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HESI MED SURG NEWEST 2024/2025 TEST BANK
(2 VERSIONS A & B) WITH 500+ QUESTIONS AND
CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) |ALREADY GRADED A+
The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding?
- nuchal rigidity
- palpable cervical lymph nodes.
- jugular vein distention
- carotid bruit - Correct Answer - D) carotid bruit
A client experiences an ABO incompatibility reaction after multiple blood transfusions.Which finding should the nurse report immediately to the health care provider?
- low back pain and hypotension
- rhinitis and nasal stuffiness
- delayed painful rash and urticarial
- arthritic joint changes and chronic pain - Correct Answer - A) low back pain and
hypotension
An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red and the client reports a burning sensation. What action should the nurse take?
- apply a cool compress to the affected fingers for 20 min
- secure a pulse oximeter to monitor the client's oxygen saturation
- Report the finding to the healthcare provider as soon as possible 1 / 4
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- Continue to monitor the fingers until color returns to normal - Correct Answer - D)
Continue to monitor the fingers until color returns to normal
What instruction should the nurse include in the discharge teaching plan a a client who had a cataract extraction today?
- sexual activities may be resumed upon return home
- light housekeeping is permitted but avoid heavy lifting
- use a metal eye shield on operative eye during the day
- administer eye ointment before applying eye drops - Correct Answer - b) light
housekeeping is permitted but avoid heavy lifting
A hospitalized client with chemotherapy-induced stomatitis complains of mouth pain.What is the best initial nursing action?
- cleanse the tongue and mouth with glycerin swabs
- admin a topical analgesic per PRN protocol
- obtain a soft diet for the patient
- encourage frequent mouth care - Correct Answer - B) administer a topical analgesic
per PRN protocol
The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse notes a temperature of 101.4° F, a productive cough with yellow sputum and a respiratory rate of 20. Which of the following nursing diagnosis is most appropriate based upon this assessment?
- Hyperthermia related to infectious illness
- Ineffective thermoregulation related to chilling
- Ineffective breathing pattern related to pneumonia
- Ineffective airway clearance related to thick secretions - Correct Answer - A.
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Hyperthermia related to infectious illness Because the patient has spiked a temperature and has a diagnosis of pneumonia, the logical nursing diagnosis is hyperthermia related to infectious illness. There is no evidence of a chill, and her breathing pattern is within normal limits at 20 breaths per minute. There is no evidence of ineffective airway clearance from the information given because the patient is expectorating sputum.
pg. 3 Which of the following physical assessment findings in a patient with pneumonia best supports the nursing diagnosis of ineffective airway clearance? A. Oxygen saturation of 85%
- Respiratory rate of 28
- Presence of greenish sputum
- Basilar crackles - Correct Answer - D. Basilar crackles The presence of adventitious
breath sounds indicates that there is accumulation of secretions in the lower airways.This would be consistent with a nursing diagnosis of ineffective airway clearance because the patient is retaining secretions.
Which of the following clinical manifestations would the nurse expect to find during assessment of a patient admitted with pneumococcal pneumonia?
- Hyperresonance on percussion
- Fine crackles in all lobes on auscultation
- Increased vocal fremitus on palpation
- Vesicular breath sounds in all lobes - Correct Answer - C. Increased vocal fremitus
on palpation. A typical physical examination finding for a patient with pneumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include dullness to percussion, bronchial breath sounds, and crackles in the affected area.
Which of the following nursing interventions is of the highest priority in helping a patient expectorate thick secretions related to pneumonia?
- Humidify the oxygen as able
- Increase fluid intake to 3L/day if tolerated.
- Administer cough suppressant q4hr.
- Teach patient to splint the affected area. - Correct Answer - B. Increase fluid intake to
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3L/day if tolerated. Although several interventions may help the patient expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate them more easily. Humidifying the oxygen is also helpful, but is not the primary intervention. Teaching the patient to splint the affected area may also be helpful, but does not liquefy the secretions so that they can be removed.
pg. 4 After admitting a patient to the medical unit with a diagnosis of pneumonia, the nurse will verify that which of the following physician orders have been completed before administering a dose of cefotetan (Cefotan) to the patient?
- Serum laboratory studies ordered for AM
- Pulmonary function evaluation
- Orthostatic blood pressures
- Sputum culture and sensitivity - Correct Answer - D. Sputum culture and
sensitivityThe nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before administering the cefotetan. It is important that the organisms are correctly identified (by the culture) before their numbers are affected by the antibiotic; the test will also determine whether the proper antibiotic has been ordered (sensitivity testing). Although antibiotic administration should not be unduly delayed while waiting for the patient to expectorate sputum, all of the other options will not be affected by the administration of antibiotics.
During discharge teaching for a 65-year-old patient with emphysema and pneumonia, which of the following vaccines should the nurse recommend the patient receive?
- S. aureus
- H. influenzae
- Pneumococcal
- Bacille Calmette-Guérin (BCG) - Correct Answer - C. Pneumococcal The
pneumococcal vaccine is important for patients with a history of heart or lung disease, recovering from a severe illness, age 65 or over, or living in a long-term care facility.
The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been most effective when the patient states which of the following measures to prevent a relapse?
- "I will increase my food intake to 2400 calories a day to keep my immune system
- "I must use home oxygen therapy for 3 months and then will have a chest x-ray to
- "I will seek immediate medical treatment for any upper respiratory infections."
- "I should continue to do deep-breathing and coughing exercises for at least 6
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well."
reevaluate."
weeks." - Correct Answer - D. "I should continue to do deep-breathing and coughing