meds surge hesi Flashcards

A male client who reports feeling chronically fatigued has a hemoglobin of

11.0 grams/dL (110mmol/L). hematocrit of 34% (0.34 volume fraction), and

microcytic and hypochromic red blood cells (RBCs). Based on these

findings, which dinner selection should the nurse suggest to the client?

Reference Range:

Hemoglobin [14 to 18 g/dL (140 to 180 g/L]

Hematocrit [ 42% to 52% (0.42 to 0.52 volume fraction]

A client is hospitalized with an inflammatory bowel disease (IBD) exacerbation and is being treated with a corticosteroid. The client develops a rigid abdomen with rebound tenderness. Which action should the nurse take?

A client with diabetes mellitus is admitted with an upper respiratory infection.

Which changes in blood glucose management should the nurse tell the client to

expect?

While assisting a client to the toilet, the client begins to have a seizure and the

nurse eases the client to the floor. The nurse calls for help and monitors the client

until the seizing stops. Which intervention should the nurse implement first?

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?

A client with gouty arthritis reports tenderness and swelling of the right ankle and great toe. The nurse observes the area of inflammation extends above the ankle area. The client receives prescriptions for colchicine and indomethacin. Which instruction should the nurse include in the discharge teaching?

A client asked the nurse for information about how to reduce risk factors for

benign prostatic hyperplasia (BPH). which information should the nurse provide?

The nurse is caring for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. Which is the best initial nursing action?

After teaching a client newly diagnosed with cholecystitis about recommended

diet changes, the nurse evaluates the client’s learning. Which food choices

eliminated by the client indicate to the nurse that teaching has been successful?

A client with obstructive sleep apnea (OSA) calls the clinic to report difficulty

wearing the continuous positive air pressure (CPAP) mask because it is

uncomfortable. The client asked the nurse for an alternative way to manage sleep

apnea. Which recommendation should the nurse provide?v

A client is admitted to the hospital with symptoms consistent with a right

hemisphere stroke. Which neurovascular assessment requires immediate

intervention by the nurse?

The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?

The nurse is preparing an older client for a magnetic resonance imaging (MRI)

with contrast. Which laboratory value should the nurse report to the health care

provider before the scan is performed?

Reference Range:

Glycosylated hemoglobin (A1C) [4% to 5.9%]

Creatinine [ 0.5 to 1.1 mg/dL (44 to 97 mmol/L

Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L

Blood Urea Nitrogen (BUN [ 10 to 20 mg/dL (3.6 to 7.1 mmol/L)

A client with a closed head injury demonstrates signs of syndrome of inappropriate antidiuretic hormone (SIADH). Which additional finding should the nurse expect to obtain?

Reference range:

Sodium [ 136 to 145 mEq/L (136 to 150 mmol/L

Urine Specific Gravity (1.005 to 1.03)

Which intervention should the nurse include in the teaching plan for a client with pruritus?

On the 3rd postoperative day, a client who has had a hip replacement surgery

becomes anxious and diaphoretic, and begins to experience auditory hallucinations.

The client denies having any pain. The client's vital signs are pulse rate is 125

beats/minute, respiratory rate is 36 breaths/minute, and blood pressure is 166/88

mm Hg. Which nursing intervention(s) should the nurse implement? Select all that

apply.

An older adult client with symptoms of osteoarthritis asks the nurse which form

of exercise would be most beneficial. Which is the best response by the nurse?

The nurse is providing dietary instructions for a client who is being discharged

after passing a calcium oxalate renal stone. Which food should the nurse instruct

the client to avoid?

In assessing a client with ulcers on the lower extremity, which findings indicate

that the ulcers are likely to be a venous, rather than arterial, origin?

A client who received 6 units of packed red blood cells 3 days ago for a lower

gastrointestinal bleed is now displaying of shortness of breath with occasional

stridor and is reporting muscle cramping. Which serum laboratory value should the

nurse immediately report to the health care provider?

Reference range:

Potassium (3.5 to 5 mEq/L

Magnesium (Adult 1.3 to 2.1 mEq/L)

Calcium (9 to 10.5 mg/dL

Sodium (136 to 145 mEq/L

After initializing a steroid nebulizer treatment for a client with asthma and

respiratory distress, which intervention is most important for the nurse to

implement?

The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?

The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?

A client experiences residual effects following and acute attack Meniere’s

disease and receives a new prescription for antihistamine. Which assessment

finding indicates that the medication is effective?

The nurse prepares a teaching plan for an adult client with metabolic syndrome.

Which finding(s) should the nurse address to help the client reduce the risk for

diabetes mellitus and vascular disease? Select all that apply

A client presents with the onset of severe headache, fever, nuchal rigidity, and

petechial rash on arms and legs. The nurse recognizes the client is exhibiting

symptoms of which condition?

Following a motor vehicle accident, a client with chest trauma receives a chest

tube to relieve a hemothorax. Two hours following the chest tube insertion, the

nurse observes the water level in the water seal chamber is rising during inspiration and falling during expiration. Which action should the nurse implement?

A male client who had abdominal surgery 5 days ago, and hospitalized because

of a surgical wound infection, tells the nurse that he feels like his insides just

spilled out when he coughed. Which action should the nurse take first?

A client who had a biliopancreatic diversion procedure (BDP) 3 months ago is

admitted with severe dehydration. Which assessment finding warrants immediate

intervention by the nurse?

After performing a head-to-toe assessment for a client with Addison's disease, the nurse reports findings to the healthcare provider. The findings include moist mucous membranes, strong palpable peripheral pulses, and blood pressure 132/88 mm Hg. The client verbalizes understanding of the illness and importance of taking medications every day. Which action should the nurse implement?

The nurse is developing a plan of care for an older client with hypertension who reports chest pain on exertion. Which outcome should the nurse include in the plan of care for this client?

A client is admitted with a history of hypertension and an acute myocardial

infraction 2 years ago. The client reports,

“I am feeling weak and tired, so I cannot

exercise at all. I feel out of breath when I walk even a short distance. Since I

cannot exercise, I am gaining weight. My shoes are even getting tight” the cardiac

monitor displays sinus tachycardia. Which cue should lead the nurse to further

assess the client for other symptoms of right sided heart failure?

Client with acute renal injury (AKI) wait 110.3 lbs (50 kg) and has potassium

level of 6.7 mEq/L is admitted to the hospital. Which prescribed medication should the nurse administer first?

Reference Range:

Potassium 3.5 to 5 mEq/L

A client with type 1 diabetes mellitus, hypertension, and chronic kidney disease

is to begin hemodialysis treatment. Which statement should the nurse include in

client education?

Five months following treatment for Herpes zoster (shingles), an older client

tells the home health nurse of continuing to experience pain where the rash

occurred. Which action should the nurse implement?

During a routine assessment at an outpatient clinic, the nurse notes that a client

has abdominal obesity and a high waist hip ratio with the body mass index of 32

kg/m2. Which action(s) should the nurse take in response to these findings? Select

all that apply.

A client has an absolute neutrophil count (ANC) of 500/mm³ (0.5 x 10⁹/L) after completing chemotherapy. Which intervention is most important for the nurse to implement?
Reference Range:
Neutrophils (ANC) [2500 to 5800/mm³ (2.5 to 5.8 x 10⁹/L)]

The health care provider prescribes one liter of 0.9% sodium chloride, USP

intravenously (IV) to be infused over 10 hours for a client. How many mL/hrshould the nurse program the infusion pump to deliver ( Enter numerical value

only)

The healthcare provider prescribes regular insulin 6 units/hr intravenously (IV)

. The IV solution contains 100 units of regular insulin and not 100 mL oh 0.9%

normal saline. How many mL/hr should the nurse program the infusion pump?

(Enter numerical value only)

While completing a health assessment for young adult female with the cute

appendicitis, the client informs the nurse that there is a chance that she may be

pregnant. The operating team is preparing to take the client to surgery. Which

intervention should the nurse implement immediately?

A client with acquired immune deficiency syndrome (AIDS) and Pneumocystis

jirovecii pneumonia has a CD4+ T cell count of 200 cells/mm (20%) the client

asked the nurse why they have these reoccurring massive infections. Which

pathophysiologic mechanism should the nurse describe in response to the client’s questions?

Reference Range:

T-helper CD4 cells [600 to 1500 cells/mm (60 to 75%)

The nurse is caring for a client who had a cholecystectomy two days ago. The client is febrile, reporting upper abdominal pain radiating to the back and has had three episodes of vomiting in the last 8 hours. The nurse reviews the client's serum amylase and lipase level results which are twice the normal value. Based on these findings, the nurse should recognize the client is exhibiting symptoms of which condition?

while completing a health assessment for a young adult female with acute appendicitis. the client informs the nurse that there is a chance that she may be pregnant. the operating team is preparing to take the client to surgery. which intervention should implement immediately ?

A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?

The Nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendations should the nurse recommend the client to follow?

The nurse is caring for an older male client with impaired skin integrity to sheering forces and pressure that is manifested as a draining stage 3 sacral ulcer. Which intervention is most important for the nurse to implement?

While planning care for a client with carpal tunnel syndrome. The nurse identifies a collaborative problem of pain. What is the etiology of this problem?

A young adult female visits the clinic for primary dysmenorrhea and tells the nurse that she started taking a calcium supplement to reduce her menstrual cramps. But I quit taking calcium because it caused constipation. The client to know what she does to relive her menstrual cramps. Which action should the nurse implement first to address the client's concern?

A client with a medical diagnosis of a ruptured cerebral aneurysm exhibits these symptoms no eye opening, no sound vocalized, and flexion to pain (decorticate posturing). When calculating the Glasgow Coma Scale score, Which value should the nurse document for this client?

A client with acute myelogenic leukemia (AML) is admitted to chemotherapy (CT) using cytarabine and the antitumor daunorubion . Which measures are most important for the nurse to implement during the induction stage of chemotherapy?

To reduce pulmonary complications for a client with Amyotrophic Lateral sclerosis (ALS). Which intervention should the nurse implement? (Select all that apply)

A client with polycystic Kidney is admitted because of an abrupt onset of massive polyuria. The client is pale, tachycardia and female. Which serum laboratory finding requires immediate intervention by the nurse?

A client tells the nurse, “I just received good news about my tumor, I have a neoplasm, but it is benign.”. How should the nurse respond?

The Nurse is assessing a client diagnosed with medical diagnosis of a Bartholin cyst. Which physical assessment technique should the nurse use to observe the cyst?

A client with renal calculus is complaining of severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority?

Which Technique should the nurse use when assessing for early signs of rheumatoid arthritis?

A client with cancer develops tumor lysis syndrome (TLS) following chemotherapy. Wich nursing action has the highest priority in responding to the symptoms of this syndrome?

A client with Hepatitis A is complaining of weakness and chronic fatigue. Which intervention is most important for the nurse to implement?

A client who had a cast yesterday to the lower left arm comes to the clinic complaining of pain in the cast arm. Which assessment finding is most important for the nurse to identify?

The nurse review lab values of a female client with metastatic breast cancer and notes that the client's serum calcium level is 14 mg/dL. The client is weak, fatigued, and depressed. New prescriptions include increasing the rate of intravenous fluids. Which action should the nurse take first?

A client with hypovolemic shock is admitted to the intensive care unit with an intraosseous (IO) vascular access device placed in the right proximal tibia. The client has received two liters of normal saline and one unit of packed red blood cells through the IO access device since admission. Which assessment finding warrants immediate intervention by the nurse?

Clients' laboratory findings indicate elevations in thyroxine and triiodothyronine hormones. The nurse suspects that the client may have hyperthyroidism. Which symptom is most often associated with hyperthyroidism?

Prior to initiating peritoneal dialysis, which nursing action is most important for the nurse to implement

The nurse is preparing to insert an indwelling catheter for a male client who has diabetes and a semirigid penile implant. After placing the sterile drapes and prepping the meatus, the nurse notes that the client's penis is erect. Which action should the nurse implement?

The nurse is conducting discharge teaching for a male client with a prescription for magnesium hydroxide 15 mL one time per day. His home medication cup is ounces. How many ounces should he take each dose?

Following the administration of intravenous regular insulin to a client diagnosed with hyperkalemia, the nurse should expect which outcome to occur?

An adult male who is insulin dependent diabetic. Is admitted to the hospital because of headaches. When the client stiffens and begins to seize. Which intervention is most important for the nurse to implement?

A female client returns to the clinic after being treated for chlamydia with azithromycin IM and reports that she still has symptoms. The healthcare provider obtains a swab of the discharge from the cervix for testing chlamydia. The client reports maintaining a monogamous relationship when laboratory results are positive for sexually transmitted infection. Which information should the nurse obtain to evaluate the ineffective results of treatment?

The nurse implements a change in the approach to the client care after gathering evidence of a new approach. What should the nurse do first?

The Home Health nurse is caring for a client with Parkinson's disease who is beginning to experience swallowing difficulties. Which intervention should the nurse include for this client?

A client with chronic cirrhosis has esophageal varices. it is most important for the nurse to monitor the client for?

The intracranial pressure of a brain-injured client who is on a ventilator has increased from 15 mm Hg to 25 mm Hg within the last 30 minutes. The client is beginning to flex all extremities intermittently. Based on these findings, which immediate action should the nurse take?

A young male client has a diagnosis of epididymitis and a positive culture for Escherichia coli. Which information should the nurse include in the teaching plan?

A client has a prescription for a viscous compound containing lidocaine HCL and diphenhydramine to relieve the discomfort of mucositis caused by radiation therapy. Which instructions should the nurse provide the client about administration of this prescription?

A client admitted dehydration resulting from vomiting and diarrhea. The nurse knows that the client is at greatest risk of developing which condition?

When the nurse begins discharge instructions for a client and her spouse, the client who had an above the knee amputation for complications associated with diabetes, tells the nurse that she is not ready to go home and wants to stay home in the hospital another day, which intervention is important for the nurse to implement?

The nurse admits a client who has a medical diagnosis of bacterial meningitis to the unit. Which intervention has the highest priority when providing care for the client?