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.) 1.6mL. 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?