Hesi RN Medical Surg Related

The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?

• A. Select another finger.
• B. Assess radial pulse volume.
• C. Collect the blood sample.
• D. Apply pressure to the site.

Nurses' Notes
Physical Examination
Vital Signs
Day 1, 0830
Body mass index (BMI) is 31.8 kg/m2
Pain rating of 8 on 0 to 10 scale, in the right foot
Client history has been collected, and the nurse performs a physical assessment and records vital signs

Which finding(s) in the client's health record should the nurse recognize places the client at a greater risk of developing gout? Select all that apply.

• A. Drinks beer nightly
• B. Hypertension
• C. Sleep apnea
• D. Ibuprofen for pain
• E. Daily aspirin
• F. Type 2 diabetes mellitus
• G. osteoarthritis

Patient Data
History and Physical
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
The nurse reviews the client's history of the presenting illness in the electronic medical record.

Click to highlight the two pieces of key subjective data which indicate the client is in need of health interventions.

• A. The client reports using a rescue inhaler three times, but he just couldn't catch his breath.
• B. The client reports that symptoms seem worse when outdoors and when exercising.

The nurse is caring for a client who reports a sudden, severe headache, and facial numbness. The nurse asks the client to smile and observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. Which intervention should the nurse perform in the immediate management of the client?

• A. Verify prescribed laboratory tests include prothrombin time and platelet count.
• B. Administer aspirin to prevent further clot formation and platelet clumping.
• C. Maintain elevated positioning of the dependent joints on affected side.
• D. Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.

The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

• A. The client's blood pressure reading will be less than 160/90 mm Hg.
• B. The client's daily blood pressure will be less than 140/80 mm Hg this month.
• C. The client's family will repeat signs and symptoms about the disease.
• D. The nurse will encourage the client to walk thirty minutes every day.