HESI Med-Surg 2021 Correct 100%

What instruction should the nurse include in the discharge teaching plan of a client who had a cataract extraction today? - Answer Light housekeeping is permitted but avoid heavy lifting. A male adult comes to the urgent care clinic 5 days after being diagnosed with influenza. He is short of breath, febrile, and coughing green colored sputum. Which intervention should the nurse implement first? - Answer 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? - Answer Palpate the bladder above the symphysis pubis. An adult client is admitted with diabetic keto acidosis (DKA) and a urinary tract infection (UTI). Prescriptions for IV ABX and insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse? - Answer 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 RBC. When notifying the HCP what information should the nurse provide first using the SBAR communication process? - Answer explain specific reason for urgent notification. An adult male client is admitted for pneumocystis carinil pneumonia (PCP) secondary to AIDS. While hospitalized he receives IV pentamidine isethionate therapy. In preparing this client for discharge, what important aspect regarding his medication therapy should the nurse explain? - Answer It will be necessary to continue prophylactic doses of IV or aerosol pentane every month. A client subjective data includes dysuria, urgency, and urinary frequency. Which action should the nurse implement next? - Answer 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? - Answer ask the client if the HCP has given her any information about the classification of her cancer. A client with CKD is treated on hemodialysis. During the first treatment, clients blood pressure drops form 150/90 to 80/30. Which action should the nurse take first? - Answer stop dialysis treatment A client with a DVT is receiving a continuous infusion of heparin sodium 25,000 unit in 5% dextrose injection 250 mL. The prescription indicates the dosage should be increased to 900 units/hr. The nurse should program the infusion pump to deliver how many mL/hr? - Answer 9 mL/hr 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? - Answer upper mid abdominal gnawing and boring pain. The nurse is providing preoperative education for a jewish client scheduled to receive a xenograft to promote burn healing. Which information should the nurse provide this client? - Answer xenograft is taken from nonhuman sources. A client who took a camping vacation two weeks ago in a country with 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? - Answer jaundice sclera During a home visit the nurse assesses the skin of a client with eczema who reports an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms? - Answer 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? - Answer restrict sodium intake. A male client who is 24 hours postop for an exploratory laparotomy complains that he is starving because he has no real food since before surgery. Prior to advancing his diet, which intervention should the nurse implement? - Answer Auscultate bowel sounds in all four quadrants