HESI PN MED SURGE PROCTORED EXAM

HESI PN MED SURGE PROCTORED EXAM

VERSION 8

91.A nurse is reinforcing teaching with an older adult client who has osteoporosis.Which of the following instructions should the nurse in the teaching?

• "Place throw rugs on wooden floors at home."
• "Supplement your diet with vitamin E."
• "Swim laps for 20 minutes twice per week."
• "Take calcium supplements with meals." (The nurse should instruct the client to take

calcium carbonate supplements with or following meals to increase absorption and effectiveness.) 92.A nurse is reviewing the medication record of a client who is taking digoxin. Which of the following medications should the nurse identify as increasing the risk for the client to develop digoxin toxicity?

a) Potassium chloride

b) Famotidine

c) Levothyroxine

d) Furosemide (The nurse should identify that loop diuretics, such as furosemide,

increase the urinary excretion of potassium, which can lead to hypokalemia.Hypokalemia increases the risk for the development of digoxin toxicity.) 93.A nurse is reinforcing teaching about insulin injections with an adult client who weighs 45.4 kg (100 lb.). Which of the following statements by the client indicates an understanding of the teaching?

• "I should insert the needle at a 90-degree angle."
• "I should give my shot in my belly tissue." (Clients who have low body weights can

have very little subcutaneous tissue. Therefore, the nurse should instruct the client to administer the medication in the upper abdomen for proper absorption.)

• "I will pull back on the syringe plunger to look for blood before I push the

medication in."

• "I will use the side of my hand to pull my skin to the side prior to administering the

insulin." 94.A nurse is reinforcing discharge teaching for a client who had a mechanical mitral valve replacement. Which of the following statements by the client indicates an understanding of the teaching?

• "I will notify my dentist about this procedure." (The nurse should instruct the client

to notify his dentist about the mechanical mitral valve replacement before any procedures so antibiotic therapy can be initiated to reduce the risk of endocardial infection.) 1 / 3

• "I will take an enteric-coated aspirin daily."
• "I will use a firm-bristled toothbrush."
• "I will weigh myself once a week."

95.A nurse is reviewing the medical record for an older adult client who is experiencing nausea and vomiting. Based on the client data, which of the following actions should the nurse take? (Click on the “Exhibit” button for additional client information.There are three tabs that contain separate categories of data.) View the Exhibit

Exhibit 1 Exhibit 2 Exhibit 3 Diagnosis Results Nurses’ Notes Graphic Record

Sodium 142 mEq/ 1200: Alert and Temperature

Potassium 4.2 mEq/L oriented x3 0800: 37.7° C (99.9° F)

BUN 36 mg/dL Lungs clear to 1200: 37.2° C (99.0° F)

Creatinine 1.4 mg/dL auscultation Pulse

Decreased skin turgor 0800: 96/min

Dry mucous 1200:105/min 2 / 3

membranes Respiratory rate

0800: 18/min

1200: 20/min

Blood pressure 0800; 118/62 mmHg

1200: 104/65 mm Hg

a) Encourage the client to ambulate.

b) Administer an antipyretic medication.

c) Notify the charge nurse of the client's BUN level (The client's BUN level is above

the expected reference range of 10 to 20 mg/dL, which indicates dehydration and impaired renal function. The nurse should notify the charge nurse of this finding and anticipate interventions to restore the client's fluid volume.)

d) Keep the temperature in the client's room warm.

96.A nurse is providing information regarding transmission-based precautions for a client who has Clostridium difficile to an assistive personnel (AP). Which of the following instructions should the nurse include? (Select all that apply).

• "Provide the client with disposable utensils and dishes for meals." (Clients who have
• difficile require contact precautions, which include using disposable utensils and

dishes during meals to prevent exposure to contaminants by others.)

• "Leave blood pressure equipment in the client's room." (When using contact

precautions, the health care staff should dedicate equipment to single-client use to prevent transmission of the pathogen.)

• "Clean contaminated surfaces with a bleach solution." (The health care staff should

use a bleach solution to clean equipment to prevent transmission of the pathogen.)

• "Use an alcohol-based hand sanitizer after client care."
• "Wear a face mask when in the client's room."

97.A nurse is admitting a client who is suspected having active tuberculosis (TB). Which of the following actions should the nurse take first? (chap. 20)

a) Administer antituberculosis medication.

b) Institute airborne precautions. (The greatest risk from this client is transmitting TB

to staff and other clients. Therefore, the first action the nurse should take is to implement airborne precautions.)

c) Obtain sputum cultures.

d) Auscultate breath sounds.

98.A nurse is caring for a client who is postoperative and has a Jackson-Pratt drain.Which of the following actions should the nurse take?

a) Fill the bulb reservoir with 0.9% sodium chloride.

b) Allow the Jackson-Pratt drain to hang freely.

c) Cut a slit in a gauze sponge and apply it around the tubing insertion site.

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