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Hesi Med Surg
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[Meer zien]Voorbeeld 4 van de 77 pagina's
Voorbeeld 4 van de 77 pagina's
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Voorbeeld van de inhoud
Med-Surg Test Bank1. A nurse is reinforcing teaching with a client who has HIV and is being discharged to
home. Which of the following instructions should the nurse include in the teaching?
1) Take temperature once a day.
Answer Rationale:
The nurse should reinforce to the client to take his temperature once a daily to identify if a
temperature is present due to the client’s altered immune system.
INCORRECT
2) Wash the armpits and genitals with a gentle cleanser daily.
Answer Rationale:
The nurse should instruct the client to use an antimicrobial cleanser to wash his armpits and
genitals twice daily.
INCORRECT
3) Change the litter boxes while wearing gloves.
Answer Rationale:
The client should avoid changing litter boxes. Litter boxes carry toxoplasmosis which can be life
threatening to a client who has HIV.
INCORRECT
4) Wash dishes in warm water.
Answer Rationale:
The nurse should instruct the client to wash dishes in hot soapy water to destroy the bacteria.
2. A nurse is caring for a client who is postoperative following a tracheostomy, and has
copious and tenacious secretions. Which of the following is an acceptable method for the
nurse to use to thin this client's secretions?
1) Provide humidified oxygen.
Answer Rationale:
Increasing fluid intake as tolerated and providing adequate humidification can help thin
secretions safely.
INCORRECT
2) Perform chest physiotherapy prior to suctioning.
Answer Rationale:
Performing chest physiotherapy mobilizes secretions but does not thin them.
INCORRECT
3) Prelubricate the suction catheter tip with sterile saline when suctioning the airway.
Answer Rationale:
,Prelubricating the suction catheter tip with sterile saline helps to ease the insertion of the
catheter, producing less trauma. However, it has no effect on the tenacity of the client's
secretions.
INCORRECT
4) Hyperventilate the client with 100% oxygen before suctioning the airway.
Answer Rationale:
Hyperventilating the client prior to suctioning prevents hypoxia. However, it has no effect on the
tenacity of the client's secretions.
3. Following admission, a client with a vascular occlusion of the right lower extremity calls
the nurse and reports difficulty sleeping because of cold feet. Which of the following
nursing actions should the nurse take to promote the client's comfort?
INCORRECT
1) Rub the client's feet briskly for several minutes.
Answer Rationale:
Massaging the legs or feet could mobilize a clot. Impaired arterial or venous circulation of the
lower extremities is a contraindication for leg massage.
2) Obtain a pair of slipper socks for the client.
Answer Rationale:
Slipper socks with nonskid soles will help provide warmth and increase the client's level of
comfort.
INCORRECT
3) Increase the client's oral fluid intake.
Answer Rationale:
Increasing the client's fluid intake will not increase circulation to an area an occlusion impairs.
INCORRECT
4) Place a moist heating pad under the client's feet.
Answer Rationale:
Impaired arterial or venous circulation to a lower extremity is a contraindication for applying a
heating pad.
4. A nurse is caring for a client is who is 4 hr postoperative following a transurethral
resection of the prostate (TURP). Which of the following is the priority finding for the
nurse report to the provider?
INCORRECT
1) Emesis of 100 mL
Answer Rationale:
The nurse should recognize postoperative nausea is a complication related to the administration
of anesthesia and should treat the nausea with anti-emetics and provide supportive measures;
however, it is not the priority finding.
,INCORRECT
2) Oral temperature of 37.5° C (99.5° F)
Answer Rationale:
The nurse should monitor a client who develops a fever and encourage deep breathing, coughing,
and fluid intake (if permitted); however, it is not the priority finding to report. The increase in
temperature is likely due to decreased respiratory effort related to the use of anesthesia and
should clear with pulmonary hygiene.
3) Thick, red-colored urine
Answer Rationale:
The nurse should recognize viscous drainage that is red in color may indicate hemorrhage and
should be reported to the provider immediately.
INCORRECT
4) Pain level of 4 on a 0 to 10 rating scale
Answer Rationale:
The nurse should assess for and treat postoperative pain which is an expected finding in the
postoperative client; however it is not the priority finding to report. Specific pain, such as
bladder spasms, may indicate complications however and should be reported to the provider.
5. A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a
prescription for a hypothermia blanket. The nurse should monitor the client for which of
the following adverse effects of the hypothermia blanket?
1) Shivering
Answer Rationale:
The hypothermia blanket can cause shivering if the client is cooled too quickly. Shivering can
cause the client’s temperature to increase.
INCORRECT
2) Infection
Answer Rationale:
Infection is not a complication of the hypothermia blanket therapy. A manifestation of infection
is hyperthermia.
INCORRECT
3) Burns
Answer Rationale:
Burns are associated with the improper use of heating pads, not hypothermia blankets.
INCORRECT
4) Hypervolemia
Answer Rationale:
Hypervolemia is not a complication of the hypothermia blanket therapy. Dehydration is a risk
associated with hyperthermia due to fluid loss.
6. A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes
mellitus. Which of the following statements by the client indicates an understanding of
the teaching?
, INCORRECT
1) "I will carry a complex carbohydrate snack with me when I exercise."
Answer Rationale:
The nurse should reinforce that the client should carry a simple carbohydrate such as hard candy
or glucose tablets for use during exercise if the client becomes hypoglycemic.
INCORRECT
2) "I should exercise first thing in the morning before eating breakfast."
Answer Rationale:
The nurse should reinforce that exercise should follow a meal. Exercising first thing in the
morning on an empty stomach places the client at risk for hypoglycemia.
INCORRECT
3) "I should avoid injecting insulin into my thigh if I am going to go running."
Answer Rationale:
The nurse should reinforce that the client should avoid injecting insulin into an area that will
soon be exercised to avoid increasing the absorption rate of the insulin.
4) "I will not exercise if my urine is positive for ketones."
Answer Rationale:
The nurse should reinforce that exercise should be avoided if ketones are present in the urine as
this indicates an elevated blood glucose level or ketoacidosis.
7. A nurse notes a small section of bowel protruding from the abdominal incision of a client
who is postoperative. After calling for assistance, which of the following actions should
the nurse take first?
1) Cover the client's wound with a moist, sterile dressing.
Answer Rationale:
According to evidence-based practice, the nurse's first action should be to cover the wound with
a moist, sterile dressing to prevent entry of bacteria into the wound and to keep the tissue moist.
INCORRECT
2) Have the client lie supine with knees flexed.
Answer Rationale:
The nurse should have the client lie supine with knees flexed to promote adequate circulation to
the vital organs. However, evidence-based practice indicates that this is not the first action the
nurse should take.
INCORRECT
3) Check the client's vital signs.
Answer Rationale:
The nurse should check the client’s vital signs because the client is at risk for shock following
wound evisceration. However, evidence-based practice indicates that this is not the first action
the nurse should take.
INCORRECT
4) Inform the client about the need to return to surgery.
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