BIO MED SURG 1/ HESI P 1 (GRADED A) Questions and Answer solution | 100% Guaranteed Pass.
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BIO MED SURG 1/ HESI P 1 1. A client with gout experiences an acute attack. The client reports he has been trying to lose weight. Which client information is most important for the nurse to obtain? • Serum cholesterol level (not related to the acute attack gout) • Capillary glucose level (not r...
1 a client with gout experiences an acute attack the client reports he has been trying to lose weight which client information is most important for the nurse to obtain
2 a male client with a c 6
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BIO MED SURG 1/ HESI P 1
1. A client with gout experiences an acute attack. The client reports he has been trying to
lose weight. Which client information is most important for the nurse to obtain?
• Serum cholesterol level (not related to the acute attack gout)
• Capillary glucose level (not related to the acute attack gout)
• Daily caloric intake (Starvation diet can cause an acute attack of gout)
• Daily calcium intake (not related to the acute attack gout)
2. A male client with a C-6 spinal cord injury is in rehabilitation. In the middle of the night
he reports a severe, pounding headache, and has observable goose bumps. The nurse
should assess for which trigger?
• Loud hallway noise (Not manifestation of autonomic hyperreflexia)
• Fever (Not manifestation of autonomic hyperreflexia)
• Full bladder
• Frequent cough (Not manifestation of autonomic hyperreflexia)
* A pounding headache is a sign of autonomic hyperreflexia, an acute emergency that occurs
because of an exaggerated sympathetic response in a client with a high-level spinal cord injury.
Any stimulus below the level of injury can trigger autonomic hyperreflexia, but the most
common cause is an overly distended bladder.
3. After learning that she as terminal pancreatic cancer, a female client becomes very angry
and says to the nurse, “God has abandoned me. What did I do to deserve this”? Based
on this response, the nurse deicides to include Which nursing problem in the client’s
plan of care?
• Acute pain (physical pain less than 6 month)
• Spiritual distress (indicates anger toward God for her disease)
• Ineffective coping (not reflect)
• Complicated grieving (not reflect)
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4. A nurse working on an Endocrine Unit should see which client first?
• An Adolescent male with type 1 diabetes who is arguing about his insulin dose (dealt
with at a later time)
• A older client with Addison’s disease whose current blood sugar level is 62 mg/dl (blood
sugar level is low (normal 60 -110 mg/dl, but is not critical)
• An adult with a blood sugar of 384 mg/dl and a urine output of 350 ml in the last hour
(exhibiting sign of diabetes insipidus, which include hyperglycemia & urine output, but
this patient can be seen after corticosteroid pt)
• A client taking corticosteroids who has become disoriented in the last two hours (safety)
* Rationale: safety is a priority intervention. Mania & psychosis can occur during corticosteroid
therapy, which places the client at risk for injury, so this should be first seen.
5. A young boy who is in a chronic vegetative state and living at home is readmitted to the
hospital with pneumonia and pressure ulcers. The mother insists that she is capable of
caring for her son and that she is going to take him home when he is discharged. Which
action should the nurse implement next?
• Report the incident to the local Child Protective Service (further assessment is needed
before implementing)
• Find a home health agency that specializes in brain injuries (further assessment is
needed before implementing)
• Determine the mother’s basic skill level in providing care (client is manifesting disease
syndrome complications, and the mother’s skill in providing basic care should be
determined)
• Consult the ethics committee to determine how to proceed (further assessment is
needed before implementing)
6. A male client with persistent low back pain has received a prescription for an electronic
stimulator (TENS) unit. After the nurse applies the electrodes and turns on the power,
the client reports feeling a tingling sensation. How should the nurse respond?
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• Determine if the sensation feels uncomfortable (Electronic stimulators, such as a
transelectrial nerve stimulator (TENS) unit, effective in reducing low back pain by
“closing the gate” to pain stimuli. A tingling sensation should be felt when the power is
turned on, and the nurse should assess whether the sensation is too strong, causing
discomfort or muscle twitching)
• Decrease the strength of the electrical signals (indicated if the sensation is too strong)
• Remove electrodes and observe for skin redness (not necessary because the tingling
sensation is expected)
• Check the amount of gel coating on the electrodes (not necessary because the tingling
sensation is expected)
7. A male client returns to the mental health clinic for assistance with his anxiety reaction
that is manifested by a rapid heartbeat, sweating, shaking, and nausea while driving over
the bay bridge. What action in the treatment plan should the nurse implement?
• Tell client to drive over the bridge until fear is manageable
• Teach client to listen to music or audio books while driving
• Encourage client to have spouse drive in stressful places
• Recommend that the client avoid driving over the bridge
8. The nurse preparing to administer 1.6 ml of medication IM to a 4-month-old infant.
Which action the nurse include?
• Select a 22 gauge 1 ½ inch (3.8 cm) needle for the intramuscular injection A short, small
gauge needle should be to inject into the small muscle mass of an infant rather than
which is used for an adult)
• Administer into the deltoid muscle while the parent holds the infant securely (deltoid
muscle site in the arm should not be used in infants whose muscle mass is
underdeveloped)
• Divide the medication into two injections with volumes under 1 ml
• Use a quick dart-like motion to inject into the dorsogluteal site (dorsoglutel site is not
recommended due to the proximity to nerves and blood vessels)
* IM injection for children under 3 year of age should not exceed 1 ml, so the prescribed dose
should be divided into smaller volumes for injection in two different sites.
9. Which problem reported by a client taking lovastatin requires the most immediate
follow-up by the nurse?
• Diarrhea and flatulence (are also side effect of lovastatin that require intervention, but
are of loss priority)
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• Abdominal cramps (are also side effect of lovastatin that require intervention, but are of
loss priority)
• Muscle pain (Lovastatin main priority of side effect)
• Altered taste (are also side effect of lovastatin that require intervention, but are of loss
priority)
* Statins can cause rhabdomyolysis, a potentially fatal disease of skeletal muscle characterized
by myoglobinuria and manifested with muscle pain, so this symptom should immediately be
reported to the health care provider
10. The nurse is triaging victims of a tornado at an emergency shelter. An adult woman who
has been wandering and crying comes to the nurse. What action should the nurse take?
• Check the client’s temperature, blood sugar, and urine output
• Transport the client for laboratory tests and electrocardiogram (EKG)
• Delegate care of the crying client to an unlicensed assistant
• Send the client to the shelter’s nutrient center to obtain water and food
11. The nurse is collecting a sterile sample for culture and sensitivity form a disposable three
chamber-seal drainage system connected to a pleural chest tube. The nurse should
obtain the sample from which site on the drainage system?
• Tubing located on the top of the suction chamber (do not provide access to chest
drainage)
• Plastic tubing located at the chest insertion site (should not be disconnected or accessed
to collect a sample)
• Stopper port located above the water-seal level (do not provide access to chest
drainage)
• Rubberized port at the bottom of collection chamber (with one-way value)
12. The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis.
Selection of which food items indicates to the nurse that the client understands the
prescribed diet?
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