2023 H ESI Med S urg Exam Test Bank New Latest Version 300+ Questions and 100% Correct Answer A client who took a camping vacation two weeks ago in a country with a 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? a. jaundice sclera b. intestinal cramping c. weakness and fatigue d. weight loss ------- Correct Answer -------- a. jaundice sclera Patient begins with flu symptoms but as a green expectoration worse Have goes to the ED is the first thing you do? -------- Correct Answer -------- measuring Oxygen saturation Patient moved from the operating room has postoperative room first thing you do? -------
- Correct Answer -------- assessment of vital signs Pt With cast fracture have pain? -------- Correct Answer -------- Evaluate Peripheral pulses During a home visit the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms? a. an old friend with eczema came for visit b. recently received an influenza immunization c. corticosteroid cream was applied to eczema d. a grandson and his new dog recently visited ------- Correct Answer -------- d. 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? a. select a protein rich food daily b. restrict sodium intake c. eat high potassium foods d. Avoid foods high in carbohydrate ------- Correct Answer -------- b. restrict sodium intake A male client who is 24hr post operative for an exploratory laparoctomy complains that he is starving because he has had no real food since before surgery. Prior to advancing his diet which intervention should the nurse implememt? a. discontinue intravenous therapy b. Assess for abdominal distension and tenderness c. Obtain a prescription for a diet change d. Auscultate bowel sound in all four quadrants ------- Correct Answer -------- d. auscultate bowel sounds in all four quadrants A client diagnosed with stable angina secondary to ischemic heart disease has a prescription for sublingual (SL) nitroglycerin (NTG). The nurse should tell the client to follow which instructions if chest pain is not relieved after taking 3 NTG tablets 5 m in apart? a. drive to the nearest emergency department b. take another NTG SL tablet and lie down until angina subsides c. call primary healthcare provider d. call 911 if pain is unrelieved and chew a tablet of aspirin 325mg ------- Correct Answer -------- d. call 911 if pain is unrelieved and chew a tablet of aspirin 325 mg After taking orlistat (Xenical) for one week a female client tells the home health nurse that she is experiencing increasingly frequent oily stools and flatus. What action should the nurse take? a. obtain stool specimen to evaluate for occult blood and fat content b. instruct the client to increase her intake of saturated fats over the next week c. ask the client to describe her dietary intake history for the last several days d. advice the client to stop taking the drug and contact the healthcare provider ------- Correct Answer -------- c. ask the client to describe her dietary intake history for the last several days Two days after an abscess of the chin was drained the client returns to the clinic with fever chills and a maculopapular rash with pruritis. The client has taken an oral antibiotic and cleansed the wound today with provide iodine (Betadine) solution. Which intervention should the nurse implement first? a. determine if the client has a history of diabetes b. assess airway patency and oxygen saturation c. review recent medication history and allergies d. obtain samples for complete blood count and cultures ------- Correct Answer -------- b. assess airway patency and oxygen saturation A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the health care provider? a. low back pain and hypotension b. rhinitis and nasal stuffiness c. delayed painful rash with urticarial d. arthritic joint changes and chronic pain ------- Correct Answer -------- a. low back pain and hypotension A young adult male who has had type 2 diabetes mellitus (DM) is admitted to the intensive care unit with hyperglycemic nonketotic syndrome (HHNS). A sliding scale protocol for an isotonic IV solution with regular insulin is prescribed based on the results of a continuous blood glucose monitoring device that is attached to the client's central venous catheter. When the client's respirations become labored and his lungs sound indicate crackles what action should the nurse take? a. collect a specimen for a white blood cell count and cultures b. determine the clients glycosylated hemoglobin (A1C) c. administer insulin IV push until the clients fluid volume is adjusted d. decrease infusion rate to address fluid overload ------- Correct Answer -------- d. decrease infusion rate to address fluid overload When preparing to apply a fentanyl (Duragesic) transdermal patch the nurse notes that the previously applied patch is intact on the client's upper back and the client denies pain. What action should the nurse take? a. Remove the patch and consult with the healthcare provider about the client pain resolution b. Place the patch on the clients shoulder and leave both patches in place for 12 hours c. Administer an oral analgesic and evaluate its effectiveness before applying a new patch d. Apply a new patch in a different location after removing the original patch ------- Correct Answer -------- d. apply a new patch in a different location after removing the original patch A client who had a myocardial infarction is admitted to the coronary critical care unit (CCU) with a nitroglycerin drip infusing. The clients last blood pressure measurements was 78/36. What action should the nurse implement? a. obtain blood pressure q5 minutes using duranap machine b. change the dilution of the nitroglycerin infusion c. reduce the rate of the nitroglycerin infusion d. begin dopamine infusion at 5mcg/kg per minute ------- Correct Answer -------- c. reduce the rate of the nitroglycerin infusion What instruction should the nurse include in the discharge teaching plan of a client who had a cataract extraction today? a. sexual activities may be resumed upon return home b. light housekeeping is permitted but avoid heavy lifting c. use a metal eye shield on operative eye during the day d. administer eye ointment before applying eye drops ------- Correct Answer -------- b. 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? a. Obtain a sputum sample for culture b. Check his oxygen saturation level c. Administer an oral antipyretic d. Auscultate bilateral lung sound ------- Correct Answer -------- a. obtain a sputum sample for culture
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