Med Surg Hesi and study guide 1. A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the best initial nursing action? Observe the color, consistenc y, and amount of sputum. 2. A client is brought to the Emergency Department by ambulance in cardiac arre...
1 a client with a productive cough has obtained a sputum specimen for culture as instructed what is the best initial nursing action
3 after a hospitalization of inappropriate antidiuretic hormone
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Med Surg Hesi and study guide
1. A client with a productive cough has obtained a sputum specimen for culture as
instructed. What is the best initial nursing action?
Observe the color, consistency, and amount of sputum.
2. A client is brought to the Emergency Department by ambulance in cardiac arrest
with cardiopulmonary resuscitation (CPR) in progress. The client is intubated
and is receiving 100% oxygen per self-inflating (ambu) bag. The nurse
determines that the client is cyanotic, cold, and diaphoretic. Which assessment
is most important for the nurse to obtain?
Breath sounds over bilateral lung fields.
3. After a hospitalization of inappropriate antidiuretic hormone (SIADH), a client
develops positive myelinolysis. Which intervention should the nurse implement
first?
Reorient client to his room.
4. A client who is admitted to the intensive care unit with syndrome of inappropriate
antidiuretic hormone (SIADH) has developed osmotic demyelination. Which
intervention should the nurse implement first?
Evaluate swallow.
5. A male client with heart failure (HF) calls the clinic and reports that he cannot
put his shoes on because they are too tight. Which additional information should
the nurse obtain?
Has his weight changed in the last several days?
6. An older adult woman with a long history of chronic obstructive pulmonary
disease (COPD) is admitted with progressive shortness of breath and a
persistent cough. She is anxious and is complaining of a dry mouth. Which
intervention should the nurse implement?
Apply a high-flow venturi mask.
7. Client with a history of asthma and bronchitis arrives at the clinic with shortness
of breath, productive cough with thickened, tenacious mucous, and the inability
to walk up a flight of stairs without experiencing breathlessness. Which action is
most important for the nurse to instruct the client about self-care?
Increase the daily intake of oral fluids to liquefy secretions.
,8. A cardiac catheterization of a client with heart disease indicates the following
blockages: 95% proximal left anterior descending (LAD), 99% proximal
circumflex, and ? % proximal right coronary artery (RCA). The client later asks
the nurse "what does all this mean for me?" What information should the nurse
provide?
Three main arteries have major blockages, with only 1 to 5% of blood flow getting
through to the heart muscle.
9. A client who weighs 175 pounds is receiving IV bolus dose of heparin 80
units/kg. The heparin is available in a 2 ml vial, labeled 10,000 units/ml. How
many ml should the nurse administer? (Enter numeric value only. If rounding is
required, round to the nearest tenth.)
1.6 mL.
10. What information should the nurse include in the teaching plan of a client
diagnosed with gastroesophageal reflux disease (GERD)?
Minimize symptoms by wearing loose, comfortable clothing.
11. The nurse is caring for a client with a lower left lobe pulmonary abscess. Which
position should the nurse instruct the client to maintain?
Left lateral.
12. A client with cholelithiasis has a gallstone lodged in the common bile duct and is
unable to eat or drink without becoming nausea and vomiting. Which finding
should the nurse report to the healthcare provider?
Yellow sclera.
13. The nurse is planning care for a client following an incisional cholecystectomy
for cholelithiasis. Which intervention is the highest nursing priority for this client?
Assisting the client to turn, cough and deep breathe every 2 hours.
14. While caring for a client with Amyotrophic Lateral Sclerosis (ALS), a nurse
performs a neurological assessment every 4 hours. Which assessment finding
warrants immediate intervention by the nurse?
Weakened cough effort.
,15. The nurse is providing preoperative education for a Jewish client scheduled to
receive a xenograft graft to promote burn healing. Which information should the
nurse provide this client?
The xenograft is taken from nonhuman sources.
16. A male client who had colon surgery 3 days ago is anxious and requesting
assistance to reposition. While the nurse is turning him, the wound dehiscences
and eviscerates. The nurse moistens an available sterile dressing and places it
over the wound. What intervention should the nurse implement next?
Prepare the client to return to the operating room.
17. A client with carcinoma of the lung is complaining of weakness and has a serum
sodium level 117 mEq/L. Which nursing problem should the nurse include in this
client's plan of care?
Fluid volume excess.
18. A female client enters the clinic and insists on being seen. She is weak,
nervous, and reports a racing heartbeat and recent weight loss of 15 pounds.
After ruling out substance withdrawal, the healthcare provider suspects
hyperthyroidism and admits her for further testing. Which action should the
nurse implement?
Space the client's care to provide periods of rest.
19. The nurse is teaching a client with glomerulonephritis about self-care. Which
dietary recommendations should the nurse encourage the client to follow?
Restrict protein intake by limiting meats and other high-protein foods.
20. An overweight, young adult made who was recently diagnosed with type 2
diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is
feeling very weak and jittery. Which actions should the nurse implement? (Select
all that apply.)
Check his fingerstick glucose level
Assess his skin temperature and moisture
Measure his pulse and blood pressure
21. A client with Cushing's syndrome is recovering from an elective laparoscopic
procedure. Which assessment finding warrants immediate intervention by the
nurse?
Irregular apical pulse.
, 22. An adult woman with primary Raynaud phenomenon develops pallor and then
cyanosis of her fingers. After warming her hands, the fingers turn red and the
client reports a burning sensation. What action should the nurse take?
Continue to monitor the fingers until color returns to normal.
23. A male client with muscular dystrophy fell in his home and is admitted with a
right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are
coarse with diminished bibasilar breath sounds. Vital signs are temperature
101F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood
pressure 122/82. Which intervention is most important for the nurse to
implement first?
Assess lower extremity circulation.
24. The nurse is completing the preoperative assessment of a client who is
scheduled for a laparoscopic cholecystectomy under general anesthesia. Which
finding warrants notification of the healthcare provider prior to proceeding with
the scheduled procedure?
The client's blood pressure reading is 184/88 mm Hg.
25. A client who has a history of hypothyroidism was initially admitted with lethargy
and confusion. Which additional finding warrants the most immediate action by
the nurse?
Further decline in level of consciousness.
26. Following surgical repair of the bladder, a female client is being discharged from
the hospital to home with an indwelling urinary catheter. Which instruction is
most important for the nurse to provide to this client?
Keep the drainage bag lower than the level of the bladder.
27. Which client has the highest risk for developing skin cancer?
A 65-year-old fair-skinned male who is a construction worker.
28. When caring for a client with nephrotic syndrome, which assessment is most
important for the nurse to obtain?
Daily weight.
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