MED SURG II HESI (Elsevier)

A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline at 125 mL/hr has been started. One hour after the IV initiation the client begins screaming, "I can't breathe!" The nursing priority action is: 1. Discontinue the IV site and contact the primary health care provider 2. Elevate the head of the bed and obtain vital signs 3. Contact the primary health care provider to obtain a prescription for a sedative 4. Assess for allergies and change the IV to an intermittent infusion device - answer-Elevate the head of the bed and obtain vital signs A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, the nurse expects the client to state: 1. "My ankles are swollen." 2. "I am tired at the end of the day." 3. "When I eat a large meal, I feel bloated." 4. "I have trouble breathing when I walk rapidly - answer-4. "I have trouble breathing when I walk rapidly A client who had a myocardial infarction asks the nurse, "What's the chance of my having another heart attack if I carefully watch my diet and stress levels?" What is the nurse's most appropriate initial response? 1. Focus on the client's feelings by exploring the reason why the question was asked. 2. Explain that it is all right to be frightened and refer the client to the psychiatric nurse. 3. Provide information that the client is correct in being especially careful in these areas. 4. Suggest that the client discuss follow-up care with the health care provider and the dietitian. - answer-1. Focus on the client's feelings by exploring the reason why the question was asked. The nurse is assessing a client for signs of right ventricular failure. What should the nurse expect if this occurs? 1. Slowed pulse rate 2. Pleural friction rub 3. Neck vein distention 4. Increasing hypotension - answer-3. Neck vein distention A client with bilateral varicose veins of the lower extremities questions the nurse about the brownish discoloration of the lower legs. The best response by the nurse is, "This is probably the result of: 1. Inadequate arterial blood supply." 2. Delayed healing of tissues after an injury." 3. Increased production of melanin in the area." 4. Leakage of red blood cells through the vascular wall." - answer-4. Leakage of red blood cells through the vascular wall." A client with arterial insufficiency of both lower extremities is visited by the home health care nurse. An essential nursing intervention is to teach the client to: 1. Maintain elevation of both legs 2. Massage the legs when painful 3. Apply a hot water bottle to the legs 4. Check pulses in the legs regularly - answer-4. Check pulses in the legs regularly A client is hospitalized for the treatment of thrombophlebitis. What should the nurse include in the client's teaching plan related to how to prevent thrombophlebitis? 1. Perform leg exercises 2. Sit with the knees flexed 3. Apply warm soaks to the legs daily 4. Put on elastic stockings before arising - answer-4. Put on elastic stockings before arising During chest physiotherapy (CPT), a client reports fatigue, and the client's heart rate increases from 90 to 140 beats per minute. What should the nurse do next? 1. Interrupt the therapy. 2. Encourage deep breathing. 3. Place the client in the low-Fowler position. 4. Have the client complete the therapy before resting. - answer-1. Interrupt the therapy. The nurse is providing teaching to a client with atrial flutter who has received a prescription for an oral anticoagulant. The client asks the nurse to provide a list of foods that are high in Vitamin K and that should be avoided. What should the nurse include on