HESI NUR209-HESI NUR209 (NEW 2024-2025 UPDATE) MEDICAL SERGICAL NURSING QUESTION AND VERI, Exams of Nursing

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HESI NUR209- NUR 209 (NEW 2024/

2025 UPDATE) MEDICAL

SURGICAL NURSING II

QUESTIONS AND VERIFIED

ANSWERS 100% CORRECT

A GRADE – FORTIS

QUESTION

The nurse reviews lab values of a female 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 IV fluids. Which action should the nurse take first? a. Increase the IV fluids as prescribed. b. Offer to provide privacy so the client can rest. c. Encourage verbalization of the client's feelings. d. Provide a nutritional supplement for a snack. Answer: a. Increase the IV fluids as prescribed.

QUESTION

A client with hypovolemic shock is admitted to the ICU with an intraosseous vascular device placed in the right proximal tibia. The client has received 2 L of normal saline and one unit of PRBC through the IO access device since admission. Which assessment finding warrants immediate intervention by the nurse? a. Client reports tenderness at IO insertion site. b. Client verbalizes feeling tightness in the right calf muscle. c. IO vascular access in place greater than 24 hours. d. Sluggish IO blood return when aspirated. Answer: c. IO vascular access in place greater than 24 hours.

A client has a neutrophil count of 500/mm3 after completing chemotherapy. Which intervention is most important for the nurse to implement? a. Implement bleeding precautions. b. Review needs for pneumococcal vaccine. c. Assess vital signs every 4 hours. d Provide the client with protective isolation. Answer: d Provide the client with protective isolation.

QUESTION

A client's lab 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? a. Atrophied thyroid gland. b. Increased pulse rate. c. Periorbital edema. d. Diarrhea stools. Answer: b. Increased pulse rate.

QUESTION

Prior to initiating peritoneal dialysis, which nursing action is most important for the nurse to implement? a. Determine the client's O2 saturation. b. Obtain and record the client's vital signs. c. Auscultate the client's vital signs. d. Observe the amount and color of the client's urine. Answer: b. Obtain and record the client's vital signs.

QUESTION

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? a. Ask the client to deflate the implant. b. Talk to the client about his implant. c. Continue to insert the catheter. d. Wait until the erection subsides. Answer: c. Continue to insert the catheter.

QUESTION

Which finding should the nurse document as a primary manifestation of osteoporosis in an older woman? a. Loss of height over time. b. Decreased serum calcium level. c. Pain in the spine and neck. d. Abnormal cardiac status in the ECG. Answer: a. Loss of height over time.Th

QUESTION

The nurse is conducting discharge teaching for a male client with a prescription for magnesium hydroxide 15 mL QD. His home medication cup is in ounces. How many ounces should he take each dose? a. 0.5 ounces. b. 0.05 ounces. c. 0.25 ounces. d. 1 ounce. Answer: a. 0.5 ounces.

QUESTION

An adult male who is an 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. Pad all side rails with available pillows and blankets. b. Determine the client's blood glucose level. c. Give the client a rapid form of glucose supplement. d. Obtain a suction set-up in the room. Answer: c. Give the client a rapid form of glucose supplement.

QUESTION

A young adult is burned when wearing a shirt that was splashed with lighter fluid and caught on fire while attempting to light a charcoal grill. The client ripped off the shirt immediately without unbuttoning the sleeves which caused circumferential burns to both arms. When the client is admitted, which intervention should the nurse implement first? a. Place sterile bandages on both wrists. b. Assess ROM. c. Monitor pulse intensity. d. Evaluate extremity sensation. Answer: d. Evaluate extremity sensation.

QUESTION

A female client returns to the clinic after being treated for chlamydia with azithromycin IM and reports that she still has symptoms. The HCP obtains a swab of the discharge from the cervix for testing chlamydia. The client reports maintaining a monogamous relationship when lab results are positive for STI. Which information should the nurse obtain to evaluate the ineffective results of treatment? a. Determine if the clients sexual partner received treatment for chlamydia. b. Ask the client if the course of ABX was completed. c. Confer with the HCP about a different course of ABX. d. Inquire further about all sexual encounters and any other sexual activity.

Answer: a. Determine if the clients sexual partner received treatment for chlamydia.

QUESTION

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? a. Engage staff in evidence-based practice. b. Consult with clinical nursing expert. c. Revise clinical practice guidelines. d. Evaluate effectiveness of the change. Answer: a. Engage staff in evidence-based practice.

QUESTION

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. Teach the client to take his medication an hour before meals to enhance the swallowing reflex. b. Tell the client to lay on his left side to prevent his tongue from falling back in his mouth. c. Prepare the client and the family for the future need of a gastrostomy tube for feeding. d. Encourage the client and family to provide a semi-solid diet with thick liquids. Answer: d. Encourage the client and family to provide a semi-solid diet with thick liquids.

QUESTION

A client with chronic cirrhosis has esophageal varices. It is most important for the nurse to monitor the client for the onset of which problem? a. Hematemesis. b. Brown foamy urine. c. Anorexia. d. Clay colored stool.

d. Serial blood pressure and pulse. Answer: b. Last administration of analgesia.

QUESTION

An older client who is agitated, dyspneic, orthopneic, and using accessory muscle to breathe is admitted for further treatment. Initial assessment indicates 126 beats/minute and irregular, respirations 36 breaths/minute, blood pressure 168/100 mmHg, wheezes and crackles in all lung fields. An hour after the administered furosemide 60 mg IV, which assessment should the nurse obtain to determine the client's response to treatment? (Select all that apply). a. Skin. b. Pain scale. c. Lung sounds. d. Urinary output e. Oxygen saturation. Answer: c. Lung sounds. e. Oxygen saturation.

QUESTION

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? a. Teach the family how to perform wound care. b. Encourage a diet high in protein. c. Ensure that IV fluids are administered as prescribed. d. Daily range of motion exercise. Answer: b. Encourage a diet high in protein.

QUESTION

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. Compression of a nerve. b. Diminished blood flow. c. Ischemic tissue changes. d. Irritation of nerve endings. Answer: a. Compression of a nerve.

QUESTION

A young female adult visits the clinic for primary dysmenorrhea and tells the nurse that she started taking a calcium supplement to reduce her menstrual cramps, but she quit taking the calcium because it caused constipation. The client wants to know what she can do to relieve her menstrual cramps. Which action should the nurse implement first to address the client's concern? a. Encourage client to increase her dietary intake fiber. b. Question the client about her use of birth control pills. c. Ask her how much calcium she had been taking daily. d. Determine if she takes any OTC analgesics. Answer: c. Ask her how much calcium she had been taking daily.

QUESTION

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. 13. b. 9. c. 3. d. 5. Answer: d. 5.

Answer: a. Sodium 184 mEq/L.

QUESTION

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? a. Inform the HCP that the client does not understand the test results. b. Ask the client if the diagnostic test indicates any secondary metastasis. c. Reinforce the clients joy and clarify the typical use of the term "neoplasm". d. Explain to the client the seriousness of having neoplastic disease. Answer: b. Ask the client if the diagnostic test indicates any secondary metastasis.

QUESTION

The nurse is assessing a client diagnosed with a Bartholin Cyst. Which physical assessment technique should the nurse use to observe the cyst? a. Listen for bowel sounds in all four quarters of the abdomen. b. Place the client in lithotomy position to perform a pelvic exam. c. Ask the client to lie flat and cough while the nurse visualizes the inguinal area. d. Expose the lesson to a woods lamp and observe for fluorescence. Answer: b. Place the client in lithotomy position to perform a pelvic exam.

QUESTION

The nurse is preparing to administer enoxaparin 90 mg SQ daily to a client with a pulmonary embolism. The pharmacy provides a prefilled syringe labeled, "enoxaparin 100 mg/1mL". How many mL should the nurse administer? Answer: 0.9 mL

QUESTION

While performing a neurovascular assessment distal to a client's fracture site, the nurse determines the client's pulse is present, regular, and full. Which nursing action should be taken next? a. Notify the healthcare provider of assessment findings. b. Document the neurovascular assessment as normal. c. Discontinue elevating the client's affected extremity. d. Assess for color, feeling, discomfort, and movement. Answer: b. Document the neurovascular assessment as normal.

QUESTION

Magnesium Hydroxide 1.5 ounces PO is prescribed for a client complaining of heartburn. After taking the prescribed dose 3 times today, how many mL has the client ingested? Answer: 135 mL.

QUESTION

A client with renal calculus is complaining of severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority? a. Acute pain related to renal calculus. b. Impaired renal function related to pain. c. Nutritional deficit related to nausea. d. Risk for aspiration related to vomiting. Answer: a. Acute pain related to renal calculus.

QUESTION

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 to the nurse to identify? a. Pain level of 8 on a scale of 1-10. b. Presence of a pressure ulcer under the cast. c. Location of burning pain below the cast. d. Circulatory impairment distal to the cast. Answer: d. Circulatory impairment distal to the cast.

QUESTION

The ESR (sedimentation rate) of a client being treated with corticosteroids for Rheumatoid Arthritis has decreased. Which explanation should the nurse provide the client to explain this change in lab vales? a. The treatment so far has not been effective. b. A value of 0 will indicate that the client is cured. c. The client is most likely responding to treatment. d. The client disease is currently in a remission. Answer: c. The client is most likely responding to treatment.

QUESTION

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. Saturate a sterile dressing with the solution and pack the wound lightly. b. Dab the solution over the reddened areas and cover the site with occlusive dressing. c. Gently pat the solution on the sore areas, using cotton tipped applicators. d. Swish the solution around in the mouth, and swallow the remaining solution. Answer: c. Gently pat the solution on the sore areas, using cotton tipped applicators.

QUESTION

A client is admitted with dehydration resulting from vomiting and diarrhea. The nurse knows that the client is at greatest risk of developing which condition? a. Bowel perforation. b. Papilledema. c. Tinnitus. d. Cardiac dysrhythmia. Answer: d. Cardiac dysrhythmia.

QUESTION

The client who had an above the knee amputation for complications associated with diabetes is receiving discharge instructions with her husband, she tells the nurse that she is not ready to go home and wants to stay in the hospital another day. Which intervention is important for the nurse to implement? a. Explain the take home medications that can help the client manage her anxiety. b. Tell the spouse to wait outside the room so the nurse can interview the client alone. c. Ask the client what frightens her about leaving the hospital and returning home. d. Review the details of the home health care plan devised by the multidisciplinary team. Answer: b. Tell the spouse to wait outside the room so the nurse can interview the client alone.

QUESTION

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? a. Obtain results of C&S of CSF. b. Administer initial dose of broad-spectrum ABX. c. Instruct the client to force fluids hourly. d. Assess the client for symptoms of hyponatremia. Answer: a. Obtain results of C&S of CSF.

Answer: a. Pupillary changes to ipsilateral dilation.

QUESTION

Achieve maximum mobility and independence for a client with multiple sclerosis (MS). Which intervention is most important for the nurse to implement? a. Provide a walker for ambulation. b. Frequently assist the client to the bathroom. c. Apply alternating patches over the eyes. d. Teach strengthening exercises. Answer: d. Teach strengthening exercises.

QUESTION

The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendations should the nurse recommend the client to follow? a. Limit oral fluid intake to 500 mL/day. b. Restrict protein intake by including meats and other high protein foods. c. Increase intake of potassium-rich foods such as bananas or cantaloupe. d. Increase intake of high fiber foods, such as bran cereal. Answer: b. Restrict protein intake by including meats and other high protein foods.

QUESTION

The nurse Is caring for a client with herpes zoster who reports painful blisters that align from the back along the chest curvature to the anterior chest. Which intervention is the highest priority for the nurse? a. Place the client on contact precautions. b. Administer antiviral medication. c. Place wet compresses to ruptured vesicles.

d. Administer narcotic analgesics. Answer: b. Administer antiviral medication.

QUESTION

A young adult who suffered a severe brain injury in an automobile collision has been mechanically ventilated for the past three days and has no spontaneous respiratory effort. After serial EEG's reveal no brain activity, the HCP discontinue life support. Which intervention should the nurse implement? a. Ask the family if they wish would remain at bedside during withdrawal. b. Request a living will be placed in the client's medical record. c. Discuss the withdrawal procedure with the family and offer support. d. Turn off the mechanical ventilator and note the time of death. Answer: c. Discuss the withdrawal procedure with the family and offer support.

QUESTION

Following a transurethral resection of the prostate (TURP), a client is discharged from the hospital with an indwelling urinary catheter. Which instruction is most important for the nurse to include in the discharge teaching plan? a. Eliminate all the spicy food from your diet. b. Drink 3L of water each day. c. Clamp the catheter when taking a shower. d. Avoid driving a car for 2 weeks. Answer: b. Drink 3L of water each day.

QUESTION

On the first postoperative day, the nurse finds an older male client disoriented and trying to climb over the bed railing. Previously he was oriented to person, place, and time on admission. Which intervention should the nurse implement first?