HESI MED SURG 1 TEST PRACTICE STUDY GUIDE LATEST EXAM

A. Continue with the shift report and talk to the nurse about the incident at a later time. Continuing with the shift report is the best immediate action because it allows the nurse who was floated some cooling off time. At a later time (after the nurse has cooled off) the charge nurse should discuss the conduct of the nurse in private. - During the shift report, the charge nurse informs a nurse of a reassignment to another unit for the day. The nurse begins to sigh deeply and tosses about her belongings when preparing to leave. What is the best immediate action for the charge nurse to take? A.Apply heat packs to your knees as needed for pain. B.Support your knees while you are in bed with a pillow or a rolled towel. E.Get 7 to 8 hours of sleep every night. F.Eat a balanced diet, including fish with Omega-3 fatty acids. - The clinic nurse is teaching a client with osteoarthritis to the knees bilaterally about self-care. Which teaching points will the nurse include in the client's plan of care? (Select all that apply.) A.Around the waist The waist is the anchor point for the bandage for an above the knee amputation. - The client is return demonstrating wrapping of the left limb amputated above the knee. The nurse evaluates the client is starting the wrapping method correctly when the client places the end of the bandage at which point? A.Bean soup B.Spinach E.Dark chocolate F.Shellfish - Which foods will the nurse recommend for the client with tuberculosis being discharged to home? (Select all that apply.) A.Determine if all employees have had the hepatitis B vaccine series. Hepatitis B vaccine should be administered to all health care providers. Hepatitis A (not hepatitis B) can be transmitted by fecal-oral contamination. - A resident in a long-term care facility is diagnosed with hepatitis B. Which action should the nurse take with the staff caring for this client? A.Facial muscle spasms B.Sudden facial pain Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the area innervated by one or more branches of the trigeminal nerve (cranial V). - The nurse is providing care for a client diagnosed with trigeminal neuralgia (tic douloureux). Which symptoms will the nurse be looking for in the focused assessment related to this condition? (Select all that apply.) A.Frequent oral care every 2 hours while awake. B.Use incentive spirometer every 2 hours. C.Empty contents from NG tube every 8 hours. One hour post op is too soon to ambulate for this client. Visitors help support the patient and are encouraged to visit. Oral care is necessary as the client will be NPO. To decrease the risk of infection post operatively, implement routine pulmonary exercises. The client will have an NG tube in place, likely to intermittent suction, to decompress the stomach post surgery. - The nurse is concerned about infection for a client after an esophagogastrostomy for esophageal cancer. Which actions should the nurse include in the client's plan of care? (Select all that apply.) A.Frequent vital signs. B.Determine if the client is allergic to aspirin. D.Offer fluids of choice. F.Monitor infusion of IV nitroglycerine. - The nurse is providing care to a client after a percutaneous transluminal coronary angioplasty (PTCA). What actions will the nurse include in the client's plan of care? (Select all that apply.) A.Monitor blood glucose levels daily. Cushing syndrome results from a hypersecretion of glucocorticoids in the adrenal cortex. Clients with Cushing syndrome often develop diabetes mellitus. Monitoring of serum glucose levels assesses for increased blood glucose levels so that treatment can begin early - Which nursing action would be appropriate for a client who is newly diagnosed with Cushing syndrome? A.Nausea and vomiting B.Loss of appetite C.Abdominal cramping D.Guarding with abdominal palpation - A client is diagnosed with an acute small bowel obstruction and suddenly spikes a temperature of 102°F/38.9°C. What other assessments should the nurse include in the client's focused assessment? (Select all that apply.) A.Prepare the client for a pericardial tap. The client is exhibiting symptoms of cardiac tamponade, a collection of fluid in the pericardial sac that results in a reduction in cardiac output, which is a potentially fatal complication of pericarditis. Treatment for tamponade is a pericardial tap. - During assessment of a client in the intensive care unit, the nurse notes that the client's breath sounds are clear on auscultation, but jugular vein distention and muffled heart sounds are present. Which action should the nurse take first? A.Tidaling of water in water seal chamber