MED-SURGE HESI RN QUESTIONS AND ANSWERS WITH RATIONALE
1. A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid
... [Show More] 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.
Rationale:
With uncontrolled atrial fibrillation, the treatment of choice is synchronized cardioversion to convert the cardiac rhythm back to normal sinus rhythm. Option A is a medication used for ventricular dysrhythmias. Option 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. Option D is the drug of choice in symptomatic sinus bradycardia, not atrial fibrillation.
2.A practical nurse (PN) tells the charge nurse in a long-term facility that she does not want to be assigned to one particular resident. She reports that the male client keeps insisting that she is his daughter and begs her to stay in his room. What is the best managerial decision?
A. Notify the family that the resident will have to be discharged if his behavior does not improve.
B. Notify administration of the PN's insubordination and need for counseling about her statements.
C. Ask the PN what she has done to encourage the resident to believe that she is his daughter.
D. Reassign the PN until the resident can be assessed more completely for reality orientation.
Rationale:
Temporary reassignment is the best option until the resident can be examined and his medications reviewed. He may have worsening cerebral dysfunction from an infection or electrolyte imbalance. Option A is not the best option because the family cannot control the resident's actions. The administration may need to know about the situation, but not as a case of insubordination. Implying that the PN is somehow creating the situation is inappropriate until a further evaluation has been conducted.
3. Client census is often used to determine staffing needs. Which method of obtaining census determination for a particular unit provides the best formula for determining long-range staffing patterns?
A. Midnight census
B. Oncoming shift census
C. Average daily census
D. Hourly census
Rationale:
An average daily census is determined by trend data and takes into account seasonal and daily fluctuations, so it is the best method for determining staffing needs. Options A and B provide data at a certain point in time, and that data could change quickly. It is unrealistic to expect to obtain an hourly census, and such data would only provide information about a certain point in time.
4. The nurse is counseling a healthy 30-year-old female client regarding osteoporosis prevention. Which activity would be most beneficial in achieving the client's goal of osteoporosis prevention?
A. Cross-country skiing
B. Scuba diving
C. Horseback riding
D. Kayaking
Rationale:
Weight-bearing exercise is an important measure to reduce the risk of osteoporosis. Of the activities listed, cross-country skiing includes the most weight-bearing, whereas options B, C, and D involve less.
5. Which condition should the nurse anticipate as a potential problem in a female client with a neurogenic bladder?
A. Stress incontinence
B. Infection
C. Painless gross hematuria
D. Peritonitis
Rationale:
Infection is the major complication resulting from stasis of urine and subsequent catheterization. Option A is the involuntary loss of urine through an intact urethra
as a result of a sudden increase in intraabdominal pressure. Option C is the most common symptom of bladder cancer. Option D is the most common and serious complication of peritoneal dialysis.
6.A client is being discharged following radioactive seed implantation for prostate cancer. What is the most important information that the nurse should provide to this client's family?
A. Follow exposure precautions.
B. Encourage regular meals.
C. Collect all urine.
D. Avoid touching the client.
Rationale:
Clients being treated for prostate cancer with radioactive seed implants should be instructed regarding the amount of time and distance needed to prevent excessive exposure that would pose a hazard to others. Option B is a good suggestion to promote adequate nutrition but is not as important as option A. Option C is unnecessary. Contact with the client is permitted but should be brief to limit radiation exposure.
7. In assessing a client with an arteriovenous (AV) shunt who is scheduled for dialysis today, the nurse notes the absence of a thrill or bruit at the shunt site. What action should the nurse take?
A. Advise the client that the shunt is intact and ready for dialysis as scheduled.
B. Encourage the client to keep the shunt site elevated above the level of the heart.
C. Notify the health care provider of the findings immediately.
D. Flush the site at least once with a heparinized saline solution.
Rationale:
Absence of a thrill or bruit indicates that the shunt may be obstructed. The nurse should notify the health care provider so that intervention can be initiated to restore function of the shunt. Option A is incorrect. Option B will not resolve the obstruction. An AV shunt is internal and cannot be flushed without access using special needles.
8. The nurse includes frequent oral care in the plan of care for a client scheduled for an esophagogastrostomy for esophageal cancer. This intervention is included in the client's plan of care to address which nursing diagnosis?
A. Fluid volume deficit
B. Self-care deficit
C. Risk for infection
D. Impaired nutrition
Rationale:
The primary reason for performing frequent mouth care preoperatively is to reduce the risk of postoperative infection because these clients may be regurgitating retained food particles, blood, or pus from the tumor. Meticulous oral care should be provided several times a day before surgery. Although oral care will be of benefit to the client who may also be experiencing option A, B, or D, these problems are not the primary reason for the provision of frequent oral care.
9. 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.
Rationale:
The least invasive nursing action should be performed first to determine why the drainage has diminished. Option A is completed after assessing for any problems causing the decrease in drainage. Option B is no longer considered standard protocol because the increase in pressure may be harmful to the client. Option C is an appropriate nursing action after the tube has been assessed for kinks or dependent loops.
10. The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which symptom of hyperglycemia is an older adult most likely to exhibit?
A. Polyuria
B. Polydipsia
C. Weight loss
D. Infection
Rationale:
Signs and symptoms of hyperglycemia in older adults may include fatigue, infection, and evidence of neuropathy (e.g., sensory changes). The nurse needs to remember that classic signs and symptoms of hyperglycemia, such as options A, B, and C and polyphagia, may be absent in older adults.
11. Which abnormal laboratory finding indicates that a client with diabetes needs further evaluation for diabetic nephropathy?
A. Hypokalemia
B. Microalbuminuria
C. Elevated serum lipid levels
D. Ketonuria
Rationale:
Microalbuminuria is the earliest sign of diabetic nephropathy and indicates the need for follow-up evaluation. Hyperkalemia, not option A, is associated with end- stage renal disease caused by diabetic nephropathy. Option C may be elevated in end-stage renal disease. Option D may signal the onset of diabetic ketoacidosis (DKA).
12. Which change in laboratory values indicates to the nurse that a client with rheumatoid arthritis may be experiencing an adverse effect of methotrexate (Mexate) therapy?
A. Increase in rheumatoid factor
B. Decrease in hemoglobin level
C. Increase in blood glucose level
D. Decrease in erythrocyte sedimentation rate (ESR; sed rate)
Rationale:
Methotrexate is an immunosuppressant. A common side effect is bone marrow depression, which would be reflected by a decrease in the hemoglobin level.
Option A indicates disease progression but is not a side effect of the medication.
Option C is not related to methotrexate. Option D indicates that inflammation associated with the disease has diminished.
13. Which consideration is most important when the nurse is assigning a room for a client being admitted with progressive systemic sclerosis (scleroderma)?
A. Provide a room that can be kept warm.
B. Make sure that the room can be kept dark.
C. Keep the client close to the nursing unit.
D. Select a room that is visible from the nurses' desk.
Rationale:
Abnormal blood flow in response to cold (Raynaud phenomenon) is precipitated in clients with scleroderma. Option B is not a significant factor. Stress can also precipitate the severe pain of Raynaud phenomenon, so a quiet environment is preferred to option C, which is often very noisy. Option D is not necessary.
14. The nurse is reviewing routine medications taken by a client with chronic angle-closure glaucoma. Which medication prescription should the nurse question?
A. Antianginal with a therapeutic effect of vasodilation
B. Anticholinergic with a side effect of pupillary dilation
C. Antihistamine with a side effect of sedation
D. Corticosteroid with a side effect of hyperglycemia
Rationale:
Clients with angle-closure glaucoma should not take medications that dilate the pupil because this can precipitate acute and severely increased intraocular pressure. Options A, C, and D do not cause increased intracranial pressure, which is the primary concern with angle-closure glaucoma.
15. The nurse is observing an unlicensed assistive personnel (UAP) performing morning care for a bedridden client with Huntington disease. Which care measure is most important for the nurse to supervise?
A. Oral care
B. Bathing
C. Foot care
D. Catheter care
Rationale:
The client with Huntington disease experiences problems with motor skills such as swallowing and is at high risk for aspiration, so the highest priority for the nurse to observe is the UAP's ability to perform oral care safely. Options B, C, and D do not necessarily require registered nurse (RN) supervision because they do not ordinarily pose life-threatening consequences. [Show Less]