lOMoAR cPSD|18634763 lOMoAR cPSD|1863476 HESI PN MED SURG ACTUAL EXAM 20 23 GRADED A HESI MED SURG 202 3 Final Exam Review WITH Explanations These are all practice questions for the 202 3 Med/Surg HESI. All the explanations listed are found in Lewis’s Medical -Surgical Nursing, Assessment and Management of Clinical Problems, Eleventh Edition by Harding, Kwong, Roberts, Hagler, and Reinisch. • A nurse is caring for a client w diabetes insipidus. Which data warrants the most immediate intervention by the nurse? ◦ Serum sodium of 185 ‣ Normal range of sodium is 135 -145 • Textbook pg 1148 ◦ “Diabetes insipidus is caused by a deficiency of production or secretion of ADH or a decreased renal response to ADH. The decrease in ADH results in fluid and electrolyte imbalances” • A nurse is obtaining the admission history for a client w suspected peptic ulcer disease. Which subjective data reported by the client supports this medical diagnosis? ◦ Upper mid-abdominal pain described as gnawing and burning • Textbook pages 905-911 ◦ “Peptic ulcer disease is a condition characterized by erosion of the GI mucosa from the digestive action of HCL acid and pepsin.” ◦ “In gastric ulcers, the discomfort is generally high in the epigastrium and occurs about 1 -2 hrs after meals. The pain is described as “burning” or “gaseous” • The nurse assesses a client who is newly diagnosed w hyperthyroidism and observes that the client’s eyeballs are protuberant, causing a wide -eyed appearance and eye discomfort. Based on this finding, which action should the nurse include in this client’s plan of care? ◦ Obtain a prescription for artificial tear drops • Textbook pg 1150 ◦ “A classic finding in Graves’ disease is exophthalmos, a protrusion of the eyeballs from the orbits that is usually bilateral…The increased pressure forces the eyeballs outward. The upper lids are usually retracted and elevated, with the sclera visible above the iris. When the eyelids do not close completely, the exposed corneal surfaces become dry and irritated.” • To reduce the risk for pulmonary complication for a client w Amyotropic Lateral Sclerosis, which interventions should the nurse implement? ◦ Perform chest physiotherapy ◦ Teach the client breathing exercises ◦ Encourage use of incentive spirometer ‣ These are the only options that have to do with the pulmonary system • Textbook pg 1379 lOMoAR cPSD|18634763 • A client is hospitalized w heart failure. Which intervention should the nurse implement to improve ventilation and reduce venous return? ◦ Place the client in high fowler’s position ‣ The only option that encourages BOTH ventilation and reduces venous return • Textbook pg 748 • A client who was involved in a motor vehicle collision is admitted w a fractured left femur which is immobilized using a fracture traction splint in prep for an open reduction internal fixation (ORIF). The nurse determines that the client’s distal pulses are diminished in the L foot. Which interventions should the nurse implement? ◦ Verify pedal pulses using a Doppler pulse device ◦ Evaluate the application of the splint to the left leg ◦ Monitor left leg for pain, pallor, parenthesis, paralysis, pressure ‣ Only options that involve the left leg • Textbook pg 1456 -1457 • “The neurovascular assessment consists of peripheral vascular assessment (color, temperature, cap refill, peripheral pulses, edema) and peripheral neurologic assessment (sensation, motor function, pain). • The healthcare provider prescribes diagnostic tests for a client whose chest X-ray indicates pneumonia. Which diagnostic test should the nurse review for implementation in the most therapeutic treatment of the pneumonia? ◦ Sputum culture and sensitivity • Textbook pg 506-507 ◦ “Ideally, a sputum specimen for culture and Gram stain to identify the organism is obtained before beginning antibiotic thereby…” • A client w a history of bronchitis arrives at t he clinic w shortness of breath, productive cough w 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 • Textbook pg 503 ◦ “Treatment is supportive. It includes cough suppressants, encouraging oral fluid intake, and using a humidifier.” • The home health nurse provides teaching about insulin self injection to a client who was recently diagnosed w diabetes mellitus. When the client begins to perform a return demonstration of an insulin injection into the abdomen, which instruction should the nurse provide? ◦ Continue w the insulin injection • The nurse observes an increased number of blood clots in the drainage tubing of a client w continuous bladder irrigation following a trans urethral resectionof the prostate (TURP). Wha t is lOMoAR cPSD|18634763 the best initial nursing action? ◦ Increase the flow of the bladder irrigation • Pg 1261 ◦ “With CBI, irrigation solution is continuously infused and drained from the bladder. The rate of infusion is based on the color of drainage. Ideally, the urine drainage should be light pink without clots.” • Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first? ◦ Assess pulses w a vascular Doppler • A client arrives to the Med/Surg unit 4 hours after a transurethral resection of the prostate. A triple -lumen Catheter for continuous bladder irrigation w normal saline is infusing and the nurse observes dark, pink -tinged outflow w blood clots in the tubing and collection bag. Which action should the nurse take? ◦ Monitor catheter drainage • Pg 1261 ◦ “With CBI, irrigation solut ion is continuously induced and drained from the bladder. The rate of infusion is based on the color of drainage…Continuously monitor the inflow and outflow of the irrigant” • The nurse is planning care for an older adult client who experienced a cerebrovascular accident several weeks ago. The client has expressive aphasia and often becomes flustered w the nursing staff. Which intervention should the nurse implement? ◦ Encourage client’s use of picture charts • Pg 1336 ◦ “Types of aphasia include…expressive aphasia (inability to produce language.” (Using picture charts will allow the client to answer questions right now, without having to do other training.) • After 3 days of persistent epigastric pain, a female client pres ents to the clinic. She has been taking oral antacids without relief. Her vital signs are HR 122, resp 16, O2 90%, and BP 116/70. The nurse obtains a 12 -lead ECG. Which assessment finding is the most critical? ◦ ST elevation in three leads • Pg 718 ◦ “A STEMI, caused by an occlusive thrombus, results in ST - elevation in the ECG leads facing the area of infarction…A STEMI is an emergency. To limit the infarct size, the artery must be opened within 90 minutes of presentation to restore blood t and O12 to the heart muscle and limit infarct size.” • A client w acute renal injury (AKI) weight 50 kg and has potassium level of 6.7 is admitted to
