HESI Medical Surgical Test Bank With Answers (239 Solved Questions)

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c.ThePTwillbe1.5timesthenormalc.Whitebloodcell(WBC)countMS4 HESI MED SURG EXAMS TEST BANK1. Following long-term administration of warfarin sodium to a client with a medical diagnosis ofdeep vein thrombosis, the nurse should expect which treatment?a.The hemoglobin will be greater than 10 g/dlb.The hematocrit will be less than 35%d.The PTT will be 1.5 times the normal2. A client who has been taking finasteride, an enzyme (5 alpha reductase) inhibitor used toshrink the prostate gland, is admitted because of continuing benign prostate prostatichypertrophy (BPH) symptoms when planning care. Which nursing problem should the nurseaddress first?a.Chronic painc.Risk for infectiond.Disturbed sleep pattern3. An older client has been diagnosed with chronic venous insufficiency. To prevent venousreturn, which action should the nurse encourage the client toa.Wear cotton socks and enclosed toe shoes whenever outsideb.Drink 8 to 10 ounces of water a dayc.Sit at the side of the bed for 15 minutes before standingd.Lie down in bed 2 times a day4. When caring for a client with a full thickness burn covering 40% of the body, the nurseobserves pertinent drainage at the wound. Before reporting this finding to the healthcareprovider,the nurse should review which of the client’s laboratory values?a.Hematocritb.Platelet countd.Blood pH level5. An older client arrives at the outpatient eye surgery clinic for a right cataract extraction andimplant. During the immediate postoperative period, which intervention should the nurseimplementa.Provide an eye shield to be worn while sleepingb.Obtain vital signs every 2 hours during hospitalizationb.Urinary retention

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c.Encourage deep breathing and coughing exercisesd.Teach a family member to administer eye drops6. After several days of coughing and taking acetaminophen to treat temperatures of 101 F (38.3 C), a client with DI is admitted to the hospital with an upper respiratory infection. Severalhours after admission, the client reports having a severe headache and freezing dizzy. Whichintervention should the nurse implement first?a.Reassess vital signsb.Obtain sputum for culturec.Obtain a fingerstick glucosed.Administer an antipyretic7.a client takes daily supplemental iron tablets for iron deficiency anemia reports feelingincreasingly fatigued. Which laboratory values should the nurse review?a.Serum electrolytesb.Completebloodcountc.Liver enzymesd.Platelet count8. The nurse is caring for a client post anesthesia care unit (PACU) who underwent athoracotomy two hours ago. The nurse observes the following vital signs: heart rate 140beats/minute, respirations 26 breaths/minute, and blood pressure 140/90 mmHg. Whichintervention is most important for the nurse to implement?a.Administer IV fluid bolus as prescribed by the healthcare providerb.Medicate for pain and monitor vital signs according to protocolc.Encourage the client to splint the incision with a pillow to cough and deep breathed.Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter9. A client who was involved in a motor vehicle collision is admitted with a fractured left femurwhich is immobilized using a fracture traction splint in preparation for an open reduction internalfraction (ORIF). The nurse determines that theclient’sdistal pulses are diminished in the leftfoot. Which interventions should the nurse implement? (SATA)a.Offer ice chips and oral clear liquidse.Administer oral antispasmodics and narcotics analgesics10. A nurse is caring for a client with Diabetes Insipidus (DI). which data warrants the mostimmediate intervention by the nurse?bcd.Evaluate the application ofthe splint tothe left leg.Monitorleft leg forpain, pallor, paresthesia,paralysis, pressure.Verifypedal pulses using adoppler pulse device

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c.d.b.Painreliefcanbeprovidedbyshrinkingtumorsthatpressagainstspinalnervesd.Troponin Ic.Provideabedsidecommodefortoiletinga.Dry skin with inelastic turgorb.Apical rate of 110 beats per minutec.Polyuria and excessive thirst11. The nurse assesses a client with petechiae and ecchymosis scattered across the arms andlegs. Which laboratory result should the nurse review?tb.Red blood cell countc.Hemoglobin levels white blood cell count12. A male client is admitted to the emergency department with vomiting of dark brown, foul-smelling emesis. He reports he had a surgical repair of a recurrent inguinal hernia one weekago and complains of intense abdominal pain. After assessing that his bowel sounds arehyperactive, which prescription should the nurse implement first13. A client is admitted to the hospital for shortness of breath and chest pain after an episode ofsyncope. Which laboratory finding is most important for the nurse to report to the healthcareprovider?a.Hematocritb.Blood glucosec.Oxygen saturation14. A client is hospitalized after experiencing a myocardial infarction (MI) to reduce cardiacworkload, which intervention should the nurse include inthe client’splan of care?a.Teach to sleep in a side-lying positionb.Encourage active range of motion exercisesd.Assist with ambulation in the hallway15. The healthcare provider prescribes radiation therapy (RT) for a client with terminalmetastaticwho is experiencing increased pain due to spinal compression. The clientasks the nurse why radiation therapy is prescribed. Which mechanism supports the use of RT intheclient’s metastatic cancer?a.Implementation of all possible treatments offers clients the best chance of survivalEvidence indicates that RT can prolong life in clients with metastatic cancersRT is an alternative to surgery that affects tumor growth and eradicates cancerInsert a nasogastric tube (NGT) and attach to low intermittent suctiona.Plateletcound.Serumsodiumof185mEq/L

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b.d.Serumcreatinineandbloodureanitrogen(BUN)c.SensationinfeetandlegendsSkinconditionoflowerextremitiesa.visualacuityc.Bilateraldiffusewheezinga.Increasetheflowofthebladderirrigationc.Thestomamucosaispurpleincolor16. The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving a PUVAtreatment. Which assessment finding indicates that the client has been overexposed to thetreatment?a.Brown, rough, greasy, wart-like papules on the faceb.Thick skin plagues topped by silvery white scalesc.Requires sunglasses because sunlight hurts eyesd.Tenderness upon palpation and generalized erythema17. An older client with long-term type 2 diabetes mellitus (DM) is seen in the clinic for a routinehealth assessment. Which assessments would the nurseto determine if the patient withtype 2 DM is experiencing long-term complications? (SATA)e.Signs of respiratory tract infection18. A client with a history of chronic obstructive disease (COPD) is admitted with pneumonia.Vital signs include oxygen saturation 89% temperature 100.5 F (C) heart rate 120beats/minute, respirations 28 breaths/minute and blood pressure 170/90mmHg. Which findingwarrants immediate intervention by the nurse?a.Shortness of breath on exertionb.Coarse breath soundsd.Yellow expectorated sputum19. The nurse observes an increased number of blood clots in the drainage tubing of a clientwith continuous bladder irrigation following a transurethral resection of the prostate (TURP).What is the best initial nursing action?b.Measure theclient’sintake and outputc.Administer a PRN dose of an antispasmodic agentd.Provide additional oral fluid intake20. The nurse assesses an adult client 24 hours after a bowel exploration and formation of asigmoid colostomy. Which assessment finding should be reported to the surgeon?a.The fecal matter is brown and has a solid consistencyb.There are no bowel sounds in the left lower quadrantd.The stoma has streaks of bright red blood

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21. The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterialmeningitis. Which diagnostic procedure should the nurse prepare the client for the healthcareprovider?a.Skull radiographyb.Computerized tomography (CT) scanc.Magnetic resonance imaging (MRI)d.Lumbar puncture22. A young adult male client has a leg cast following an open reduction for fractured tibia. He isin skeletal traction with 10 lbs of weight. Approximately two hours after returning to the unit, hereports severe pain in the affected extremity, and the nurse observes that the limb is blue andblunched. Which action should the nurse promote first?a.Release the traction and notify the healthcare providerb.Administer PRN pain medication routinely as prescribedd.Record the observations and check the imb every 15 minutes.23. A client is receiving combination chemotherapy for treatment of metastatic carcinoma.When monitoring the client for systemic, side effects which assessment findings warrantsintervention by the nurse?a.Polycythemiac.Ascitesd.nystagmus24. The nurse is planning care for an older adult male who experienced a cerebrovascularaccident several weeks ago. Because of expressive aphasia, the client often becomesfrustrated with the nursing staff. Which intervention should the nurse implement?a.Encourage client’s use of picturechartsb.Ask the client simple questionsc.Teach the client use of basic sign languaged.Speak slowly to the client25. The nurse has determined that a client with trigeminal neuralgia has the nursing problem,“imbalancednutrition, less than bodyrequirements”.Which causecontributing to theproblem?a.Altered taste sensationb.Nauseac.Fatiguec.Notify the healthcare provider of the assessment findingsb.Leukopenia

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.Painwheneatinga.Irregular apicalpulsea.Take the clientstemperature using anothermethodd26.A client with Cushing’s syndrome is recovering from an elective laparoscopic procedure.Which assessment finding warrants immediate intervention by the nurse?b.Purple marks on skin of the abdomenc.Pitting ankle edemad.Quarter size blood spot on dressing27. The nurse is assessing a client who has herpes zoster. Which question will allow the nurseto gather further information about this condition?a.Has everyone at home already had varicella?b.Do you have any dry patches on your feet and hands?c.Do your family members share combs and brushes?d.Have the antifungal creams been effective?28. The healthcare provider prescribed D5W 1800 mL IV to infuse in 24 hours. The IVadministration set delivers 60 microdroplets. The nurs should program the29. A client with COPD arrives at the emergency department reporting of shortness of breathupon exertion andweakness. The clientthe nurse of normally receiving dialysisthree times a week but missed the last treatment. Theclient’sserum potassium is 4.8 mEq/Land creatinine os 1.4, accompanied with a blood pressure of 200/120 mmHg. The clienthas salt crystals present on the skin. Which finding is most important for the nurse to bring tothe attention of the healthcare provider?a.Potassium levelb.Blood pressurec.Uremic frostd.Creatinine results30. The nurse determines that an adult client who is admitted to the post anesthesia care unit(PACU) following abdominal surgery has a tympanic temperature of 94.6 F(34,8 *C), a pulserate of 88 beats/minute, a respiratory rate of 14breaths/minute, and a blood pressure of94.64mmHg. Which action should the nurse implement?b.Check the blood pressure every five minutes for one hourc.Ask the client to cough and deep breathed.Raise the head of the bed to 60 to 90 degrees.31. An adult client is diagnosed with restless leg syndrome and is referred to the sleep clinic.ANS 75

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c.Serumironandferritinc.Performchestphysiotherapyc.MonitorurinarystreamfordecreasedoutputThe healthcare provider prescribessulfate 300 mg PO daily. Which laboratory valuesshould the nurse monitor?a.Serum electrolytesb.Platelet count and hematocritd.Neutrophils and eosinophils32. To reduce the risk for pulmonary complication for a client with Amyotrophic. Lateral Sclerosis(ALS), what interventions should the nurse implement? (SATA)b.Establish a regular bladder routined.Initiate passive range of motion exercises33. A client withureterolithiasisis preparing for discharge after a ureteroscopy removal.Which instruction should the nurse include in thisclient’s postoperativedischarge teaching?a.Use incentive spirometerb.Report when hematuria becomes pink triggeredd.Restrict physical activities34. After assessing in a left lateral thoracentesis for a client with pleural effusion, the nursethe pleural fluid samples and sends them to the labprocedure, which finding warrantsimmediate intervention by the nurse?a.Oxygen saturation 90% on 4 liters nasal cannulab.Left-sided pain on inhalationd.Decreased left lung breath sounds35. During a preoperative assessment phone call, a client states taking several“pills” everyday. Which response should the office nurse provide?a.“Obtaina copy of your medications records from your healthcareprovider”b.“Bringall your pill containers to your preoperativeappointment”c.“Discusswith your healthcare provider which medications to take beforesurgery”d.“Bringcopies of all your prescriptions to your preoperative appointment”36. Which food is most important for the nurse to encourage a client with osteomalacia toc.Subcutaneous emphysema around insertion sitee.Teach the clientbreathing exercisesa.Encourageuseofincentivespirometer

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c.Teach the client to elevate the head of the bed on blocksinclude in a daily diet?b.Citrus fruits and juicesc.Red meats and eggsd.Green leafy vegetables37. The healthcare provider prescribes metoclopramide 7.5 mg/mL IM every 3 hours PRNvomiting for a client who is receiving chemotherapy. The nurse preparesusing a 2 mLprefilled syringe cartridgelabeled, “metoclopramide5mg/mL” Howmany mL should the nurseadminister?ANS: 338.The nurse is assessing a client’s arteriovenous(AV) fistula. Which finding provides evidenceof its normal function?a.Ecchymotic areab.Enlarg ed veinc.Pulselessnessd.redness39. Which instruction should the nurse include in the discharge teaching for a client who hasgastroesophageal reflux?a.Encourage the client to lie down and rest after mealsb.Remind the client to avoid high-fiber foodsd.Instruct the client to use antacids only as a last resort40. The home health nurse is evaluating a male client who manages his asthma and measureshis peak expiratory flow rate (PEFR). Today he is experiencing an acute exacerbation and tellsthe nurse his PERF is 60% of his personal-best reading. He is experiencing expiratory andinspiratory wheezes and has a RR of 24 breaths/minute, and oxygen saturation rate of 94% onroom air. Which PRN medication should the nurse instruct the client to use?a.Albuterol 2.5 to 5 mg per nebulizationb.Epinephrine auto-injector 0.15mgc.Salmeterol 2 puffs per measured- dose inhaledd.Oxygen at 6 liter.minute by nasal cannula41.The nurse assesses a client who is newly diagnosed with hyperthyroidism and observes thatthe clients eyeballs are protuberant causign a wide eyed appearance and eye discomfort.42. The nurse prepares a teaching plan for an adult client with metabolic syndrome. WhichObtain prescriptionforartificialteardropsa.Fortifiedmilkandcereals

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Complete thefullcourseof antibioticsfinding should the nurse address to help the client reduce the risk for diabetes mellitus andvascular disease?(Select all that apply)s43. A client with gouty arthritis reports tenderness and swelling of the right ankle and great toe.The nurse observes the area of inflammation. The client receives prescriptions for colchicineand indomethacin, Which instruction should the nurse include in the discharge teaching?A.Limit use of mobility equipment to avoid muscle atrophyB.Massage joints to relax muscles and decrease painC.Substitute natural fruit juices for carbonated drinks44. After teaching a female client newly diagnosed with cholecystitis about recommended dietchanges, the nurse evaluates the clients learning. Elimination of which food choices by theclient indicates teaching is successful?45. A client with chronic obstructive pulmonary disease (COPD) is admitted to a non-emergentcholecystectomy. The admission arterial blood gas ) ABG PCO2 48 mmHG46. A client with pyelonephritis is receiving discharge instructions with the goal to preventreadmission.Which instruction is most important to include in the discharge teaching plan.47. A client with heart failure is receiving intravenous fluids at 125 ml/hour. The nurse observesan increased jugular venous distention. Which assessment should the nurse make beforereporting to the healthcare provider.b.Assess for inflammation of the calves48.The nurse is caring for a client after a cerebrovascular accident (CVA) who is adapting tofunctional changes in mobility. The client continues to experience awareness of the urge tourinate and retains a large amount of residual urine after voiding. Which action should the nurseinclude?49.Which dietary instruction is most important for the nurse to explain to a client who had agastric bypass surgery?a.Sip fluids with each mealb.Eat small frequent mealsc.ChewSlowlyandthoroughlyRemindtheclienttopracticepelvicfloor(Kegel)exercisesregularlyWholemilkanddailyicecreamservingsD.ReturnforperiodicliverfunctionsstudiesBloodpressureof150/96AbdominalobesitylcemiaHypergyIncreasedtriglyceridelevelAdministeraPRNbronchodilatora.Observeforchangeinbreathingpattern

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D. avoidwashingtheskininsidetheradiationportalsite..Initiateairborneparticulateisolationprecautions-Rythmofapicalpulse-Re-orienttheclienttohispresentlocationandcircumstancesC.Gatheradditionalassessmentdataaboutthepainandweaknessd.Reduce intake of fatty foods50.The nurse is providing teaching to a client with Type 2 diabetes mellitus and peripheralneuropathy. What information should the nurse provide?A.Heading pads are useful if on the lowest settingB.Shoes should be worn outside the house, but it is fine to be barefoot inside.C.Family members can help with regular foot examsD.Aching feet may be soaked in lukewarm water for one hour or more51. A client with a history of heart failure reports increasing fatigue over the past week. Onassessment the nurse obtains the following blood pressure 122/70 mmgHg, and respiratory rate24 breaths/minute. While waiting for an electrocardiogram (ECG),,52. The nurse assists a client with parkinson's disease to ambulate in the hallway.The clientappears to “Freeze”and then tells the nurse of pretending to step over a crack on the floor. Howshould the nurse respond?53. When completing a health assessnent for a client with migraine headachesm the nurseassesses bilateral weakness in the… troubletwisting a door knob due to weakness. Whataction should the nurse take in response to these findings?54. A client is admitted with a deep and productive cough, hemophytisis, and a low grade fever.The client’sMantoux skin test has 15mm induration. Which intervention should the nurseimplement first?A.Provide a mask for the client to wear in public areasBC.Administer the initial dose of rifampin and isonaizaidD.Collect a sputum specimen for acid fast baccilus55. The nurse is caring for a client who is receiving teletheraphy radiation for a maligant tumor.Which instructions regarding skin care of the

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1. Following long-term administration of warfarin sodium to a client with a medical diagnosis ofdeep vein thrombosis, the nurse should expect which treatment?a.The hemoglobin will be greater than 10 g/dlb.The hematocrit will be less than 35%c.The PT will be 1.5 times the normal-goodd.The PTT will be 1.5 times the normal-2. A client who has been taking finasteride, an enzyme (5 alpha reductase) inhibitor used toshrink the prostate gland, is admitted because of continuing benign prostate prostatichypertrophy (BPH) symptoms when planning care. Which nursing problem should the nurseaddress first?a.Chronic painb.Urinary retention-goodc.Risk for infectiond.Disturbed sleep pattern3. An older client has been diagnosed with chronic venous insufficiency. To prevent venousreturn, which action should the nurse encourage the client toa.Wear cotton socks and enclosed toe shoes whenever outside(-goodb.Drink 8 to 10 ounces of water a dayc.Sit at the side of the bed for 15 minutes before standingd.Lie down in bed 2 times a day4. When caring for a client with a full thickness burn covering 40% of the body, the nurseobserves pertinent drainage at the wound. Before reporting this finding to the healthcareprovider, the nurse should review which of theclient’s laboratoryvalues?a.HematocritbPlatelet count (other pick)b.White blood cell (WBC) count (on quizlet)-goodc.Blood pH level5. An older client arrives at the outpatient eye surgery clinic for a right cataract extraction andimplant. During the immediate postoperative period, which intervention should the nurseimplementa.Provide an eye shield to be worn while sleeping-goodb.Obtain vital signs every 2 hours during hospitalizationc.Encourage deep breathing and coughing exercisesd.Teach a family member to administer eye drops6. After several days of coughing and taking acetaminophen to treat temperatures of 101 F (38.3 C), a client with DI is admitted to the hospital with an upper respiratory infection. Severalhours after admission, the client reports having a severe headache and freling dizzy. Whichintervention should the nurse implement first?a.Reassess vital signsb.Obtain sputum for culturec.Obtain a fingerstick glucose-goodd.Administer an antipyretic7.a client takes daily supplemental iron tablets for iron deficiency anemia reports feelingincreasingly fatigued. Which laboratory values should the nurse review?a.Serum electrolytesb.Complete blood count-goodc.Liver enzymes

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d.Platelet count8. The nurse is caring for a client post anesthesia care unit (PACU) who underwent athoracotomy two hours ago. The nurse observes the following vital signs: heart rate 140 beats/minute, respirations 26 breaths/minute, and blood pressure 140/90 mmHg. Which intervention ismost important for the nurse to implement?a.Administer IV fluid bolus as prescribed by the healthcare providerb.Medicate for pain and monitor vital signs according to protocol-i put thisc.Encourage the client to splint the incision with a pillow to cough and deep breathed.Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter9. A client who was involved in a motor vehicle collision is admitted with a fractured left femurwhich is immobilized using a fracture traction splint in preparation for an open reduction internalfraction (ORIF). The nurse determines that the client’s distal pulses are diminished in the leftfoot. Which interventions should the nurse implement? (SATA)-gooda.Offer ice chips and oral clear liquidsb.Verify pedal pulses using a doppler pulse devicec.Monitor left leg for pain, pallor, paresthesia, paralysis, pressured.Evaluate the application of the splint to the left lege.Administer oral antispasmodics and narcotics analgesics10. A nurse is caring for a client with Diabetes Insipidus (DI). which data warrants the mostimmediate intervention by the nurse?-g00da.Dry skin with inelastic turgorb.Apical rate of 110 beats per minutec.Polyuria and excessive thirstd.Serum sodium of 185 mEq/L11. The nurse assesses a client with petechiae and ecchymosis scattered across the arms andlegs. Which laboratory result should the nurse review?a.Platelet count -goodb.Red blood cell countc.Hemoglobin levelsd.White blood cell count12. A male client is admitted to the emergency department with vomiting of dark brown, foul-smelling emesis. He reports he had a surgical repair of a recurrent inguinal hernia one weekago and complains of intense abdominal pain. After assessing that his bowel sounds arehyperactive, which prescription should the nurse implement first●Insert a nasogastric tube (NGT) and attach to low intermittent suction-good13. A client is admitted to the hospital for shortness of breath and chest pain after an episode ofsyncope. Which laboratory finding is most important for the nurse to report to the healthcareprovider?a.Hematocritb.Blood glucosec.Oxygen saturationd.Troponin I-good14. A client is hospitalized after experiencing a myocardial infarction (MI) to reduce cardiacworkload, which intervention should the nurse include in theclient’s plan ofcare?a.Teach to sleep in a side-lying position

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b.Encourage active range of motion exercisesc.Provide a bedside commode for toileting?-goodd.Assist with ambulation in the hallway15. The healthcare provider prescribes radiation therapy (RT) for a client with terminalmetastaticwho is experiencing increased pain due to spinal compression. The clientasks the nurse why radiation therapy is prescribed. Which mechanism supports the use of RT intheclient’s metastatic cancer?a.Implementation of all possible treatments offers clients the best chance of survivalb.Pain relief can be provided by shrinking tumors that press against spinal nervesc.Evidence indicates that RT can prolong life in clients with metastatic cancersd.RT is an alternative to surgery that affects tumor growth and eradicates cancer-good16. The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving a PUVAtreatment. Which assessment finding indicates that the client has been overexposed to thetreatment?a.Brown, rough, greasy, wart-like papules on the faceb.Thick skin plagues topped by silvery white scalesc.Requires sunglasses because sunlight hurts eyesd.Tenderness upon palpation and generalized erythema-good17. An older client with long-term type 2 diabetes mellitus (DM) is seen in the clinic for a routinehealth assessment. Which assessments would the nurseto determine if the patient withtype 2 DM is experiencing long-term complications? (SATA)-gooda.visual acuityb.Skin condition of lower extremitiesc.Sensation in feet and legendsd.Serum creatinine and blood urea nitrogen (BUN)e.Signs of respiratory tract infection18. A client with a history of chronic obstructive disease (COPD) is admitted with pneumonia.Vital signs include oxygen saturation 89% temperature 100.5 F (C) heart rate 120 beats/minute, respirations 28 breaths/minute and blood pressure 170/90mmHg. Which findingwarrants immediate intervention by the nurse?-gooda.Shortness of breath on exertionb.Coarse breath sounds?c.Bilateral diffuse wheezingd.Yellow expectorated sputum19. The nurse observes an increased number of blood clots in the drainage tubing of a clientwith continuous bladder irrigation following a transurethral resection of the prostate (TURP).What is the best initial nursing action?-gooda.Increase the flow of the bladder irrigationb.Measure theclient’sintake and outputc.Administer a PRN dose of an antispasmodic agentd.Provide additional oral fluid intake20. The nurse assesses an adult client 24 hours after a bowel exploration and formation of asigmoid colostomy. Which assessment finding should be reported to the surgeon?-gooda.The fecal matter is brown and has a solid consistencyb.There are no bowel sounds in the left lower quadrantc.The stoma mucosa is purple in colord.The stoma has streaks of bright red blood

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21. The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterialmeningitis. Which diagnostic procedure should the nurse prepare the client for the healthcareprovider?-gooda.Skull radiographyb.Computerized tomography (CT) scanc.Magnetic resonance imaging (MRI)d.Lumbar puncture22. A young adult male client has a leg cast following an open reduction for fractured tibia. He isin skeletal traction with 10 lbs of weight. Approximately two hours after returning to the unit, hereports severe pain in the affected extremity, and the nurse observes that the limb is blue andblunched. Which action should the nurse promote first?a.Release the traction and notify the healthcare providerb.Administer PRN pain medication routinely as prescribedc.Notify the healthcare provider of the assessment findings-g0odd.Record the observations and check the imb every 15 minutes.23. A client is receiving combination chemotherapy for treatment of metastatic carcinoma.When monitoring the client for systemic, side effects which assessment findings warrantsintervention by the nurse?a.Polycythemiab.Leukopenia-goodc.Ascitesd.nystagmus24. The nurse is planning care for an older adult male who experienced a cerebrovascularaccident several weeks ago. Because of expressive aphasia, the client often becomesfrustrated with the nursing staff. Which intervention should the nurse implement?a.Encourageclient’suse of picture charts -goodb.Ask the client simple questionsc.Teach the client use of basic sign languaged.Speak slowly to the client25. The nurse has determined that a client with trigeminal neuralgia has the nursing problem,“imbalancednutrition, less than bodyrequirements”. Which causecontributing to theproblem?a.Altered taste sensationb.Nauseac.Fatigued.Pain when eating-good26. A client withCushing’ssyndrome is recovering from an elective laparoscopic procedure.Which assessment finding warrants immediate intervention by the nurse?a.Irregular apical pulse-goodb.Purple marks on skin of the abdomenc.Pitting ankle edemad.Quarter size blood spot on dressing27. The nurse is assessing a client who has herpes zoster. Which question will allow the nurseto gather further information about this condition?a.Has everyone at home already had varicella?-good

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b.Do you have any dry patches on your feet and hands?c.Do your family members share combs and brushes?d.Have the antifungal creams been effective?28. The healthcare provider prescribed D5W 1800 mL IV to infuse in 24 hours. The IVadministration set delivers 60 microdroplets. The nurs should program the●ANS 75 -good29. A client with COPD arrives at the emergency department reporting of shortness of breathupon exertion andweakness. The clientthe nurse of normally receiving dialysisthree times a week but missed the last treatment. The client’s serum potassium is 4.8 mEq/Land creatinine os 1.4, accompanied with a blood pressure of 200/120 mmHg. The clienthas salt crystals present on the skin. Which finding is most important for the nurse to bring tothe attention of the healthcare provider?a.Potassium levelb.Blood pressure??-goodc.Uremic frostd.Creatinine results30. The nurse determines that an adult client who is admitted to the post anesthesia care unit(PACU) following abdominal surgery has a tympanic temperature of 94.6 F(34,8 *C), a pulserate of 88 beats/minute, a respiratory rate of 14breaths/minute, and a blood pressure of94.64mmHg. Which action should the nurse implement?a.Take the clients temperature using another methodb.Check the blood pressure every five minutes for one hourc.Ask the client to cough and deep breathed.Raise the head of the bed to 60 to 90 degrees.-good31. An adult client is diagnosed with restless leg syndrome and is referred to the sleep clinic.The healthcare provider prescribessulfate 300 mg PO daily. Which laboratory valuesshould the nurse monitor?a.Serum electrolytesb.Platelet count and hematocritc.Serum iron and ferritin-goodd.Neutrophils and eosinophils32. To reduce the risk for pulmonary complication for a client with Amyotrophic. Lateral Sclerosis(ALS), what interventions should the nurse implement? (SATA)gooda.Encourage use of incentive spirometerb.Establish a regular bladder routinec.Perform chest physiotherapyd.Initiate passive range of motion exercisese.Teach the client breathing exercises33.A client withureterolithiasisis preparing for discharge after a ureteroscopy removal. Whichinstruction should the nurse includein this client’spostoperative discharge teaching?a.Use incentive spirometerb.Report when hematuria becomes pink triggeredc.Monitor urinary stream for decreased output-goodd.Restrict physical activities

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