A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the best initial nursing action?
A. Administer the first dose of antibiotic therapy
B. Observe the color, consistency, and amount of sputum
C. Encourage the client to consume plenty of warm liqui...
a client with a productive cough has obtained a sp
a client is brought to the ed by ambulance in card
after a hospitalization for syndrome of inappropri
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Med Surg Final HESI 2023-2024
A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the
best initial nursing action?
A. Administer the first dose of antibiotic therapy
B. Observe the color, consistency, and amount of sputum
C. Encourage the client to consume plenty of warm liquids
D. Send the specimen to the lab for analysis - ANS-B. Observe the color, consistency, and amount of
sputum
A client is brought to the ED by ambulance in cardiac arrest with cardiopulmonary resuscitation (CPR) in
progress. The client is intubated and is receiving 100% oxygen per self-inflating (ambu) bag. The nurse
determines that the client is cyanotic, cold, and diaphoretic. Which assessment is most important for the
nurse to obtain?
A. Breath sounds over bilateral lung fields.
B. Carotid pulsation during compressions
C. Deep tendon reflexes
D. Core body temperature - ANS-A. Breath sounds over bilateral lung fields.
After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a client develops
pontine myselinolysis. Which intervention should the nurse implement first?
A. Reorient client to his room
B. Place a patch on one eye
C. Evaluate client's ability to swallow
D. Perform range of motion exercises - ANS-A. Reorient client to his room
A male client with heart failure (HF) calls the clinic and reports that he cannot put his shoes on because
they are too tight. Which additional information should the nurse obtain?
,A. What time did he take his last medications?
B. Has his weight changed in the last several days?
C. Is he still able to tighten his belt buckle?
D. How many hours did he sleep last night? - ANS-B. Has his weight changed in the last several days?
An older adult woman with a long history of chronic obstructive pulmonary disease (COPD) is admitted
with progressive shortness of breath and a persistent cough. She is anxious and is complaining of a dry
mouth. Which intervention should the nurse implement?
A. Administer a prescribed sedative
B. Encourage client to drink water
C. Apply a high-flow venturi mask
D. Assist her to an upright position - ANS-D. Assist her to an upright position
A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive
cough with thickened tenacious mucous, and the inability to walk up a flight of stairs without
experiencing breathlessness. Which action is most important for the nurse to instruct the client about
self-care?
A. Increase the daily intake of oral fluids to liquefy secretions
B. Avoid crowded enclosed areas to reduce pathogen exposure
C. Call the clinic if undesirable side effects of mediations occur
D. Teach anxiety reduction methods for feelings of suffocation - ANS-A. Increase the daily intake of oral
fluids to liquefy secretions
A cardiac catherterization of a client with heart disease indicates the following blockages: 95% proximal
left anterior descending (LAD), 99% proximal circumflex, and ? % proximal right coronary artery (RCA).
The client later asks the nurse "what does all this mean for me?" What information should the nurse
provide?
A. Blood supply to the heart is diminished by artherosclerotic lesions, which necessitate lifestyle
changes.
,B. Blood vessels supplying the pumping chamber have blockages indicating a past heart attack.
C. Three main arteries have major blockages, with only 1 to 5% of blood flow getting through to the
heart muscle.
D. The heart is not receiving enough blood, so there is a risk of heart failure and fluid retention. - ANS-C.
Three main arteries have major blockages, with only 1 to 5% of blood flow getting through to the heart
muscle.
A client who weighs 175 pounds is receiving IV bolus dose of heparin 80 units/kg. The heparin is
available in a 2 ml vial, labeled 10,000 units/ml. How many ml should the nurse administer? (Enter
numeric value only. If rounding is required, round to the nearest tenth.) - ANS-0.6 ml
What information should the nurse include in the teaching plan of a client diagnosed with
gastroesophageal reflux disease (GERD)?
A. Sleep without pillows at night to maintain neck alignment.
B. Adjust food intake to three full meals per day and no snacks.
C. Minimize symptoms by wearing loose, comfortable clothing
D. Avoid participation in any aerobic exercise programs - ANS-C. Minimize symptoms by wearing loose,
comfortable clothing
The nurse is caring for a client with a lower left lobe pulmonary abscess. Which position should the
nurse instruct the client to maintain?
A. left lateral
B. Supine, knees flexed
C. Dorsal recumbent
D. Knee-chest - ANS-A. left lateral
A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink
without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare
provider.
, A. Belching
B. Amber urine
C. Yellow sclera
D. Flatulence - ANS-C. Yellow sclera
While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological
assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?
A. Inappropriate laughter
B. Increasing anxiety
C. Weakened cough effort
D. Asymmetrical weakness - ANS-C. Weakened cough effort
The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft graft
to promote burn healing. Which information should the nurse provide this client?
A. Grafting increases the risk for bacterial infections
B. The xenograft is taken from nonhuman sources
C. Grafts are later removed by a debriding procedure
D. As the burn heals, the graft permanently attaches - ANS-B. The xenograft is taken from nonhuman
sources
A male client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While
the nurse is turning him, the wound dehiscences and eviscerates. The nurse moistens an available sterile
dressing and places it over the wound. What intervention should the nurse implement next?
A. Bring additional sterile dressing supplies to the room
B. Prepare the client to return to the operating room
C. Obtain a sample of the drainage to send to the lab
D. Auscultate the abdomen for bowel sound activity - ANS-B. Prepare the client to return to the
operating room
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