HESI Medical Surgical Nursing Practice Exam With Answers (375 Solved Questions)

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MED SURG 1 & 2 HESI EXAM WITH SATISFIED SOLUTIONSHyperglycemia s/s - Polydipsia, poly iris, polyphagia, blurred vision, weakness, weight loss,syncopeEncourage water, check BG, assess for ketoacidosis, insulin asdirHypoglycemia s/s - Headache, nausea, sweating, tremors, lethargy, hunger, confusion,slurred speech, tingling around mouth, anxietyOccurs rapidly, treat with complex carbs ( glucose gel, fruit juice, 10-16 jelly beans, gumdrops, life saversCheck BG, <40 May seizeHypoglycemia s/s -SMBG - Record results for provider,Prediabetes - Fasting BG 100-125 or HBA1C 5.7-6.4surgical risk factors - age; nutrition status; fluid/electrolyte status; general health (cardiacconditions, coagulation probs => hemorrhage, URTI => surgery delayed, COPD exacerbationpossible r/t anesthesia, renal probs impair electrolyte stuff, uncontrolled DM => poorhealing and infection, meds including OTC (anticoagulants, tranquilizers - hypotension, heroin- dec CNS response, antibiotics - incompatible w anesthetics, diuretics - electrolyteimbalance, steroids, OTC herbs, vitamin EPreop - time from decision to have surgery until taken to OR; Nurse gets hx, teaching,checklistpreop history - age, allergies (iodine), current meds, hx of med/surg probs, prev. surgeries,prev. experience w/ anesthesia, tobacco, drug abuse, understanding of procedure, copingresources, cultural and ethical factors affecting surgery

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preop teaching - regulations about valuables, food and fluid restrictions (NPO aftermidnight), invasive procedures (foley, IV, NG, enema, douche), preop meds, OR,transportation, skin prep, post-anesthesia, post op (res. care, activity - ROM, ambulation,turning, pain control such as PCA, diet restrictions, PACUpreop checklist - informed consent; site marked by surgeon, all team members confirm; hxand physical noted in chart; chest radiograph, ECG, and urinalysis if prescribed; hgb, hct,electrolytes, glucose, type/crossmatch of blood; chart on hand; ID band on PT w/ allergiesnoted; contacts, dentures, and all that jazz are removed; PT has voided or catheterized; PThas gown; VS taken; premeds (antibiotics) given; skin prep performed (cleaned, hairremoved if needed, then cleaned again); nurse's signature completesintraop care - keep quiet; SAFETY (client ID, procedure, site; sponge, needle, and instrumentcounts accurate, position to prev injury, grounding device if electrocautery used; asepsis,suction, correct labeling and handling of all specimens); monitor physical status (blood loss- see effect on client, report VS changes to surgeon, positioning critical); psychological(emotional support, provide info to the fam if it takes too long)Postop care - Admission to PACU to recovery; on arrival, VS assessed along with LOC, skincolor and condition, dressing, fluids, tubes, and O2; once stabilized, PT taken back to thefloorPostop care includes: monitor for signs of shock and hemorrhage (hypotension, narrowpulse pressure, rapid weak pulse, cold moist skin, inc capillary refill time); position on sideto prev aspiration, side rails up; heated blanket for warmth; manage n/v w drugs; pain w IVanalgesics; check and assess drainsacute respiratory distress syndrome (ARDS) - low O2 and high CO2; hypoxemia that persistseven with 100% O2 on; dec. pulmonary compliance; dyspnea; non-cardiac pulmonary edema;dense pulmonary infiltrates on radiography; unexpected, catastrophic; high mortality; noabnormal sounds b/c edema happens in interstitial spaces;causes of ARDS - COPD exacerbation; pneumonia; TB; contusion; aspiration; inhaled toxins;emboli; OD; fluid overload; DIC; shock

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assessment of ARDS - dyspnea, hyperpnea, crackles; intercostal retractions; cyanosis,pallor; hyposemia (PaO2 < 50); anxiety, restlessnessARDS interventions - position for max lung expansion; s/s hypoxemia; breath sounds;emotional support; VS and cardiac monitor; monitor ABGs; vital organ status (LOC, renalsystem output, apical pulse); fluids and lytes; metabolic statusABGS - pH - 7.35-7.45PCO2 - 35-45HCO3 - 21-28PO2 - 80-100O2 Sat - 95-100Base excess - 0+- 2*perform allen test before taking blood from radialMetformin - biguanide; careful w/ contrast dye (renal failyre and lactic acidosis)rapid acting insulin - lispro (humalog) - 10-15 min *all peak w/in 30-60 minsaspart (novolog) - 5-15 minglulisine (apidra) - 5-15 minshort acting - regular (humalog r, novolin r, iletin II regular) 1-1.5h; peak in 2h; only insulinthat can be given IV-often mixed w/ intermediate, never with long actingintermediate acting - NPH (humulin n, iletin II lente, iletin II NPH, novolin N) 2-4h; peak in 4-12h;very long acting - glargine (lantus) CANNOT MIX THIS.detemis (levemir) *onset iin 1h w/ no peakHypothyroidism - dec thyroid hormone; primary or secondary;s/s: weakness, fatigue, cold intolerance, weight gain, constipation, goiter, slow speech, drycool skin, puffy face, dry coarse hair, thick brittle nails

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Cushings - adrenal hypofunction; high adrenocortical hormones; weight gain, muscleweakness, buffalo hump, thinning extremities w/ muscle wasting, thin fragile skin, moonface, ruddy complexion, hirsutism, truncal obesity, broad purple striae, bruising,hyperglycemia, hyper atresia, hypokalemia, impaired wound healing; treated w/ surgery,HTN, radiation, or drug therapyTeach to take steroids w meals to prev GI distress, don't skip doses; avoid infection; lowsodium diet;Hypocalcemia s/s -HHNS - occurs w/ type 2 most of the time, esp older PTs; characterized by hyperosmolarityof blood and hyperglycemia; caused by stress; slower onset than DKA; normal pH; osmolality> 350 ( BG usually 600-1200); BUN and creatinine elevated; higher mortality that DKA;mental status changes, severe dehydration, postural hypotensionDKA - Results fro insulin deficiency; features are hyperglycemia, dehydration/electrolyteloss (diuresis), and acidosis; fat breakdown forms free fatty acids and glycerol; rapid onset;osmolality 300-350; BUN and creatinine elevatedcauses of DKA - Missed insulin dose, illness/infection, undiagnosed diabetesDKA clinical manifestations - Polyuria, polydipsia, fatigue; ketonuria; pH < 7.3; n/v,dehydration, abdominal pain, kussmaul respirations; acetone odorDKA PT prevention education - Take insulin as usual, BG and urine ketones q4h, fluids (lytereplacement), report n/v/d to providerDKA treatment - rehydration - isotonic (NS), electrolyte replacement (esp K), reversingacidosis (insulin drip w/ regular insulin, not too fast bc cerebral edema)DM nursing assessment findings - Skin infections, non healing. Wounds, periodontal disease,cataracts, retinopathy, angina, dyspnea, HTN, hair loss in extremities, coolness, shiny thinskin, weak peripheral pulses, pallor, thick nails wth ridges, edema, UTI, signs of renal failure

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( edema, anorexia, nausea, fatigue, difficulty concentrating), neuropathy (numbness, tingling,pain, burning), diarrhea at night, impotence, dry vag, period probs, depressionSomogyi phenomenon - dec in BG around 2-3am to hypoglycemic levels; should dec eveninginsulin dosedawn phenomenon - normal BG until like 3am; should change time of evening injection fromdinnertime to bedtimeinsulin waning - progressive rise in BG from bed til morning; should inc evening dosePheocromocytoma - tumor of adrenal medulla; triad: headache, diaphoresis, and palpitationsin the PT w/ HTN; fatal if undetected; patient is anxious and weak; bed rest w/ HOB elevated;alpha adrenergic blocker, maybe w/ a beta blocker; adrenalectomydiabetic retinopathy - capillary basement membrane thickening; asymptomatic at first;destruction of retinal vessels; abnormal new growth of vessels rupture and form scar tissuewhich causes retina to detach; prevention key; huge cause of blindnessAddisons - Emergency; vascular collapse (IV fluids), hypoglycemia (IV glucose), aldosteronereplacement; Autoimmune; may be caused by sudden withdrawal from steroids or stress;lack of cortisol, androgens, and aldosterone; secondary is caused by lack of ACTH frompituitary;S/s: fatigue, weakness, weight loss, anorexia, n/v, postural hypotension, hypoglycemia,hyponatremia, hyperkalmia, hyper pigmentation, shock, loss of body hair, hypovolemiaDM - Hyperglycemia; affects metabolism of protein, carbs, and fat; 4 ways to dx: FPG > 126;BHA1C > 6.5; random BG of 200; OGTT > 200Type 1: B cell destruction; autoimmuneType 2: insulin deficit or dec uptake; obesity major risk factorAny stressful event inc BG, so illness causes hyperglycemiaIn doubt of whether it's hyper or hypo, treat for hypoFOOT CARE

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shock - widespread reduction of tissue perfusion; those at risk are post MI, very old andvery young, PT w/ severe dysrhythmias, adrenocorticoid dysfunction, recent hemorrhage,burns, massive infection*early signs are agitation and restlessness resulting from cerebral hypoxia*all types can lead to systemic inflammatory respiratory syndrome (SIRS) and myltipleorgan dysfunction syndrome (MODS)hypovolemic shock - internal or external blood or fluid loss; most commonstage 1 (initial): apprehension and restlessness, inc HR, cool pale skin, fatiguestage 2 (compensatory): flattened neck veins; delayed venous filling; inc pulse and rr; pallor;diaphoresis; cool skin; dec urinary output; sunken, soft eyeballs; confusionstage 3 (progressive): edema; inc blood viscosity; excessively low bp; dysrhythmia; ischemia,MI; weak thready or absent peripheral pulsesstage 4 (irreversible): profound hypotension; unresponsive to vasopressors; severshypxemia; unresponsive to O2; anuria; renal shutdown; HR slows, BP falls; cardiac andrespiratory arrest; death inevitablecardiogenic shock - related to ischemia or impairment in tissue perfusion resulting from MI,serious arrhythmia, or HF; all of these dec. COposition client in high fowlers if pulmonary edema w/ legs dependentanaphylactic shock - related to allergens; aute and life threatening w/ respiratory distressr/t bronchial constriction leading to airway obstruction; vascular collapse may followneurogenic shock - r/t injury to descending sympathetic pathways in spinal cord; resultsfrom loss of vasomotor tone and sympathetic innervation to heartseptic shock - r/t endotoxins released by bacteria; cause vascular pooling, diminishedvenous return, and dec. COobstructive shock - physical obstruction r/t tamponade, emboli, compartment syndromethat impedes filling or outflow of blood resulting in dec. CO

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medical treatment of shock - oxygenation and ventilation; fluid resuscitation w/ fluid(isotonic), whole blood, not done w/ cardiogenic b/c pulmonary edema results; drug therapyw/ drugs that increase (blood products, cryastalloids) or decrease preload (morphine,nitrates, diuretics), drugs that inc. afterload (vasopressors, dopamine) or dec. afterload(ACE, ARB), drugs that dec contractility (beta blockers, calcium channel blockers) or inccontractility (digoxin)assessment findings of PT in shock - VS: tachycardia, tachypnea, BP decmental status: in early shock they are restless and hyperalert, in late shock they have decalertness, lethargy, comaskin changes: cool and clammy, diaphoresis, palenessfluid status: urine dec, urins specific gravity > 1.020interventions for PT in shock - monitor VS q15min; I/O to mantain at least 30mL out per hr;call provider if output falls below 30mL/hr; fluids asdir; position appropriately; meds givenIV b/c of dec perfusion IM and SQ; keep PT warm; side rails up; get blood for labs; monitormedication effects esp w/ vasopressor and vasodilator drugsDIC - first phase has abnormal clotting in microcirculation that uses up clotting factors andthen hemorrhage occurs; suspected w/ acute hypotension and septicemia w/ blood oozingfrom more than one place; dx with prolonged PT, PTT; dec fibrinogen and platelets; and incFDPDIC Assessment - petichiae, purpuraa, hematomas; oozing from IV sites, drains, gums, andwounds; GI & GU bleeding; hemoptysis; mental status change, hypotension/tachycardia; painDIC interventions - monitor for bleeding; monitor VS & PT/INR; prevent injury and bleeding(gentle oral care, minimal needle sticks, turn frequently, minimize BP measurements, gentlesuction if needed, pressure to oozing siteif discovered in clotting phase, heparin can stop the micro-clots; if PT gets past that point,clotting factors are given along w/ palliative care for symptomsangina - cardiac O2 demand exceeds supply;caused by: atherosclerosis, HTN, coronary artery spasm, hypertrophic cardiomyopathy,activities that inc heart's O2 demand (physical exertion, cold temperatures)

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angina assessment - pain described as heavy, squeezing, pressure, burning, choking, aching,feeling of apprehensionsubsternal, radiating to L arm and/or shouldertransient or prolonged, with gradual or sudden onset, often short durationdyspnea, tachycardia, palpitationsn/v, fatigue, diaphoresis, pallor, weakness, syncope, dysrhythmias,ECG usually at baseline; ST depression in anginal attacks and T wave inversion (exercisestress test shows same)stress echocardiogram looks for changes in wall motion (indicated in women)cardiac catheterization: detects arterial blockageangina risk factors - nonmodifiable: heredity, gender (male > female until menopause),ethnic background (african americans), agemodifiable: hyperlipidemia, serum cholesterol > 300, LDL elevated, HDL low, HTN, smoking,obesity, physical inactivity, DM, stressLDL - <100 desirable; bad cholesterolHDL - >60 desirable; good cholesterolangina interventions - monitor meds; determine what precipitates pain; teach risk factors;During attack: immediate rest, VS, ECG, nitroglycerin tabs 5 min apart not to exceed tabs,emergency treatment w/ no reliefteach to avoid isometric activity, start exercise program, teach that sex is ok when exerciseis tolerated, can take nitroglycerin before hand, provide nutrition info;medical tx: PTCAMI - disruption in or deficiency of coronary artery blood supply resulting in necrosis ofcardiac tissueCaused by: thrombus or clotting; shock or hemorrhageMI assessment - Pain: onset in lower sternal region; severity inc to unbearabe, radiates toshoulder and down arm or to neck; women may have DOB or fatigue; differs from angina b/c

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sudden onset; not relieved by rest, may have n/v, anxiety, feeling of impending doom, notrelieved by nitroglycerin; those w/ diabetic neuropathy may not have pain... silent MIrapid irregular feeble pulse, dec LOC, dysrhythmias, cardiogenic shock or fluid retention,elevated cardiac markers, troponin best, HF - wet lung sounds, ECG changes as early as 2hr,n/v gastric discomfort or indigestion, cool pale sweaty skinwomen: dyspnea, unusual fatigue, sleep disturbancesMI interventions - MONA; VS, ECG, O2 AT 2-6L NC;hyponatremia - cause: diuretics, GI fluid loss, hypotonic tube feeding, D5W or hypotonic IVfluids, diaphoresiss/s: anorexia, n/v, weakness, lethargy, confusion, muscle cramps and twitching, seizures;Na < 135tx: restrict fluids (safest); IV saline asdir if restricting fluids doesnt workhypernatremia - cause: water deprivation, hypertonic tube feeding, diabetes insipidus,heatsrtoke, hyperventiation, watery diarrhea, renal failure, cushingss/s: thirst, hyperpyrexia, sticky mucous membranes, dry mouth, hallucinations, lethargy,irritability, seizures; Na > 145tx: restrict sodium, inc waterhypokalemia - cause: diuretics, diarrhea, vomiting, GI suction, steroids, hyperaldosteronism,bulimia, cushingss/s: fatigue, anorexia, n/v, muscle weakness, dec GI motility, dysrhythmias, parathesia, flatT waves; K < 3.5tx: supplements (don't give on empty stomach); NEVER GIVE IV BOLUS. WILL KILL YOUR BUTTDEAD; high K diet (banana, orange, spinach, avocado, cantaloupe, potatoes); renal statusbefore givinghyperkalemia - cause: oliguria, acidosis, renal failure, addisons, multiple blood transfusionss/s: muscle weakness, bradycardia, dysrhythmias, flaccid paralysis, intestinal colic, tall twaves; K > 5

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tx:50% glucose w/ regular insulin; Kayexalate; ECG; calcium gluconate; loop diuretics;dialysishypocalcemia - renal failure, hypoparathyroidism, malabsorption, pancreatitis, alkalosiss/s: diarrhea, numbness, tingling, convulsions, positive trousseau or chvostek; Ca < 8.5tx: supplements; slow IV infusion; inc intake (dairy, greens)hypercalcemia - cause: hyperparathyroidism, malignant bone disease, prolongedimmobilization, excess supplementations/s: muscle weakness, constipation, anorexia, n/v, polyuria, polydipsia, neurosis,dysrhythmias; Ca > 10.5hypomagnesemia - cause: alcoholism, malabsorption, DKA, prolonged GI suction, diuretics;s/s: anorexia, distention, neuromuscular irritability, depression, disorientation; Mg < 1.5tx: MgSO4 IV; high Mg diet (meats, nuts, legumes, fish, veggies)hypermagnesemia - cause: renal failure, adrenal insufficiency, excess replacement;s/s: flushing, hypotension, drowsiness, lethargy, dec DTR; depressed respirations,bradycardia; Mg > 2.5tx: avoid Mg based antacids and laxatives, restrict diet, also calcium gluconate for toxicityhypophosphatemia (dec pH) - cause: refeeding after starvation, alcohol withdrawal, DKA,respiratory alkalosiss/s: parethesias, muscle weakness, muscle pain, mental changes, cardiomyopathy,respiratory failure; pH < 2tx: treat cause; oral replacements w/ vit Dhyperphosphatemia (inc pH) - cause: renal failure, excess intake of phosphoruss/s: short term: tetany symptoms; long term: phosphorus precipitation in nonosseous sites;pH > 4.5tx: aluinum hydroxide w/ meals to bind phosphorus; dialysis if renal failure is causeisotonic IV solutions - osmolality close to ECindicated for intravascular hydration

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NS; LR; D5W (almost hypotonic)ex: dehydration caused by running, labor, feverhypotonic IV solutions - osmolality lower than ECFcause fluid to move from ECF to ICFused for cellular dehydration1/2NS (HNS); D2.5HNSex: dehydration caused by prolonged dehydration, also seen w/ PT on TPN for a long timehypertonic IV solutions - osmolality higher than ECFindicated for intravascular dehydration with interstitial or cerebral overhydrationused carefullyonly used when serum osmolality is dangerously lowD5LR; D5HNS; D5NS; D10Wex: dehydration from surgery.. blood loss causes intravascular dehydration but tissue cutsinflame and pull fluid in to the area, causing interstitial overhydration; also seen with ascitesand third spacingPRBCs - for acute blood loss, low danger of fluid overloadplatelets - bleeding r/t thrombocytopenia; bad agitated periodicallyalbumin prep'd from plasma, 5% & 25% solutions - hypovolemic shock, hypoalbuminemia;25g/100mL is osmotically equal to 500mL of plasmacryoprecipitates - replacement of clotting factors; used for hemophiliarespiratory acidosis - dec pH; inc PCO2; normal C=HCO3caused by hypoventilationCOPD, pulmonary disease, drugs, obesity, mechanical asphyxia, sleep apnearespiratory alkalosis - inc pH; dec PCO2; normal HCO3caused by hyperventilation

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overventilation on ventilator, response to acidosis, bacteremia, thyrotoxicosis, fever,hepatic failure, response to hypoxia, hysteriametabolic acidosis - dec pH; normal PCO2; dec HCO3caused byaddition of large amounts of fixed acids to body fluidslactic acidosis (circulatory failure), ketoacidosis, phosphates and sulfates (renal disease),acid ingestion, secondary to respiratory alkalsis, adrenal insufficiencymetabolic alkalosis - inc pH; normal PCO2; inc HCO3caused by retention of base or removal of acid from bodyexcessive gastric drainage, vomiting, potassium depletion (diuretic therapy), burns,excessive NaHCO3 administrationHIV - retrovirus that attacks CD4 T cells; destroys them and reduces body's ability to fightinfection; initial symptoms within 3 wks of exposure, then become asymptomaticHIV risk factors - homo/bisexual males; IV drug abusers; heterosexual partners of riskgroup member; recipients of blood products before screening (1985); taking steroids orother meds that cause immunosuppression; infants of infected moms; breastfeeding infantsof affected momsHIV primary infection - CD4 > 800;flu like symptoms, fever, malaisemononucleosis like illness, lymphadenopathy, fever, malaise, rashsymptoms usually occur within 3 wks of initial exposure, then asymptomaticHIV asymptomatic - CD4 > 500; CDC Ano clinical problemscontinuous viral replicationcan last for years (10+)HIV symptomatic - CD4 betwee 200-499; CDC Bpersistent generalized lymphadenopathy; persistent fever; weight loss, diarrhea, peripheralneuropathy, herpes zoste, candidiasis, cervical dysplasia, hairy leukoplakia oral

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AIDS - CD4 < 200 CDC Cvariety of bacteria, parasites, or viruses overwhelm body's immune systemonce classified ad category C, stays that way.. has implication for entitlements (healthbenefits, housing, food stamps)HIV assessment - positive ELISA, confirmed by western blot test (electrophoresis)symptoms: extreme fatigue, appetite loss/weight loss (>10lb in 2mo); swollen glands; legweakness or pain; night sweats; unexplained diarrhea; cry cough; white spots in mouth andthroat; painful blisters, maybe shingles; painless purple-blue lesions on skin; confusion;disorientation; in women, recurrent vaginal infectionsHIV Interventions - assess respiratory status frequently; avoid known sources of infection;strict asepsis for invasive procedures; frequent VS; plan for rest periods; elevate HOB; referto nutritionise; small, frequent meals; weigh daily; encourage PT to avoid fatty foods; monitorfor skin breakdown; safety precautions; emotional support for PT and family; IV fluids forhydration; TPN asdir; meds and pain mgmtopportunistic infections of HIV - pneumonia; kaposi sarcoma; cryptosporidiosis; candidiasisof oral cavity and esophagus; cryptococcal meningitis; cytomegalovirus (CMS, preggo nurseshouldn't have this PT) Retinitis; CMV colitis; disseminated CMV; perirectal mucutaneousherpes simplex; lymphoma of CNS; TB; HIV encephalopathyHIV dugs - NRTI's; Non-NRTI's; protease inhibitors; COMBINATION PRODUCTS; CCR5 inhibitor;fusion inhibitor; antiprotozoals; antivirals; antifungalspneumonia - inflammation of lower respiratory tract; caused by aspiration, inhalation, orhematogenous spread; can be bacterial, viral, fungal (rare), or chemical; community ornosocomial acquiredat risk for pneumonia - PT w/ lots of lung secretions; smokers; immobile;immunosuppressed; depressed gag or cough reflex; sedated; neuromuscular disorders;NG/OG intubation; hospitalized; altered LOC; anyone susceptible to aspiration; brain injury;drug OD; stroke victim

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pneumonia assessment - tachypnea, shallow often w/ accessory muscles; abrupt onset offever w/ shaking and chills; productive cough w/ pleuritic pain; rapid, bounding pulse; painand dullness ofer affected lung area; bronchial breath sounds, crackles; CXR showsinfiltrates w/ consolidation or pleural effusion; elevated WBC; ABG indicates hypoxemia; dropin O2 sat.. should be > 90% but 95% preferred; older adults: confusion, lethargy/malaise,anorexia, rapid rr, tachycardia*fever can cause dehydration and inc O2 demand*irritibility and restlessness are early signs of cerebral hypoxiapneumonia interventions - assess sputum (vol, color, consistency, clarity); deep breath q2h;humidity to loosen secretions; fluids up to 3L qday; lung sounds before and after coughing;rate, depth, and pattern of respirations; ABGs; O2 sat; skin color; mental status; O2 asdir; VSregularly (temp)rest periods; teach to get immunizationspreventing pneuomonia - older adults: get flu shots and pneomovax, avoid sources ofinfection and indoor pollutants, don't smokeimmunosuppressed: flu shots, pneumovax, avoid infection sources, sensible nutrition, fluidintake, balance of rest and activitycomatose/immobile: elevation of HOB for 1hr after feeding, turn frequentlyasplenia: flu and pneumovaxMED SURGE HESI EXAM 2 WITH NGN (LATEST UPDATED 2024)1. The nurse is providing teaching to a client with Type 2 diabetes mellitus and peripheralneuropathy. Which information should the nurse provide?a. Family members can help with regular foot examsb. Heating pads are useful if on the low setting

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c. Aching feet may be soaked in lukewarm water for one hour or mored. Shoes should be worn outside the house, but it is fine to be barefoot inside - a. Familymembers can help with regular foot exams2. A client in the operating room received succinylcholine. The client is experiencing musclerigidity and has an extremely high temperature. What action should the nurse implement?a. Hold a prescription for dantrolene until fever is reducedb. Prepare ice packs for placement in the clients axillary areac. Call the PACU nurse to prepare for prolonged ventilator supportd. Determine if prescribed antibiotics were administered preoperatively - b. Prepare icepacks for placement in the clients axillary area3. The nurse is developing a plan of care for a client who reports blurred vision and who isnewly diagnosed with cardiovascular disease. Which outcome should the nurse include in theplan of care for this client?a. The nurse will encourage the client to walk thirty minutes every dayb. The clients family will state signs and symptoms about the diseasec. The clients daily blood pressure will be less than 140/80 this monthd. The client blood pressure readings will be less than 160/90 - c. The clients daily bloodpressure will be less than 140/80 this month4. The family suspects that acquired immune deficiency syndrome (AIDS) dementia isoccuring in their son who is human immunodeficiency virus (HIV) positive. Which symptomsconfirm their suspicions?a. He has begun to sleep 18 out of 24 hoursb. A change has recently occurred in his handwritingc. He refuses to see any of his friends or to return their phone callsd. He exhibits angry outburst when the subject of dying is approached - b. A change hasrecently occurred in his handwriting

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