HESI MEDSURG EXAM PACK 4 VERSIONS ALL INCLUSIVE TEST BANK ACCURATELY UPDATED 2024 | VERIFIED QUESTIONS AND ANSWERS | GUARANTEED PASS | HIGHEST LEVEL A client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly treated at a community hemodi alysis facility. Before his scheduled dialysis treatment, which electrolyte imbalance should the nurse anticipate? A) Hypophosphatemia. B) Hypocalcemia. C) Hyponatremia. D) Hypokalemia B. Hypocalcemia develops in CKD because of chronic hyperphosphatemia. Increased phosphate levels cause the peripheral deposition of calcium and resistance to vitamin D absorption needed for calcium absorption. Prior to dialysis, the nurse would expect to find the client hypernatremic and hyperkalemic, not with C or D. The ho me health nurse is assessing a male client being treated for Parkinson's disease with Sinemet. The nurse observes that he does not demonstrate any apparent emotion when speaking and rarely blinks. Which intervention should the nurse implement? A) Perform a complete cranial nerve assessment. B) Instruct the client that he may be experiencing medication toxicity. C) Document the presence of these assessment findings. D) Advise the client to seek immediate medical evaluation. C. A masklike expression and infr equent blinking are common clinical features of parkinsonism. The nurse should document these expected findings. Signs of toxicity of Sinemet include dyskinesia, hallucinations, and psychosis. A client with CHF and Afib develops ventricular ectopy with a p attern of 8 ectopic beats/min. Which action should the nurse take based on this observation? A) Assess for bilateral jugular vein distention. B) Increase oxygen flow via nasal cannula. C) Administer PRN Lasix. D) Auscultate for a pleural friction rub. B. The client should have the oxygen flow immediately increased to promote oxygenation of the myocardium. Ventricular ectopy, characterized by multiple PVCs, is often caused by myocardial ischemia exacerbated by hypokalemia. During the change of shift report, the charge nurse reviews the infusions being received by clients on the oncology unit. The client receiving which infusion should be assessed first? A) Continuous IV infusion of magnesium. B) One -time infusion of albumin. C) Continuous epidural infusion of morphine. D) Intermittent infusion of IV vancomycin. C. All four of these clients have a potential to have significant complications. The client with the morphine epidural infusion is at highest risk for respiratory depression and should be assessed first. A 25 -year-old client was admitted yesterday after a motor vehicle collision. Neurodiagnostic studies have shown a basal skull fracture in the middle fossa. Assessment on admission revealed both halo and battle signs. Which new symtom indicates that the client is likely to be experiencing a common life -threatening complication associated with a basal skull fracture? A) Bilateral jugular vein distension. B) Oral temp of 102. C) Intermittent focal motor seizures. D) Intractable pain in the cervical region . B. Clients with basilar skull fractures are at high risk for infection of the brain, as indicated by an increased oral temp because the fracture leaves the meninges open to bacterial invasion. An older client is admitted with a diagnosis of bacterial pne umonia. Which symptom should the nurse report to the HCP after assessing the client? A)Leukocytosis and febrile. B) Polycythemia and crackles. C) Pharyngitis and sputum production. D) Confusion and tachycardia. D. The onset of Pneumonia in the older clien t may be signaled by general deterioration, confusion, increased HR, and/or increased respirations. A, B, and C are often absent in the older client with bacterial pneumonia. The nurse is reviewing routine medications taken by a client with chronic angle c losure 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) Corticoste roid with a side effect of hyperglycemia. B. Clients with angle -closure glaucoma should not take medications that dilate the pupil because they can precipitate acute and severely increased IOP. A, C, and D do not cause increased IOP, which is the primary c oncern with angle -closure glaucoma. The nurse is caring for a critically ill client with cirrhosis of the liver who has a NG tube draining bright red blood. The nurse notes that the client's serum hemoglobin and hematocrit levels are decreased. Which addit ional change in laboratory data should the nurse expect? A) Increased serum albumin level. B) Decreased serum creatinine. C) Decreased serum ammonia level. D) Increased liver function test results. C. The breakdown of glutamine in the intestine and the in creased activity of colonic bacteria from the digestion of proteins increase ammonia levels in clients with advanced liver disease, so removal of blood, a protein source, from the intestine results in a reduced level of ammonia. A, B, and D will not be sig nificantly affected by the removal of blood. A resident in a long -term care facility is diagnosed with Hep B. Which intervention should the nurse implement with the staff caring for this client? A) Determine if all employees have had the Hep B vaccine ser ies. B) Explain that this type of hepatitis can be transmitted when feeding the client. C) Assure the employees that they cannot contract Hep B when providing direct care. D) Tell the employees that wearing gloves and a gown are required when providing car e. A. Hep B vaccine should be administered to all health care providers. Hep A (not Hep B) can be transmitted by fecal -oral contamination. There is a chance that staff could contract Hep B if exposed to the client's blood and/or body fluids, therefore C is incorrect. There is no need to wear gloves and gowns except with blood or body fluid contact. A client with HTN has been receiving ramipril (altace), 5mg, PO, daily for 2 weeks and is scheduled to receive a dose at 0900. At 0830, the client's blood pressu re is 120/70. Which action should the nurse take? A) Administer the prescribed dose at the scheduled time. B) Hold the dose and contact the HCP. C) Hold the dose and recheck the BP in 1 hour. D) Check with the HCP's prescription to clarify dose. A. The cl ient's BP is within normal limits, indicating that the ramipril, an antihypertensive, is having the desired effect and should be administered. B and C would be appropriate if the client's BP was excessively low (<100 systolic) or if the client were exhibit ing signs of hypotension such as dizziness. The nurse assesses a client who has been prescribed furosemide (Lasix) for cardiac disease. Which ECG change would be a concern for a client taking a diuretic? A) Tall, spiked T waves. B) A prolonged QT interval . C) A widening QRS complex. D) Presence of a U wave. D. A U wave is a positive deflection following the T wave and is often present with hypokalemia. A, B and C are all signs of hyperkalemia. The nurse is observing a UAP performing morning care for a bedr idden client with Huntington's disease. Which care measure is most important for the nurse to supervise? A) Oral care. B) Bathing. C) Foot care. D) Catheter care. A. The client with Huntington's disease experiences problems with motor skills such as swall owing and is at high risk for aspiration. B, C, and D do not necessarily require RN supervision because they do not ordinarily post life -threatening consequences. A family member was taught to suction a client's tracheostomy prior to the client's discharge from the hospital. Which observation by the nurse indicates that the family member is capable of correctly performing the suctioning technique? A) Turns on the continuous wall suction to -190 mm Hg. B) Inserts the catheter until resistance or coughing oc curs. C) Withdraws the catheter while maintaining suctioning. D) Reclears the tracheostomy after suctioning the mouth. B. Indicates correct technique for performing suctioning. Suction pressure should be between -80 and -120 mm Hg, not -190 mm Hg. The cath eter should be withdrawn 1 -2 cm at a time with
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