nurse assesses fluctuations in the water seal chamber of a client’s closed chest drainage system. The nurse evaluates this finding as indicating
  9. the system is functioning properly.
  10. an air leak is present.
  11. the tubing is kinked.
  12. the lung has re expanded.
  13. The nurse assesses a college-age client complaining of shortness of breath after jogging and tightness in his chest. Upon further questioning, the client denies a sore throat, fever, or productive cough. The nurse notifies the physician that this client’s clinical manifestations are most likely related to
  14. pneumonia.
  15. bronchitis.
  16. pneumoconiosis.
  17. asthma.
  18. Which of the following is a priority to include in the instructions given to a client who has bronchitis?
  19. Avoid cigarette smoking
  20. Decrease overweight status
  21. Increase activity
  22. A void malnutrition
  23. The nurse is assessing the respiratory status of a client following a thoracentesis. Which finding would indicate further assessment is needed?
  24. Equal bilateral chest expansion
  25. Scattered crackles, unchanged from baseline
  26. Diminished breath sounds on the affected side
  27. Respiratory rate of 22 breaths/minute
  28. The nurse is admitting a client who complains of fever, chills, chest pain, and dyspnea. The client has a heart rate of 110, respiratory rate of 28, and a nonproductive hacking cough. A chest x-ray confirms a diagnosis of left lower lobe pneumonia. Upon auscultation of the left lower lobe, the nurse documents which of the following breath sounds?
  29. Bronchial
  30. Bronchovesicular

This study source was downloaded by 100000848403111 from CourseHero on 06-28-2022 12:13:18 GMT -05:

  1. Vesicular
  2. Absent breath sounds
  3. The nurse is preparing a client with empyema for a thoracentesis. Which of the following should the nurse have available in the event that the procedure is ineffective?
  4. A ventilator
  5. A chest tube insertion kit
  6. A n intubation tray
  7. A crash cart
  8. A client is admitted to a burn unit with second and third-degree burns over 18% of the body. An inhalation injury is also suspected. The nurse should monitor which of the following to determine the extent of carbon monoxide poisoning?
  9. Pulse oximetry
  10. Urine myoglobin
  11. Arterial blood gases
  12. Serum carboxyhemoglobin levels
  13. Which of the following should the nurse include when suctioning a client’s tracheostomy?
  14. Instill sterile saline down the trachea to stimulate a cough, then suction with continuous suctioning
  15. Insert the catheter until a cough reflex is obtained or until resistance is felt
  16. Adjust the wall suction to 150 mm Hg for the procedure
  17. Suction the client’s mouth before entering the trachea
  18. A client with pneumonia has a poor appetite, is dyspneic and complains of decreased taste sensation, and is receiving chest physiotherapy treatments and breathing treatments. Which of the following actions should the nurse include to improve the client’s appetite?
  19. Provide mouth care before meals
  20. Provide juice and fluids at the bedside
  21. Provide three balanced meals each day
  22. Increase fluid intake to 3 L a day
  23. During a routine physical examination, a client reports recent occipital headaches, blurred vision, fatigue, and increasing edema. The nurse reports these findings as indicative of
  24. endocarditis.
  25. hypovolemic shock.
  26. hypertension.
  27. ventricular tachycardia.
  28. A client’s parents ask the nurse, “What is the prognosis of myocarditis?” The most appropriate response by the nurse is
  29. “A heart transplant would be very promising.”
  30. “Most often, a person will do well with coronary artery bypass surgery.”
  31. “A coronary angioplasty would only involve a 1- to 3-day hospitalization.”
  32. “Recovery usually happens without any special treatment.”

This study source was downloaded by 100000848403111 from CourseHero on 06-28-2022 12:13:18 GMT -05:

  1. “I will not take my diuretic pill on weekends when I am traveling, in order to avoid incontinence.”
  2. The nurse should monitor a client after a coronary angioplasty for which of the following clinical manifestations indicating cardiac tamponade? Select all that apply: [ ] 1. Muffled heart sounds [ ] 2. Headache [ ] 3. Hypotension [ ] 4. Vision changes [ ] 5. Cool, diaphoretic skin [ ] 6. Tachycardia 36 nurse is assessing a client’s gastrointestinal tract. Which of the following subjective assessments should be included?
  3. Rebound tenderness
  4. Diarrhea
  5. Generalized red abdominal rash
  6. Hematuria
  7. I n planning the post procedure care for a client who has a barium enema, the nurse should include which of the following? S elect all that apply: [ ] 1. Position the client on the right side [ ] 2. Observe and record the amount of rectal drainage [ ] 3. Encourage fluids [ ] 4. Maintain bed rest for 12 hours [ ] 5. Monitor the client for a rise in body temperature and abdominal pain [ ] 6. Administer a laxative
  8. When providing care for a client who has had an upper gastrointestinal endoscopy, the nurse should include which of the following interventions?
  9. Assist the client to maintain a right-side lying position
  10. Provide the client with a fatty “test meal”
  11. Keep the client NPO until the gag reflex returns
  12. Administer the prescribed bulk-forming laxative
  13. The nurse is caring for a client with gastroesophageal reflux disease. Which of the following measures would be essential to include in the client’s discharge instructions? S elect all that apply: [ ] 1. Small, frequent meals [ ] 2. Avoid fluids at mealtime [ ] 3. High-calorie and high-protein diet [ ] 4. Bulk-forming laxatives [ ] 5. Sleep with the head of the bed elevated [ ] 6. A void caffeine in the diet

This study source was downloaded by 100000848403111 from CourseHero on 06-28-2022 12:13:18 GMT -05:

  1. The nurse is caring for a client with gastroenteritis. Which of the following nursing measures should receive priority in the client’s plan of care?
  2. Maintain a clean environment free from odors
  3. Assist the client to wash hands and face before meals
  4. Encourage fluids and monitor intake and output
  5. Provide foods the client likes and allow plenty of time for meals
  6. Which of the following should the nurse include when performing a Hematest?
  7. Open the front flap on the cover of the slide, apply a thin smear of stool in the first box only
  8. Open the flap on the back of the slide and apply a drop of developing solution
  9. Place test tablet on top of the stool specimen on guaiac paper and follow with 2 drops of water
  10. Document results after waiting five minutes to observe color changes
  11. The nurse obtains a pH of 8 when aspirating for gastric contents when assessing correct tube placement. The nurse evaluates a pH of 8 to be
  12. alkaline, which indicates respiratory secretions.
  13. a neutral pH.
  14. acidic, confirming gastric secretions.
  15. indicative of intestinal secretions.
  16. Based on an understanding of the adverse reactions to drugs, which of the following drugs does the nurse evaluate from the medication history to cause constipation?
  17. Fluoxetine (Prozac)
  18. Digoxin (Lanoxin)
  19. Amoxycillin (Polymox)
  20. Amitriptyline (Elavil)
  21. When assessing a client with a nasogastric tube, the nurse discovers it is set on continuous high suction. Which of the following nursing actions should the nurse implement?
  22. C lamp the tube for 30 minutes, then reconnect it to continuous high suction
  23. C all the physician and remove the tube
  24. Irrigate the tube with 30 ml of normal saline and record the characteristics of the drainage
  25. Change the suction to low intermittent suction
  26. During an inspection of the abdomen, which of the abdominal findings should the nurse report as abnormal?
  27. Bilateral symmetrical abdomen
  28. Flat abdominal contour
  29. Strong abdominal pulsations
  30. Depressed umbilicus beneath the abdominal surface

This study source was downloaded by 100000848403111 from CourseHero on 06-28-2022 12:13:18 GMT -05:

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50 hesi questions.docx.pdf med surg

Course: Med-Surg (NURS 1111)

35 Documents
Students shared 35 documents in this course

University: Our Lady of Lourdes School of Nursing

Was this document helpful?
1.The nurse on the cardiac unit has received the shift report from
the outgoing nurse. Which client should the nurse assess first?
1. The client who has just been brought to the unit from the
emergency department (ED) with no report of complaints.
2. The client who received pain medication 30 minutes ago for chest pain
that was a level 3 on a 1-to-10 pain scale.
3. The client who had a cardiac catheterization in the morning and has
palpable pedal pulses bilaterally.
4. The client who has been turning on the call light frequently and stating her
care has been neglected.
2. The nurse on the cardiac unit is preparing to administer
medications after receiving the morning change-of-shift report.
Which medication should the nurse administer first?
1. The cardiac glycoside to the client who has an apical pulse of 58.
2. The loop diuretic to a client with a serum K+ level of 3.2 mEq/L.
3. The antidysrhythmic to the client in ventricular fibrillation.
4. The calcium-channel blocker who has a blood pressure of 110/68.
3. Which client should the telemetry nurse assess first after
receiving the a.m. shift report?
1. The client diagnosed with deep vein thrombosis who has an edematous
right calf.
2. The client diagnosed with mitral valve stenosis who has heart palpitations.
3. The client diagnosed with arterial occlusive disease who has intermittent
claudication.
4. The client diagnosed with congestive heart failure who has pink
frothy sputum.
4. The charge nurse is making assignments for clients on a cardiac
unit. Which client should the charge nurse assign to a new graduate
nurse?
1. The 44-year-old client diagnosed with a myocardial infarction.
2. The 65-year-old client admitted with unstable angina.
3. The 75-year-old client scheduled for a cardiac catheterization.
4. The 50-year-old client complaining of chest pain.
5. The charge nurse is making assignments for a 30-bed cardiac
unit staffed with three registered nurses (RNs), three licensed
practical nurses (LPNs), and three unlicensed assistive personnel
(UAPs). Which assignment is most appropriate by the charge nurse?
1. Assign an RN to perform all sterile procedures.
2. Assign an LPN to give all IV medications.
3. Assign an UAP to complete the a.m. care.
4. Assign an LPN to write the care plans.
6. The nurse on a cardiac unit is discussing a client with the case
manager. Which information should the nurse share with the case
manager?
This study source was downloaded by 100000848403111 from CourseHero.com on 06-28-2022 12:13:18 GMT -05:00
https://www.coursehero.com/file/65354891/50-hesi-questionsdocx/

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