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HESI - Medical Surgical Nursing test-Exam TEST BANK FOR MEDICAL SURGICAL NURSING 11TH EDITION IGNATAVICIUS extra practice prior to final - direct from midterms Questions With Complete Solutions$22.99
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HESI - Medical Surgical Nursing test-Exam TEST BANK FOR MEDICAL SURGICAL NURSING 11TH EDITION IGNATAVICIUS extra practice prior to final - direct from midterms Questions With Complete Solutions
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HESI - Medical Surgical Nursing test-Exam TEST BANK FOR MEDICAL SURGICAL NURSING 11TH EDITION IGNATAVICIUS extra practice prior to final - direct from midterms Questions With Complete Solutions
HESI - Medical Surgical Nursing test-Exam TEST BANK
FOR MEDICAL SURGICAL NURSING 11TH EDITION
IGNATAVICIUS extra practice prior to final - direct from
midterms Questions With Complete Solutions
A client asks the nurse why it is important to be weighed every
day if he has right-sided heart failure. What is the nurse's best
response?
A) "The hospital requires that all inpatients be weighed daily."
B) "Weight is the best indication that you are gaining or losing
fluid."
C) "You need to lose weight to decrease the incidence of heart
failure."
D) "Daily weights will help us make sure that you're eating
properly." Correct Answer B
Daily weights are needed to document fluid retention or fluid
loss. One liter of fluid equals 2.2 pounds.
A client has a deep wound covered with a wet-to-damp dressing.
Which intervention does the nurse include on this client's care
plan?
A) Apply a new dressing when the seal breaks and the dressing
leaks.
B) Change the dressing when the current dressing is saturated.
C) Leave the dressing intact until next week.
D) Change the dressing every 6 hours around the clock. Correct
Answer D
,Wet-to-damp dressings are changed every 4 to 6 hours to
provide maximum débridement. Synthetic dressings can be left
in place for extended periods of time but need to be changed if
the seal breaks and the exudate is leaking. Dry gauze dressings
should be changed when the outer layer becomes saturated.
A client has a small-bore nasoenteric feeding tube. The nurse
assesses the following vital signs: temperature, 100.2° F (37.8°
C); pulse, 112 beats/min; respiratory rate, 22 breaths/min; and
blood pressure, 106/62 mm Hg. Which action by the nurse takes
priority?
A) Auscultate bowel sounds and slow the feeding down.
B) Remove the tube immediately and notify the heath care
provider.
C) Auscultate lung sounds and obtain oxygen saturation.
D) Add blue dye to the feeding tube formula. Correct Answer
C
The client may have aspirated. The nurse should further assess
the client's respiratory and oxygenation status. The client may
have another reason for the abnormal vital signs, so the nurse
should not pull out the tube before performing other
assessments. Adding blue dye to the tube feeding formula is not
recommended to check for aspiration. Slowing the feeding down
will not be helpful.
A client has a urinary tract infection. Which assessment by the
nurse is most helpful?
A) Palpating and percussing the kidneys and bladder
,B) Performing a bladder scan to assess post-void residual
C) Assessing medical history and current medical problems
D) Inquiring about recent travel to foreign countries Correct
Answer C
Clients who are severely immune compromised or who have
diabetes mellitus are more prone to fungal urinary tract
infection. The nurse should assess for these factors. A physical
examination and a post-void residual may be needed, but not
until further information is obtained. Travel to foreign countries
probably would not be as important, because even if exposed,
the client needs some degree of immune compromise to develop
a fungal urinary tract infection.
A client has a wound on his left trochanter that is 4 inches in
diameter, with black tissue at the perimeter, and bone is
exposed. Which is the nurse's best action?
A) Document as a stage I pressure ulcer and apply a transparent
dressing.
B) Document as a stage II pressure ulcer and start wet-to-dry
gauze treatments.
C) Document as a stage IV pressure ulcer and prepare the client
for débridement.
D) Document as a stage III pressure ulcer and start antibiotic
therapy. Correct Answer C
A stage IV ulcer is one in which skin loss is full thickness, with
extensive destruction, tissue necrosis, and/or damage to muscle,
bone, or supporting structures. Eschar may be present. When the
bone of the trochanter area is visible, tissue loss includes muscle
, loss. A potential intervention consists of débridement of the
necrotic tissue and a possible graft to promote healing.
A client has been admitted to the intensive care unit with
worsening pulmonary manifestations of heart failure. What is
the nurse's best action?
A) Administer loop diuretics as prescribed.
B) Begin cardiopulmonary resuscitation (CPR).
C) Promote rest and minimize activities.
D) Place the client in a high Fowler's position. Correct Answer
A
The client with worsening heart failure is most at risk for
pulmonary edema as a consequence of fluid retention.
Administering diuretics will decrease the fluid overload, thereby
decreasing the incidence of pulmonary edema. High Fowler's
position might help the client breathe easier but will not solve
the problem. CPR is not warranted in this situation. Rest is
important for clients with heart failure, but this is not the
priority.
A client has been taught to restrict dietary sodium. Which food
selection by the client indicates to the nurse that teaching has
been effective?
a. a grilled cheese sandwich with tomato soup
b. Chinese take-out, including steamed rice
c. a chicken leg, one slice of bread with butter, and steamed
carrots
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