BIO MED SURG 1
HESI P 1 2
1. A client with gout experiences an acute attack. The client reports he has been trying to
lose weight. Which client
... [Show More] information is most important for the nurse to obtain?
Serum cholesterol level (not related to the acute attack gout)
Capillary glucose level (not related to the acute attack gout)
Daily caloric intake (Starvation diet can cause an acute attack of gout)
Daily calcium intake (not related to the acute attack gout)
2. A male client with a C-6 spinal cord injury is in rehabilitation. In the middle of the night
he reports a severe, pounding headache, and has observable goose bumps. The nurse
should assess for which trigger?
Loud hallway noise (Not manifestation of autonomic hyperreflexia)
Fever (Not manifestation of autonomic hyperreflexia)
Full bladder
Frequent cough (Not manifestation of autonomic hyperreflexia)
* A pounding headache is a sign of autonomic hyperreflexia, an acute emergency that occurs
because of an exaggerated sympathetic response in a client with a high-level spinal cord injury.
Any stimulus below the level of injury can trigger autonomic hyperreflexia, but the most
common cause is an overly distended bladder.
3. After learning that she as terminal pancreatic cancer, a female client becomes very angry
and says to the nurse, “God has abandoned me. What did I do to deserve this”? Based
on this response, the nurse deicides to include Which nursing problem in the client’s
plan of care?
Acute pain (physical pain less than 6 month)
Spiritual distress (indicates anger toward God for her disease)
Ineffective coping (not reflect)
Complicated grieving (not reflect)
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4. A nurse working on an Endocrine Unit should see which client first?
An Adolescent male with type 1 diabetes who is arguing about his insulin dose (dealt
with at a later time)
A older client with Addison’s disease whose current blood sugar level is 62 mg/dl (blood
sugar level is low (normal 60 -110 mg/dl, but is not critical)
An adult with a blood sugar of 384 mg/dl and a urine output of 350 ml in the last hour
(exhibiting sign of diabetes insipidus, which include hyperglycemia & urine output, but
this patient can be seen after corticosteroid pt)
A client taking corticosteroids who has become disoriented in the last two hours (safety)
* Rationale: safety is a priority intervention. Mania & psychosis can occur during corticosteroid
therapy, which places the client at risk for injury, so this should be first seen.
5. A young boy who is in a chronic vegetative state and living at home is readmitted to the
hospital with pneumonia and pressure ulcers. The mother insists that she is capable of
caring for her son and that she is going to take him home when he is discharged. Which
action should the nurse implement next?
Report the incident to the local Child Protective Service (further assessment is needed
before implementing)
Find a home health agency that specializes in brain injuries (further assessment is
needed before implementing)
Determine the mother’s basic skill level in providing care (client is manifesting disease
syndrome complications, and the mother’s skill in providing basic care should be
determined)
Consult the ethics committee to determine how to proceed (further assessment is
needed before implementing)
6. A male client with persistent low back pain has received a prescription for an electronic
stimulator (TENS) unit. After the nurse applies the electrodes and turns on the power,
the client reports feeling a tingling sensation. How should the nurse respond?
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Determine if the sensation feels uncomfortable (Electronic stimulators, such as a
transelectrial nerve stimulator (TENS) unit, effective in reducing low back pain by
“closing the gate” to pain stimuli. A tingling sensation should be felt when the power is
turned on, and the nurse should assess whether the sensation is too strong, causing
discomfort or muscle twitching)
Decrease the strength of the electrical signals (indicated if the sensation is too strong)
Remove electrodes and observe for skin redness (not necessary because the tingling
sensation is expected)
Check the amount of gel coating on the electrodes (not necessary because the tingling
sensation is expected)
7. A male client returns to the mental health clinic for assistance with his anxiety reaction
that is manifested by a rapid heartbeat, sweating, shaking, and nausea while driving over
the bay bridge. What action in the treatment plan should the nurse implement?
Tell client to drive over the bridge until fear is manageable
Teach client to listen to music or audio books while driving
Encourage client to have spouse drive in stressful places
Recommend that the client avoid driving over the bridge
8. The nurse preparing to administer 1.6 ml of medication IM to a 4-month-old infant.
Which action the nurse include?
Select a 22 gauge 1 ½ inch (3.8 cm) needle for the intramuscular injection A short, small
gauge needle should be to inject into the small muscle mass of an infant rather than
which is used for an adult)
Administer into the deltoid muscle while the parent holds the infant securely (deltoid
muscle site in the arm should not be used in infants whose muscle mass is
underdeveloped)
Divide the medication into two injections with volumes under 1 ml
Use a quick dart-like motion to inject into the dorsogluteal site (dorsoglutel site is not
recommended due to the proximity to nerves and blood vessels)
* IM injection for children under 3 year of age should not exceed 1 ml, so the prescribed dose
should be divided into smaller volumes for injection in two different sites.
9. Which problem reported by a client taking lovastatin requires the most immediate
follow-up by the nurse?
Diarrhea and flatulence (are also side effect of lovastatin that require intervention, but
are of loss priority)
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Abdominal cramps (are also side effect of lovastatin that require intervention, but are of
loss priority)
Muscle pain (Lovastatin main priority of side effect)
Altered taste (are also side effect of lovastatin that require intervention, but are of loss
priority)
* Statins can cause rhabdomyolysis, a potentially fatal disease of skeletal muscle characterized
by myoglobinuria and manifested with muscle pain, so this symptom should immediately be
reported to the health care provider
10. The nurse is triaging victims of a tornado at an emergency shelter. An adult woman who
has been wandering and crying comes to the nurse. What action should the nurse take?
Check the client’s temperature, blood sugar, and urine output
Transport the client for laboratory tests and electrocardiogram (EKG)
Delegate care of the crying client to an unlicensed assistant
Send the client to the shelter’s nutrient center to obtain water and food
11. The nurse is collecting a sterile sample for culture and sensitivity form a disposable three
chamber-seal drainage system connected to a pleural chest tube. The nurse should
obtain the sample from which site on the drainage system?
Tubing located on the top of the suction chamber (do not provide access to chest
drainage)
Plastic tubing located at the chest insertion site (should not be disconnected or accessed
to collect a sample)
Stopper port located above the water-seal level (do not provide access to chest
drainage)
Rubberized port at the bottom of collection chamber (with one-way value)
12. The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis.
Selection of which food items indicates to the nurse that the client understands the
prescribed diet?
Roasted turkey, canned vegetables (low-fiber diet)
Baked potato with skin, raw carrots (not low-fiber diet)
Pancakes, whole-grain cereals (not low-fiber diet)
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Roast pork, fresh strawberries (not low-fiber diet)
13. A client exposed to tuberculosis is scheduled to begin prophylactic treatment with
isoniazid. Which information is most important for the nurse to note before
administering the initial dose?
Conversion of the client’s PPD test from negative to positive (indication for prophylactic
treatment)
Length of time of the exposure to tuberculosis (do not provide data indicating the need
to question or hold the prescribed treatment)
Current diagnosis of hepatitis B (contraindicated for a person with liver disease because
it may cause liver damage. The nurse should hold the prescribed dose and contact
healthcare provider)
History of intravenous drug abuse (do not provide data indicating the need to question
or hold the prescribed treatment)
14. After placing a client at 26-weeks’ gestation in the lithotomy position, the client
complains of dizziness and becomes pale and diaphoretic. What action should the nurse
implement?
Place the client in the Trendelenburg position (not alleviate pressure on the vena cava
and aorta)
Instruct the client to take deep breathe (not alleviate pressure on the vena cava and
aorta)
Place a wedge under the client’s hip
Remove the client’s legs from the stirrups (not alleviate pressure on the vena cava and
aorta)
* the client is likely to be experiencing supine hypotensive syndrome due to pressure of
enlarging uterus on the vena cava and aorta. Placing a wedge under either hip tilts the uterus
off these large vessels and relieves symptoms.
15. A gravida 2 para 1, at 38-weeks’ gestation, scheduled for a repeat cesarean section in
one week, is bought to the labor and delivery unit complaining of contraction every 10
minutes. While assessing the client, the client’s mother enters the labor suite and says in
a loud voice, “I’ve had children and I know she is in labor. I want her to have her
cesarean section right now!” What action should the nurse take?
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Request the mother to leave the room (The nurse should ask the family member to
leave the room because the behavior is disruptive to the nurse and to the client. After
the assessment is completed, the nurse should then address the family member’s
concerns)
Tell the mother to stop speaking for the client (is confrontational and could escalate the
situation)
Request security to remove her from the room (are not indicated at this time unless the
situation with the family member escalates)
Notify the charge nurse of the situation (are not indicated at this time unless the
situation with the family member escalates)
16. A client with a chronic health problem has difficulty ambulating short distances due to
generalized weakness but is able to bear weight on both legs. To assist with ambulation
and provide the greatest stability, what assistive device is best for this client?
A quad cane (used to when there is partial or complete leg paralysis or some hemiplegia
Crutches with 2-point gait (requires at least partial weight bearing on each foot, but
does not provide the stability)
Crutches with 3-point gait (useful when the client must bear all of the weight on one
foot, and this is not the problem experienced by this client)
Crutches with 4-point gait (provide stability and require weight bearing on both legs,
which this client should be able to provide)
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17. A female nurse who took drugs from the unit for personal use was temporarily released
from duty. After completion of mandatory counseling, the nurse has asked
administration to allow her to return to work. When the nurse administrator approaches
the charge nurse with impaired nurse’s request, what action is best for the charge nurse
to take?
Since treatment is completed, assign the nurse to routine RN responsibilities
Ask to meet with impaired nurse’s therapist before allowing her back on the unit
Allow the impaired nurse to return to work and monitor medication administration
(provides essential monitoring and helps ensure nurse compliance and promote client
safety)
Meet with staff to assess their feeling about the impaired nurse’s return to the unit
18. A client had subtotal parathyroidectomy two days ago and is now preparing for
discharge. Which assessment finding is most important for the nurse to provide to the
healthcare provider?
No bowel movement since surgery (are signs of discomfort, but are not as important as
a positive Chvostek’s sign)
Afebrile with normal pulse (is an expected finding)
No Appetite for breakfast (are signs of discomfort, but are not as important as a positive
Chvostek’s sign)
A positive Chvostek’s sign
* A positive Chvostek’s sign is spasm of the cheek muscle when the facial nerve is tapped
indication a decreased serum calcium caused by lack of parathyroid hormone. This critical
information should be relayed to the healthcare provider.
19. A client with cirrhosis is receiving a low protein diet. The nurse should explain to the
family that this diet restriction is implemented to reduce the risk of which complication
of cirrhosis?
Delirium tremors (decreased protein intake does not prevent)
Abdominal ascites (decreased protein intake does not prevent)
Hepatic encephalopathy
Esophageal varices (decreased protein intake does not prevent)
* Protein end-products (amino acids) are converted (deaminated) by the liver to a fuel source
by the removal of ammonia (NH3), which accumulates in the blood in those with cirrhosis and
contributes to the potentially fatal complication of hepatic encephalopathy.
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20. While completing an admission assessment for a client with unstable angina, which
closed ended questions should the nurse ask about the client’s chest pain? [Show Less]