HESI Medical Surgical Nursing Flashcards

Questions and Answers

I should stop taking medication once I feel completely well.

False

What should a client do if they have a fever higher than 100° F (37.8° C)?

Prepare for obtaining a wound culture.

Place the client in bed and instruct to elevate the foot.

Assess affected leg for pulses, skin color, and temperature.

Take twice as much medicine. (correct)

Which is the first intervention that the nurse implements for a client with a pressure ulcer on the ankle?

Place the client in bed and instruct to elevate the foot.

Draw blood for albumin, prealbumin, and total protein.

Assess the affected leg for pulses, skin color, and temperature. (correct)

Prepare for and assist with obtaining a wound culture.

What should the nurse do first when noting decreased tactile sensation in both feet of a client with a 15-year history of diabetes?

Examine the client's feet for signs of injury. Signup and view all the answers

Which nursing intervention best assists a bedridden client to keep skin intact?

Use a lift sheet to move the client in bed. Signup and view all the answers

What is the priority nursing intervention for a patient suspected to be hypothermic?

Remove wet clothes Signup and view all the answers

Which of the following orders should be questioned for an older adult with decompensated congestive heart failure?

Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr Signup and view all the answers

What finding indicates hyperthermia during a nursing assessment?

Red, sweaty skin Signup and view all the answers

Why does the nurse assess the client's pain level after taking routine vital signs?

To ensure that pain assessment occurs on a regular basis Signup and view all the answers

Which action should the nurse take when observing skin tenting on an older adult client's hand?

Assess turgor on the client's forehead Signup and view all the answers

For which assessment finding should the nurse act immediately after a TURP procedure?

Having bright red drainage with multiple blood clots Signup and view all the answers

What puts a client at the greatest risk for wound infection?

Immune compromised status Signup and view all the answers

Which clinical manifestations does the nurse expect in a client with early onset of multiple sclerosis (MS)?

Nystagmus & Diplopia Signup and view all the answers

A client scores 9 on the Braden Scale. What is the best intervention?

Consult with the health care provider Signup and view all the answers

Which nursing intervention is most appropriate for a patient experiencing fatigue due to chemotherapy?

Prioritization and administration of nursing care throughout the day Signup and view all the answers

Which intervention should the nurse teach a diabetic client with reduced sensation to prevent injury?

Use a bath thermometer to test the water temperature Signup and view all the answers

Which client is at greatest risk for pressure ulcer development?

Incontinent client with limited mobility Signup and view all the answers

What is the appropriate instruction for a nursing assistant to help prevent pressure ulcers in a frail older patient?

Turn the patient at least every 2 hours Signup and view all the answers

What important information should the nurse include in the teaching about Glucovance?

Glucovance contains a combination of glyburide and metformin Signup and view all the answers

What is the best time to assess a client for problems related to NPH insulin administered at 7 AM?

4 PM Signup and view all the answers

Which intervention should the nurse implement for a client who is immobile due to a recent stroke?

Apply sequential compression stockings Signup and view all the answers

What position should the client be in to prevent complications due to cranial nerve IX impairment after a stroke?

High Fowler's position Signup and view all the answers

Which statement indicates the client needs more teaching about mucositis?

I should use an alcohol-based mouth rinse to kill bacteria Signup and view all the answers

What is the highest priority instruction for a young woman being treated with amoxicillin for a urinary tract infection?

Use a second form of birth control while on the drug Signup and view all the answers

What should the nurse teach to ensure safe medication therapy for a patient after a myocardial infarction?

Diuretics Signup and view all the answers

What priority question should the nurse ask during interdisciplinary rounds for a client with an indwelling catheter?

Can we discontinue the indwelling catheter? Signup and view all the answers

The nurse is assessing a client who had a stroke in the right cerebral hemisphere. Which neurologic deficit does the nurse assess for in this client?

Impaired proprioception Signup and view all the answers

To delay the onset of microvascular and macrovascular complications in a client with newly diagnosed diabetes, which action should the nurse stress?

Control hyperglycemia. Signup and view all the answers

Which interventions are necessary to provide safe, quality care to a patient receiving enteral tube feedings? (Select all that apply)

Use clean technique when changing the feeding system Signup and view all the answers

A client with a pressure ulcer has the following laboratory values. Which action by the nurse is most appropriate?

Request a dietary consult. Signup and view all the answers

When explaining perfusion, which statement by the student nurse indicates understanding?

Perfusion is monitored by vital signs and capillary refill. Signup and view all the answers

Which client outcome is indicative of effective hypertension management?

No indication of renal impairment is present. Signup and view all the answers

What statement indicates that the client understands teaching about neutropenia?

I will call my doctor if I have an increase in temperature. Signup and view all the answers

Which action by the nurse takes priority for a client with a nasoenteric feeding tube showing abnormal vital signs?

Auscultate lung sounds and obtain oxygen saturation. Signup and view all the answers

What should the nurse's first action be when a client receiving chemotherapeutic agents intravenously reports burning at the site?

Discontinue the infusion. Signup and view all the answers

Which statement indicates best practice for patient safety & quality care regarding tube feeding?

If the tube becomes clogged, use 30 mL of water for flushing, while applying gentle pressure with a 50 mL piston syringe. Signup and view all the answers

What is the best action for a nurse when a client has a wound with bone exposure?

Document as a stage IV pressure ulcer and prepare the client for débridement. Signup and view all the answers

After initial placement of NG tubes is confirmed, how often must placement be checked? (Select all that apply)

According to facility policy Signup and view all the answers

What should the priority action of the nurse be if they are unable to withdraw fluid from a Salem sump nasogastric tube before starting the feeding?

Obtain orders for a chest x-ray to confirm placement before starting the feeding. Signup and view all the answers

Which assessment is most helpful for a client with a urinary tract infection?

Assessing medical history and current medical problems Signup and view all the answers

What statement by the nurse relates to maintaining blood glucose levels no lower than about 74 mg/dl?

The central nervous system cannot store glucose and needs a continuous supply for fuel. Signup and view all the answers

Which assessment finding could explain the weight gain and hunger of an overweight client?

The client started taking dexamethasone (Decadron) daily. Signup and view all the answers

What interventions are appropriate for preventing pressure sores for a client who is immobilized? (Select all that apply)

Place a small pillow between bony surfaces. Signup and view all the answers

What medication should the nurse prepare to administer for a client who experienced symptoms of thrombotic stroke 2 hours ago?

Tissue plasminogen activator Signup and view all the answers

What is the priority nursing intervention when administering captopril (Capoten) to a client with hypertension?

Educate the client to sit on the side of the bed for a few minutes before rising. Signup and view all the answers

Which adverse effect should the nurse monitor for in a client receiving clopidogrel (Plavix)?

Spontaneous ecchymosis Signup and view all the answers

What is the best response by the nurse when a client receiving chemotherapy asks why protective clothing is worn?

The clothing protects me from accidentally absorbing these drugs. Signup and view all the answers

What is the earliest and most sensitive assessment finding that would indicate an alteration in intracranial regulation?

Change in level of consciousness. Signup and view all the answers

Which client statement indicates a good understanding regarding antibiotic therapy for recurrent urinary tract infections?

I should take my antibiotics until they are all gone. Signup and view all the answers

What interrelated constructs facilitate a nurse to become culturally competent? (Select all that apply)

Cultural desire, self-awareness, cultural knowledge, and cultural skill Signup and view all the answers

The emphasis on understanding cultural influence on health care is important because of:

Increasing global diversity Signup and view all the answers

What is the most important nursing intervention for a patient with severe hypokalemia and a regular heart rhythm?

Institute fall precautions due to potential postural hypotension and weak leg muscles Signup and view all the answers

Which client is at greatest risk for developing hyponatremia?

Client who is NPO receiving intravenous D5W Signup and view all the answers

What action must the nurse be prepared to take after accidentally administering 10 mg of morphine intravenously to a client?

Administer naloxone (Narcan) Signup and view all the answers

Which action does the nurse teach a client to reduce the risk for dehydration?

Maintaining a daily oral intake approximately equal to daily fluid loss Signup and view all the answers

Which potassium level correlates with confusion in a patient taking furosemide (Lasix)?

2.9 mEq/L Signup and view all the answers

What is the most reliable means available for assessing core body temperature?

Rectal thermometer Signup and view all the answers

Which intervention will the nurse prepare for a client presenting after prolonged exposure to the cold?

Dry clothing and warm blankets Signup and view all the answers

Which action reflects The Joint Commission's main objective?

Assessing the client's respirations when administering opioids Signup and view all the answers

What is a priority nursing intervention to prevent falls for an older adult client with multiple chronic diseases?

Providing assistance to the client in getting out of the bed or chair Signup and view all the answers

Which client assessment is the most indicative of having pain?

Heart rate of 105 beats/min and restlessness Signup and view all the answers

Which actions are within the scope of nursing practice to improve quality of care?

Use sterile technique when changing dressings on a new surgical site Signup and view all the answers

Which is most indicative of pain in an older client who is confused? (Select all that apply)

Screaming Signup and view all the answers

The nursery nurse identifies a newborn at significant risk for hypothermic alteration in thermoregulation because the patient is:

Low birth weight Signup and view all the answers

Which activities most closely match the definition of functional ability?

Healthy individual, volunteers at church, works part time, takes care of family and house Signup and view all the answers

Which action demonstrates that the nurse understands the purpose of the Rapid Response Team?

Notifying the physician of the client's change in blood pressure from 140 to 88 mm Hg systolic Signup and view all the answers

Which medications are unsafe choices for treatment of severe pain in an older adult? (Select all that apply)

Propoxyphene (Darvocet) Signup and view all the answers

Which part of the SBAR hand-off does the nurse's statement about contacting a sitter represent?

Recommendation Signup and view all the answers

Understanding classifications of pain helps nurses develop a plan of care. What type of pain is characterized by aching and throbbing after tissue injury?

Nociceptive pain Signup and view all the answers

Which action should the nurse perform FIRST for a client with a high temperature?

Apply cool packs to the client's axillae and groin Signup and view all the answers

What is the nurse's first action when checking a client for pain relief after administering morphine and finding the client sleeping with a respiratory rate of 10 breaths/min?

Assess the client's respiratory status and provide necessary interventions. Signup and view all the answers

When describing patient education approaches, the nurse educator would explain that informal teaching is an approach that?

Often occurs one-to-one Signup and view all the answers

Which theory type would the nurse use to develop a plan of care for the best results of a patient's motivation style after a stroke?

Cognitive Signup and view all the answers

Which clients are at greater risk for hypothermia or frostbite? (Select all that apply)

An older man who smokes a pack of cigarettes a day Signup and view all the answers

Which statement made by a nurse represents the need for further education regarding pain management in older adult clients?

Older clients have a different pain mechanism and do not feel it as much Signup and view all the answers

What is the priority action of the nurse when a spectator comes in with a temperature of 104.1 F and shows signs of heat stroke?

Sponge the victim with cool water and remove his shirt Signup and view all the answers

What intervention does the nurse perform first when a client receiving potassium chloride intravenously reports burning around the IV site?

Stop the IV infusion Signup and view all the answers

Which economic situation presents the most serious problem for an older adult client who lives alone?

Social security as the basis of income Signup and view all the answers

Unrelieved pain has been associated with?

Prolonged stress response and a cascade of harmful effects system wide Signup and view all the answers

Which intervention in a client with dehydration induced confusion is most likely to relieve the confusion?

Increasing the IV flow rate to 250 mL/hr Signup and view all the answers

Which client is at greatest risk for dehydration?

Older adult client with cognitive impairment Signup and view all the answers

Which client does the nurse assess most carefully for hyperkalemia?

Client with heart failure using a salt substitute Signup and view all the answers

Which age-related change may have contributed to digoxin toxicity for an older adult client?

Decreased renal blood flow Signup and view all the answers

Which statement made by the client indicates understanding of dehydration after being treated?

I will weigh myself each morning before I eat or drink. Signup and view all the answers

Which intervention is the priority when a nurse notes diminished handgrip strength in a client with hypokalemia?

Assess the client's respiratory rate, rhythm, and depth Signup and view all the answers

How many tablets of Lasix (furosemide) 40 mg should be given to achieve a prescribed dosage of 60 mg?

1 1/2 Signup and view all the answers

Which food selection by a client indicates understanding of dietary sodium restrictions?

A chicken leg, one slice of bread with butter, and steamed carrots Signup and view all the answers

Which behavior best indicates that a client is experiencing changes associated with acute pain?

Inability to concentrate Signup and view all the answers

Which finding in an older client should the nurse assess first to prevent overhydration?

Just received 3 units of packed red blood cells Signup and view all the answers

Which tasks can the nurse delegate to unlicensed assistive personnel for a client who had a stroke?

Assist the client with meals Signup and view all the answers

When addressing patient education quality concerns, which interrelated concept is most relevant for a nurse manager?

Technology Signup and view all the answers

Which of the following is not a risk factor for impaired thermoregulation?

Physical agility Signup and view all the answers

What is the priority intervention for a client in physical restraints?

Assess the client every 30 to 60 minutes, releasing restraints every 2 hours Signup and view all the answers

Which client is most likely not to be treated adequately for pain?

Client with expressive aphasia Signup and view all the answers

Based on observing a client listening to music before surgery, which nonpharmacologic intervention for pain relief might the nurse try?

Imagery Signup and view all the answers

Study Notes

Patient Education Approaches

Informal teaching involves one-on-one interactions, addressing individual patient needs.
Formal education uses standardized content and group-focused plans.

Motivation Theories in Care Planning

Cognitive theory emphasizes ARCS (Attention, Relevance, Confidence, Satisfaction) to motivate learning.
Field theory focuses on personal achievement and power as motivators, while sociologic theories do not focus on motivation.

Risk Factors for Hypothermia/Frostbite

Increased risk in older adults, those with poor nutrition, alcohol users, smokers, and individuals with chronic illnesses.

Pain Management in Older Adults

Older adults may under-report pain; they experience pain similarly to younger adults.
Treatment of pain is critical for promoting overall wellness.

Emergency Response for Heat Stroke

Priority action includes cooling the patient; intravenous fluids and medications may be less effective in urgent situations.

IV Administration of Potassium Chloride

Potassium chloride is a strong tissue irritant; immediate action is to stop the infusion if patient experiences burning.

Economic Concerns for Older Adults

Social Security may be the primary source of income, making it difficult to manage increased living costs.

Effects of Unrelieved Pain

Uncontrolled pain is linked to prolonged stress responses and systemic harm, affecting overall health and recovery.

Handling Dehydration-Induced Confusion

Rapidly increasing IV fluid rates can improve cerebral perfusion and relieve confusion caused by dehydration.

Dehydration Risk in Specific Populations

Older adults, especially those with cognitive impairments, are at a heightened risk for dehydration.

Monitoring for Hyperkalemia

Individuals using potassium-based salt substitutes are at increased risk; education on label reading is essential.

Digoxin Toxicity in Older Adults

Decreased renal blood flow and glomerular filtration in aging increase the risk of accumulation and toxicity from medications like digoxin.

Understanding of Dehydration

Monitoring daily weight provides insight into fluid status and hydration levels, with significant weight loss indicating dehydration.

Priority Interventions for Hypokalemia

Respiratory assessments take precedence due to the risk of respiratory failure linked with low potassium levels.

Calculating Medication Dosage

Dosage calculations require understanding of desired and available medication strengths.

Dietary Sodium Restriction

Choosing whole foods like fresh produce and avoiding processed foods indicates understanding of dietary sodium restrictions.

Behavioral Indicators of Acute Pain

The inability to concentrate is a key behavioral sign of acute pain, while chronic pain more often involves emotional withdrawal.

Risk Assessment for Overhydration

Clients receiving blood products, such as packed red blood cells, require careful monitoring for overhydration.

Delegation of Tasks in Nursing

Unlicensed assistive personnel can assist with client meals, but not with assessments or care plans.

Quality of Patient Education

Nurse managers need to consider technology along with health promotion and patient attributes in education quality.

Thermoregulation Risk Factors

Factors like cognitive impairment and environmental exposure increase vulnerability to thermoregulation issues, unlike physical agility.

Monitoring Clients in Restraints

Frequent assessment and timely release of restraints are vital to prevent injury and monitor client well-being.

Pain in Chronic Conditions

Assessing the cause of elevated vital signs in clients with chronic pain is crucial for appropriate management.

Inequitable Pain Treatment

Nonverbal clients, such as those with expressive aphasia, are at greater risk for inadequate pain management.

Nonpharmacologic Pain Relief Strategies

Imagery as a distraction technique can be beneficial for pain management, especially in the postoperative setting.

Cultural Competence in Nursing

Key constructs for culturally competent nursing include cultural desire, self-awareness, cultural knowledge, and skill.

Importance of Cultural Understanding in Healthcare

Increasing global diversity necessitates understanding cultural influences on health care to provide effective patient care.### Nursing Assessment and Interventions
Regular heart rhythm indicates monitoring for conditions like hypokalemia, which can cause postural hypotension and muscle weakness.
Essential to institute fall precautions for patients with hypokalemia due to risks of falls from muscle weakness.

Fluid and Electrolyte Imbalances

Clients who are NPO and receiving intravenous D5W are at high risk for hyponatremia; D5W lacks electrolytes.
Monitoring potassium levels is crucial; hypokalemia can lead to confusion and lethargy, with the dangerous level being below 3.5 mEq/L.

Pain Management and Medication Safety

Administering excessive morphine can cause respiratory depression; naloxone (Narcan) can reverse overdose effects.
Certain medications (meperidine, propoxyphene, codeine) are unsafe for older adults due to the risk of accumulation of toxic metabolites; morphine is generally safe with monitoring.

Core Temperature Measurement

Rectal thermometers provide the most reliable assessment of core body temperature, essential for accurate readings in cases of suspected thermoregulation issues.

Hypothermia Management

In mild hypothermia, immediate intervention includes providing dry clothing and warm blankets.
Continuous monitoring of vital signs and appropriate rewarming techniques is necessary for severe cases.

Safety and Quality of Care

Prioritize patient safety by assessing respiratory status, especially when administering opioids.
Utilize the Rapid Response Team (RRT) for significant changes in patient conditions, like a drastic drop in blood pressure.

Functional Ability and Family Assessments

Functional ability includes the capacity to perform daily living activities, not just physical independence.
Family assessments inform about family structure and dynamics but do not emphasize political views.

Observation of Pain in Older Adults

Nonverbal cues such as facial grimace, crying, and restlessness are key indicators of pain in cognitively impaired older adults.

Managing High Temperatures and Hyperthermia

Provide cool packs directly to the skin's surface in febrile patients to manage high temperatures effectively, avoiding fans that may spread pathogens.

Collaborative Care in Hypertension

Initial teaching goals for new hypertensive patients focus on understanding the importance of medication adherence for management.

Skin Assessment in Older Adults

Assess skin turgor on areas like the forehead and abdomen instead of hands, which may not reflect turgor accurately due to age-related changes.### Assessment Findings After TURP
Continuous urge to void with catheter present is expected.
Passing small blood clots post-catheter removal is normal.
Bright red drainage with multiple blood clots signals arterial bleeding, requiring immediate action.

Risk for Wound Infection

Immune compromised status presents the greatest risk for infection.
Coexisting conditions and deep wounds also increase susceptibility but are secondary.

Early Onset Multiple Sclerosis Symptoms

Early signs include nystagmus and diplopia (eye movement issues).
Hyperresponsive reflexes, excessive somnolence, and heat intolerance occur later.

Braden Scale Score of 9 Intervention

A score of 11 or lower indicates severe risk for pressure ulcers.
Consulting with the healthcare provider is necessary for enhanced skin protection.

Managing Fatigue in Chemotherapy Patients

Prioritizing nursing care throughout the day is crucial to manage fatigue.
Activities should be paced to conserve energy, while adequate sleep alone won’t resolve fatigue.

Injury Prevention for Diabetic Clients

Using a bath thermometer is essential for testing water temperature due to numbness.
Daily foot examinations are vital, but do not directly prevent injuries.

Greatest Pressure Ulcer Development Risk

An incontinent client with limited mobility is at the highest risk due to dual risk factors.

Preventing Pressure Ulcers in Older Patients

Turning the patient at least every 2 hours is crucial to avoid skin damage.

Education on Glucovance for Diabetic Patients

Glucovance is a combination of glyburide and metformin to simplify treatment.

Assessment Timing for NPH Insulin

Assess for complications related to NPH insulin at 4 PM, when peak effects are expected.

Interventions for Immobility Post-Stroke

Applying sequential compression stockings is key to preventing complications like DVT.

Nutritional Interventions for Stroke Patients

Positioning the client in high Fowler's position aids in swallowing and reduces aspiration risk.

Patient Education on Mucositis

Avoid alcohol-based mouth rinses, as they exacerbate irritation.

Antibiotic Use in Women with Urinary Tract Infections

Counsel clients to use a second form of birth control while taking amoxicillin, as it may reduce contraceptive effectiveness.

Combination Drug Therapy for Hypertension

Include aspirin, aldosterone antagonists, ACE inhibitors/ARBs, beta blockers, and diuretics in teaching plans for managing hypertension.

Orienting Clients with Disorientation

Family photographs can help reorient confused patients post-stroke.

Indications of Improved Nutritional Status

An increase in prealbumin levels is a reliable indicator of enhanced nutritional status.

Important Factors in Health History for Elimination

Recent changes in elimination patterns, color/consistency of stool or urine, and discomfort during elimination are all critical.

Managing Indwelling Catheter Risk

Prioritize discussions about the necessity of indwelling catheters to reduce the risk of infections.

Neurologic Deficits in Right Cerebral Hemisphere Stroke

Look for impaired proprioception due to stroke effects on spatial awareness.

Diabetes Management Goals

Control hyperglycemia effectively to prevent long-term complications in diabetes.

Enteral Tube Feeding Safety Interventions

Monitor residual volume every 4-6 hours, utilize clean technique when changing feeding systems, and maintain the head of the bed at 30 degrees.

Client's Nutritional Status and Wound Healing

Request dietary consult when prealbumin levels are low, indicating nutritional risk affecting wound healing.

Monitoring Perfusion

Evaluate perfusion through vital signs and capillary refill to assess adequacy for vital organs.

Effective Hypertension Management Indicators

Absence of renal impairment signifies successful hypertension management.

Neutropenia Client Education

Instruct clients to report any increase in temperature promptly for risk management.

Aspiration Risk in Nasoenteric Feeding Tube Clients

Prioritize assessing lung sounds and oxygen saturation for clients showing respiratory distress after feeding.

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Description

This quiz focuses on patient education approaches in Medical Surgical Nursing, specifically emphasizing informal teaching methods. It is designed to enhance understanding of individualized nursing education strategies. Perfect for HESI test preparation and nursing students.