MED/SURG NCLEX-RN HESI PRACTICE QUESTION AND ANSWER 2023The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is very
... [Show More] restless and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which intervention should the nurse implement first?
A.Measure the urine specific gravity.
B.Obtain IV fluids for infusion per protocol.
C.Prepare for insertion of a central venous catheter.
D.Auscultate the client's breath sounds.
B
The client is at risk for hypovolemic shock because of the postoperative status and is exhibiting early signs of shock. A priority intervention is the initiation of IV fluids (B) to restore tissue perfusion. (A, C, and D) are all important interventions, but are of less priority than (B).
During a health fair, a male client with emphysema tells the nurse that he fatigues easily. Assessment reveals marked clubbing of the fingernails and an increased anteroposterior chest diameter. Which instruction is best to provide the client?
A."Pace your activities and schedule rest periods."
B."Increase the amount of oxygen you use at night."
C."Obtain medical evaluation for antibiotic therapy."
D."Reduce your intake of fluids containing caffeine."
A
Manifestations of emphysema include an increase in AP diameter (referred to as a barrel chest), nail bed clubbing, and fatigue. The nurse can provide instructions to promote energy management, such as pacing activities and scheduling rest periods (A). (B) may result in a decreased drive to breathe. The client is not exhibiting any symptoms of infection, so (C) is not necessary. (D) is less beneficial than (A).
During the change of shift report, the charge nurse reviews the infusions being received by clients on the oncology unit. The client receiving which infusion should be assessed first?
A.Continuous IV infusion of magnesium
B.One-time infusion of albumin
C.Continuous epidural infusion of morphine
D.Intermittent infusion of IV vancomycin
C
All four of these clients have the potential to have significant complications. The client with the morphine epidural infusion (C) is at highest risk for respiratory depression and should be assessed first. (A) can cause hypotension. The client receiving (B) is at lowest risk for serious complications. Although (D) can cause nephrotoxicity and phlebitis, these problems are not as immediately life threatening as (C).
The nurse is planning care for a client with diabetes mellitus who has gangrene of the toes to the midfoot. Which goal should be included in this client's plan of care?
A.Restore skin integrity.
B.Prevent infection.
C.Promote healing.
D.Improve nutrition.
B
The prevention of infection is a priority goal for this client (B). Gangrene is the result of necrosis (tissue death). If infection develops, there is insufficient circulation to fight the infection and the infection can result in osteomyelitis or sepsis. Because tissue death has already occurred, (A and C) are unattainable goals. (D) is important but of less priority than (B).
The nurse is conducting an osteoporosis screening clinic at a health fair. What information should the nurse provide to individuals who are at risk for osteoporosis? (Select all that apply.)
A.Encourage alcohol and smoking cessation.
B.Suggest supplementing diet with vitamin E.
C.Promote regular weight-bearing exercises.
D.Implement a home safety plan to prevent falls.
E.Propose a regular sleep pattern of 8 hours nightly.
A, C, D
(A, C, and D) are factors that decrease the risk for developing osteoporosis. Vitamin D and calcium are important supplements to aid in the decrease of bone loss (B). Regular sleep patterns are important to overall health but are not identified with a decreasing risk for osteoporosis (E).
An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that this client's tongue is somewhat cracked and his eyeballs appear sunken into his head. Which nursing intervention is indicated?
A.Help the client determine ways to increase his fluid intake.
B.Obtain an appointment for the client to have an eye examination.
C.Instruct the client to use oxygen at night and increase the humidification.
D.Schedule the client for tests to determine his sensitivity to cat hair.
A
Clients with COPD should ingest 3 L of fluids daily but may experience a fluid deficit because of shortness of breath. The nurse should suggest creative methods to increase the intake of fluids (A), such as having fruit juices in disposable containers readily available. (B) is not indicated. Humidified oxygen will not effectively treat the client's fluid deficit, and there is no indication that the client needs supplemental oxygen at night (C). These symptoms are not indicative of (D) and may unnecessarily upset the client, who depends on his pet for socialization.
The nurse is assessing a client who presents with jaundice. Which assessment finding is most important for the nurse to follow up?
A.Urine specific gravity of 1.03
B.Frothy, tea-colored urine
C.Clay-colored stools
D.Elevated serum amylase and lipase levels
D
Obstructive cholelithiasis and alcoholism are the two major causes of pancreatitis, and elevated serum amylase and lipase levels (D) indicate pancreatic injury. (A) is a normal finding. (B and C) are expected findings related to jaundice.
Which content about self-care should the nurse include in the teaching plan of a female client who has genital herpes? (Select all that apply.)
A.Encourage annual physical and Pap smear.
B.Take antiviral medication as prescribed.
C.Use condoms to avoid transmission to others.
D.Warm sitz baths may relieve itching.
E.Use Nystatin suppositories to control itching.
F.Use a douche with weak vinegar solution to decrease itching.
A, B, C, D
The nurse should include (A, B, C, and D) in the teaching plan of a female client with genital herpes. (E) is specific for Candida infections, and (F) is used to treat Trichomonas.
The nurse is interviewing a client who is taking interferon-alfa-2a (Roferon-A) and ribavirin (Virazole) combination therapy for hepatitis C. The client reports experiencing overwhelming feelings of depression. Which action should the nurse implement first?
A.Recommend mental health counseling.
B.Review the medication actions and interactions.
C.Assess for the client's daily activity level.
D.Provide information regarding a support group.
B
Interferon-alfa-2a and ribavirin combination therapy can cause severe depression (B); therefore, it is most important for the nurse to review the medication effects and report these to the health care provider. (A, C, and D) might be implemented after the physiologic aspects of the situation have been assessed.
A client in the emergency department is bleeding profusely from a gunshot wound to the abdomen. In what position should the nurse immediately place the client to promote maintenance of the client's blood pressure above a systolic pressure of 90 mm Hg?
A.Place the client in a 45-degree Trendelenburg position to promote cerebral blood flow.
B.Turn the client prone to place pressure on the abdominal wound to help staunch the bleeding.
C.Maintain the client in a supine position to reduce diaphragmatic pressure and visualize the wound.
D.Put the client on the right side to apply pressure to the liver and spleen to stop hemorrhaging.
C
Placing the client in a supine position (C) reduces diaphragmatic pressure, thereby enhancing oxygenation, and allows for visualization of the abdominal wound. (A) compromises diaphragmatic expansion and inhibits pressoreceptor activity. (B) places the client at risk of evisceration of the abdominal wound and increased bleeding. (D) will not stop internal bleeding in the liver and spleen caused by the gunshot wound.
The nurse assesses a client who has been prescribed furosemide (Lasix) for cardiac disease. Which electrocardiographic change would be a concern for a client taking a diuretic?
A.Tall, spiked T waves
B.A prolonged QT interval
C.A widening QRS complex
D.Presence of a U wave
D
A U wave (D) is a positive deflection following the T wave and is often present with hypokalemia (low potassium level). (A, B, and C) are all signs of hyperkalemia.
When a nurse assesses a client receiving total parenteral nutrition (TPN), which laboratory value is most important for the nurse to monitor regularly?
A.Albumin
B.Calcium
C.Glucose
D.Alkaline phosphatase
C
TPN solutions contain high concentrations of glucose, so the blood glucose level is often monitored as often as q6h because of the risk for hyperglycemia (C). (A) is monitored periodically because an increase in the albumin level, a serum protein, is generally a desired effect of TPN. (B) may be added to TPN solutions, but calcium imbalances are not generally a risk during TPN administration. (D) may be decreased in the client with malnutrition who receives TPN, but abnormal values, reflecting liver or bone disorders, are not a common complication of TPN administration.
A 62-year-old woman who lives alone tripped on a rug in her home and fractured her hip. Which predisposing factor most likely contributed to the fracture in the proximal end of her femur?
A.Failing eyesight resulting in an unsafe environment
B.Renal osteodystrophy resulting from chronic kidney disease (CKD)
C.Osteoporosis resulting from declining hormone levels
D.Cerebral vessel changes causing transient ischemic attacks
C
The most common cause of a fractured hip in older women is osteoporosis, resulting from reduced calcium in the bones as a result of hormonal changes in the perimenopausal years (C). (A) may or may not have contributed to the accident, but eye changes were not involved in promoting the hip fracture. (B) is not a common condition of older people but is associated with CKD. Although (D) may result in transient ischemic attacks (TIAs) or stroke, it will not result in fragility of the bones, as does osteoporosis.
The nurse receives the client's next scheduled bag of TPN labeled with the additive NPH insulin. Which action should the nurse implement?
A.Hang the solution at the current rate.
B.Refrigerate the solution until needed.
C.Prepare the solution with new tubing.
D.Return the solution to the pharmacy.
D
Only regular insulin is administered by the IV route, so the TPN solution containing NPH insulin should be returned to the pharmacy (D). (A, B, and C) are not indicated because the solution should not be administered.
A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff?
A.Immediately after feeding
B.Just prior to tube feeding
C.Continuous inflation is required
D.Inflation is not required
B
The cuff should be inflated before the feeding to block the trachea and prevent food from entering (B) if oral feedings are started while a cuffed tracheostomy tube is in place. It should remain inflated throughout the feeding to prevent aspiration of food into the respiratory system. (A and D) place the client at risk for aspiration. (C) places the client at risk for tracheal wall necrosis.
A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid ventricular response. Based on this finding, the nurse anticipates assisting the physician with which treatment?
A.Administer lidocaine,75 mg intravenous push.
B.Perform synchronized cardioversion.
C.Defibrillate the client as soon as possible.
D.Administer atropine, 0.4 mg intravenous push.
B
With uncontrolled atrial fibrillation, the treatment of choice is synchronized cardioversion (B) to convert the cardiac rhythm back to normal sinus rhythm. (A) is a medication used for ventricular dysrhythmias. (C) is not for a client with atrial fibrillation; it is reserved for clients with life-threatening dysrhythmias, such as ventricular fibrillation and unstable ventricular tachycardia. (D) is the drug of choice in symptomatic sinus bradycardia, not atrial fibrillation.
A 63-year-old client with type 2 diabetes mellitus is admitted for treatment of an ulcer on the heel of the left foot that has not healed with wound care. The nurse observes that the entire left foot is darker in color than the right foot. Which additional symptom should the nurse expect to find?
A.Pedal pulses will be weak or absent in the left foot.
B.The client will state that the left foot is usually warm.
C.Flexion and extension of the left foot will be limited.
D.Capillary refill of the client's left toes will be brisk.
A
Symptoms associated with decreased blood supply are weak or absent pedal and tibial pulses (A). The client with diabetes experiences vascular scarring as a result of atherosclerotic changes in the peripheral vessels. This results in compromised perfusion to the dependent extremities, which further delays wound healing in the affected foot. Although flexion and extension may be limited (C), depending on the degree of damage, this is not always the case. (B and D) are signs of adequate perfusion of the foot, which would not be expected in this client.
A client with cirrhosis develops increasing pedal edema and ascites. Which dietary modification is most important for the nurse to teach this client?
A.Avoid high-carbohydrate foods.
B.Decrease intake of fat-soluble vitamins.
C.Decrease caloric intake.
D.Restrict salt and fluid intake.
D
Salt and fluid restrictions are the first dietary modifications for a client who is retaining fluid as manifested by edema and ascites (D). (A, B, and C) will not affect fluid retention.
During report, the nurse learns that a client with tumor lysis syndrome is receiving an IV infusion containing insulin. Which assessment should the nurse complete first?
A.Review the client's history for diabetes mellitus.
B.Observe the extremity distal to the IV site.
C.Monitor the client's serum potassium and blood glucose levels.
D.Evaluate the client's oxygen saturation and breath sounds.
C
Clients with tumor lysis syndrome may experience hyperkalemia, requiring the addition of insulin to the IV solution to reduce the serum potassium level. It is most important for the nurse to monitor the client's serum potassium and blood glucose levels to ensure that they are not at dangerous levels (C). (A, B, and D) provide valuable assessment data but are of less priority than (C).
A resident in a long-term care facility is diagnosed with hepatitis B. Which intervention should the nurse implement with the staff caring for this client?
A.Determine if all employees have had the hepatitis B vaccine series.
B.Explain that this type of hepatitis can be transmitted when feeding the client.
C.Assure the employees that they cannot contract hepatitis B when providing direct care.
D.Tell the employees that wearing gloves and a gown are required when providing care.
A
Hepatitis B vaccine should be administered to all health care providers (A). Hepatitis A (not hepatitis B) can be transmitted by fecal-oral contamination (B). There is a chance that staff could contract hepatitis B if exposed to the client's blood and/or body fluids; therefore, (C) is incorrect. There is no need to wear gloves and gowns except with blood or body fluid contact (D).
The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours after chest tube insertion for hemothorax. What is the best initial action for the nurse to take?
A.Document this expected decrease in drainage.
B.Clamp the chest tube while assessing for air leaks.
C.Milk the tube to remove any excessive blood clot buildup.
D.Assess for kinks or dependent loops in the tubing.
D
The least invasive nursing action should be performed first to determine why the drainage has diminished (D). (A) is completed after assessing for any problems causing the decrease in drainage. (B) is no longer considered standard protocol because the increase in pressure may be harmful to the client. (C) is an appropriate nursing action after the tube has been assessed for kinks or dependent loops. [Show Less]