HESI RN Medical Surgical

HESI RN Medical Surgical Related

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Initial Assessment
Orders
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 has identified the priority problem for the client and now must determine proper care interventions. Based on the client history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.

  • A. Provide client teaching
  • B. Apply oxygen via nasal cannula.
  • C. Ask the client for a list of current medications.
  • D. Place the client in Trendelenburg position.
  • E. Notify the healthcare provider of the client's need for intubation.
  • F. Administer medications as ordered.
Correct Answer: A,B,C,F

Rationale: Client education, oxygen therapy, obtaining medication history, and administering ordered medications address the client's asthma exacerbation and promote effective management.

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A client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?

  • A. Palpitations and shortness of breath.
  • B. Bradycardia and constipation.
  • C. Muscle cramping and dry, flushed skin.
  • D. Lethargy and lack of appetite.
Correct Answer: A

Rationale: Palpitations and shortness of breath are symptoms of thyrotoxicosis, indicating excessive thyroid hormone levels, which could result from an overdose of levothyroxine.

The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portal site should the nurse provide?

  • A. Protect the skin of the radiation portal site from sunlight exposure.
  • B. Avoid washing the skin inside the radiation portal site.
  • C. Remove the ink marks of the portal after each radiation treatment.
  • D. Apply moisture lotions daily to the radiation portal site.
Correct Answer: A

Rationale: Protecting the radiation portal site from sunlight exposure prevents further damage to the sensitive irradiated skin.

The nurse is preparing a client for surgery who was admitted from the emergency department following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin sodium 5,000 units SUBQ daily. Which nursing action is a priority?

  • A. Have the client sign the surgical and transfusion permits.
  • B. Notify the healthcare provider of the client's medication history.
  • C. Ensure that the potential for bleeding is explained to the client.
  • D. Observe the heparin injections sites for signs of bruising.
Correct Answer: B

Rationale: Notifying the healthcare provider of the client's heparin use is crucial to ensure appropriate perioperative management and prevent excessive bleeding during surgery.

The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes vital signs of a heart rate of 140 beats/minute, a respiratory rate of 26 breaths/minute, and a blood pressure of 140/90 mm Hg. Which intervention is most important for the nurse to implement?

  • A. Administer IV fluid bolus as prescribed by the healthcare provider.
  • B. Medicate for pain and monitor vital signs according to protocol.
  • C. Encourage the client to splint the incision with a pillow to cough and deep breathe.
  • D. Apply oxygen at 10 L/minute via non-rebreather mask and monitor pulse oximeter.
Correct Answer: B

Rationale: Medicating for pain and monitoring vital signs is the most important intervention, as the elevated vital signs are likely due to inadequate pain control following a thoracotomy, which can lead to increased sympathetic activity.

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. Increasing anxiety.
  • B. Inappropriate laughter.
  • C. Asymmetrical weakness.
  • D. Weakened cough effort.
Correct Answer: D

Rationale: Weakened cough effort is a critical finding in a client with ALS, as it can lead to ineffective airway clearance and increase the risk of aspiration pneumonia. Immediate intervention, such as suctioning or respiratory support, may be necessary to maintain airway patency and prevent complications.

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