HESI Med surg practice questions

A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last 2 hours. Which action should the nurse take first?

A. Irrigate the nasogastric tube with sterile normal saline.
B. Reposition the client on her side.
C. Advance the nasogastric tube 5 cm.
D. Administer an intravenous antiemetic as prescribed.

B. The priority is to determined if the tube is functioning correctly, which would relieve the client’s nausea. The least invasive intervention is to reposition the client (B), should be attempted first, followed by (A & C) if these are unsuccessful then (D).

When assigning clients on a medical-surgical floor to a RN and a LPN, it is best for the charge nurse to assign which client to the LPN?

A. A child with bacterial meningitis with recent seizures.
B. An older adult client with pneumonia and viral meningitis.
C. A female client in isolation wiht meningococcal meningitis.
D. A male client 1 day post-op after drainage of a brain abscess.

B. Is the most stable. A, C, D have an increased risk for elevated ICP.

Which description of symptoms is characteristic of a client with diagnosed with trigeminal neuralgia (tic douloureux)?

A. Tinnitus, vertigo, and hearing difficulties.
B. Sudden, stabbing, severe pain over the lip and chin.
C. Unilateral facial weakness and paralysis.
D. Difficulty in talking, chewing, and swallowing.

B. Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the area innervated by one or more branches of the trigeminal nerve. A. Characteristic of Meniere’s C. Characteristic of Bell palsey D. Characteristic of disorders of the hypoglossal (12th cranial nerve)

Which abnormal lab finding indicates that a client with diabetes needs further evaluation for diabetic nephropathy?
A. Hypokalemia
B. Microalbuminauria
C. Elevated serum lipids
D. Ketonuria

B. Microalbuminuria is the earliest sign of nephropathy and indicates the need for follow-up evaluation. Hyperkalemia (A) is associated with end stage renal disease caused by diabetic nephropathy. (C) may be elevated in end stage renal disease. (D) may signal the onset of DKA.

An older male client comes to the geriatric screening clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg that is warm to touch and the nurse suspects that the client may have thrombophlebitis. Which addition assessment is most important for the nurse to perform?

A. Measure calf circumference.
B. Auscultate the client’s breath sounds.
C. Observe for ecchymosis and petechiae.
D. Obtain the client’s blood pressure.

B. Since the client may have a pulmonary embolus secondary to the thrombophlebitis. A. Would support the nurses assessment. C. Least helpful since bruising is not associated with thrombophlebitis. D. Less important then auscultation.

The nurse know that a client taking diuretics must be assessed for the development of hypokalemia, and that hypokalemia will create changes in the client’s normal ECG tracing. Which ECG change would be an expected finding in the client with hypokalemia?

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, C indicate hyperkalemia.

An older client is admitted with a diagnosis of bacterial pneumonia. The nurse’s assessment of the client will most likely reveal which S/SX?
A. Leukocytosis and febrile.
B. Polycythemia and crackles.
C. Pharyngitis and sputum production.
D. Confusion and tachycardia.

D. The onset of pneumonia is the older may be signaled by general deterioration, confusion, increased heart rate or increased respiratory rate. (A, B, C) are often absent in the older with bacterial pneumonia.

The nurse observes ventricular fibrillation on telemetry and upon entering the clients bathroom finds the client unconscious on the floor. What intervention should the nurse implement first?

A. Administer an antidysrhythmic medication.
B. Start cardiopulmonary resuscitation.
C. Defibrillate the client at 200 joules.
D. Assess the client’s pulse oximetry.

B. Ventricular fibrillation is a life-threatening dysrhythmia and CPR should be started immediately. A & C are appropriate but B is the priority. D does not address the seriousness of the situation.

An older female client with dementia is transferred from a long term care unit to an acute care unit. The client’s children express concern that their mother’s confusion is worsening. How should the nurse respond?

A. "It is to be expected that older people will experience progressive confusion."
B. "Confusion in an older person often follows relocation to new surroundings."
C. "The dementia is progressing rapidly, but we will do everything we can to keep your mother safe."
D. "The acute care staff is not as experienced as the long-term care staff at dealing with dementia."

B. Relocation often results in confusion among older clients and is stressful to clients of all ages. (A) is an inaccurate stereotype. (C) is most likely false there are many factors that cause increased temporary confusion. (D) may be true but does not offer the family a sense of security about the care.

The nurse plans to help an 18-year-old developmentally disabled female client ambulate on the first postoperative day. When the nurse tells her it is time to get out of bed, the client becomes angry and yells at the nurse. "Get out of here! I’ll get up when I’m ready." Which response should the nurse provide?

A. "Your healthcare provider has prescribed ambulation on the first postoperative day."
B. "You must ambulate to avoid serious complications that are much more painful."
C. "I know how you feel; you’re angry about having to do this, but it is required."
D. "I’ll be back in 30 minutes to help you get out of bed and walk around the room."

D. Returning in 30 minutes provides a cooling off period, is firm, direct, nonthreatening, and avoids argument with the client. B is threatening. C. assumes what the client is feeling. A. avoids the nurse’s responsibility to ambulate the client.

The nurse is performing hourly neurological check for a client with a head injury. Which new assessment finding warrants the most immediate intervention by the nurse?

A. A unilateral pupil that is dilated and nonreactive to light.
B. Client cries out when awakened by a verbal stimulus.
C. Client demonstrates a loss of memory to the events leading up to the injury.
D. Onset of nausea, headache, and vertigo.

A. Any changes in pupil size and reactivity is an indication of increasing ICP and should be reported immediately. (B) is normal for being awakened. (C & D) are common manifestations of head injury and less of an immediacy than (A).

A male client with arterial peripheral vascular disease (PVD) complains of pain in his feet. Which instruction should the nurse give to the UPA to quickly relieve the client’s pain?

A. Help the client to dangle his legs.
B. Apply compression stockings.
C. Assist with passive leg exercises.
D. Ambulate three times daily.

A. A client who has arterial PVD may benefit from a dependent position which can be achieved by dangling by improving blood flow and relieving pain. (B) is indicated for venous insufficiency and (C) is indicated for bed rest. (D) is indicated to facilitate collateral circulation and may improve long term complaints of pain.

A 58-year-old client, who has no health problems, asks the nurse about taking the pneumococcal vaccine (Pneumovax). Which statement give by the nurse would offer the client accurate information about this vaccine?

A. "The vaccine is given annually before the flue season to those over 50 years of age."
B. "The immunization is administered once to older adults or persons with a history of chronic illness."
C. "The vaccine is for all ages and is given primarily to those person traveling overseas to infected areas."
D. "The vaccine will prevent the occurrence of pneumococcal pneumonia for up to 5 years."

B. It is usually recommended that persons over 65 years of age and those with a history of chronic illness should receive the vaccine once in a lifetime. (A) the influenza vaccine is given annually. (C) travel is not the main rationale for the vaccine. (D) The vaccine is usually given once in a lifetime.

A client with hypertension has been receiving ramipril (Altace) 5 mg PO daily for 2 weeks and is scheduled to receive a dose at 0900. At 0830 the client’s blood pressure is 120/70. Which action should the nurse take?

A. Administer the dose as prescribed.
B. Hold the dose and contact the healthcare provider.
C. Hold the dose and recheck the blood pressure in 1 hour.
D. Check the healthcare provider’s prescription to clarify the dose.

A. The BP is WNL and indicates that the medication is working. (B & C) would be indicated if the BP was low (systole below 100). (D) is not required because the dose is within manufacture’s recommendations.

The nurse know that normal lab values expected for an adult may vary in an older client. Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old man who is in good overall health.

A. Complet blood count reveals increased WBC and decreased RBC counts.
B. Chemistries reveal an increased serum bilirubin with slightly increased liver enzymes.
C. Urinalysis reveals slight protein in the urine and bacteriuria with pyuria.
D. Serum electrolytes reveal a decreased sodium level with an increased potassium level.

C. In older adults the protein found in urine is slightly risen as a result of kidney changes or subclinical UTIs and the client frequently experiences asymptomatic bacteriuria and pyuria as a result of incomplete bladder emptying. (A, B, D) are not normal findings.

The nurse is completing an admission inter for a client with Parkinson disease. Which question will provide addition information about manifestations the client is likely to experience?

A. "Have you ever experienced and paralysis of your arms or legs?"
B. " Do you have frequent blackout spells?"
C. "Have you ever been ‘frozen’ in one spot, unable to move?"
D. "Do you have headaches, especially ones with throbbing pain?"

C. Parkinson clients frequently experience difficulty in initiating, maintaining, and performing motor activities. They may even experience being rooted, unable to move. (A, B, D) Does not typically occur in Parkinson.

During the change of shift report, the charge nurse reviews the infusions being received by the clients on the oncology unit. The client receiving which infusion should be seen first?

C. Has the highest risk for respiratory depression and therefor should be seen first. (A) Risk of hypotension. (B) Lowest risk. (D) Risk of nephrotoxicity and phlebitis.

The home health nurse is assessing a male client being treated for Parkinson disease with levodopa-carbidopa (Sinemet). The nurse observes that he does not demonstrate any apparent emotions 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 mask-like expression and infrequent blinking are common clinical features of Parkinsonism. The nurse should document the findings. (A & D) are not necessary. Signs of toxicity (B) are dyskinesia, hallucinations, and psychosis.

A client is placed on a mechanical ventilator following a cerebral hemorrhage, and vecuronium bromide (Norcuron) 0.04 mg/kg every 12 hours IV is prescribed. What is the priority nursing diagnosis for this client?

A. Impaired communication related to paralysis of skeletal muscles.
B. Hight risk or infection related to increased ICP.
C. Potential for injury related to impaired lung expansion.
D. Social isolation related to inability to communicate.

A. To increase the client’s tolerance of the endotracheal intubation and/or mechanical ventilation, a skeletal-muscle relaxant such as vecuronium is usually prescribed. (A) is a serious outcome because the client cannot communicate his/her needs. (D) is not as much of a priority. (B) infection is not related to ICP. (C) is incorrect because the ventilator will ensure that the lungs are expanded.

The nurse is reviewing the routine medications taken by a client with chronic angle closure glaucoma. Which medication prescription should the nurse question?

A. An antianginal with a therapeutic effect of vasodilation.
B. An anticholinergic with a side effect of pupillary dilation.
C. An antihistamine with a side effect of sedation.
D. A corticosteroid with a side effect of hyperglycemia.

B. Clients with angle closure glaucoma should not take medications that dilate the pupil (B) because this can precipitate acute and severely increased intraocular pressure. (A, C, D) do not cause increased intraocular pressure, which is the primary concern.

What is the correct location for the placement of the hand for manual chest compressions during CPR on the adult client.

A. Just above the xiphoid process on the upper third of the sternum.
B. Below the xiphoid process midway between the sternum and the umbilicus.
C. Just about the xiphoid process on the lower third of the sternum.
D. Below the xiphoid process midway between the sternum and the first rib.

C.

Twelve hours after chest tube insertion for hemothorax, the nurse notes that the client’s drainage has decreased from 50 ml/hr to 5 ml/hr. What is the best inital action for the nurse to take?

A. Document this expected decrease in drainage.
B. Clamp the chest tube while assessing for air leaks.
C. Milk the tube to remove any excessive blood clot build up.
D. Assess for kinks or dependent loops in the tubing.

D. The least invasive action should be performed to assess the decrease in drainage. (A) is completed after assessing for and problems causing the decreased drainage. (B) is no longer protocol because the increased pressure may be harmful for the client. (C) is an appropriate nursing action after the tube has been assessed for kinks or dependent loops.

A 25-year-old client was admitted yesterday after a motor vehicle collision. Neurodiagnostic studies showed a basal skull fracture in the middle fossa. Assessment on admission revealed both halo and Battle signs. Which new symptom indicates that the client is likely to be experiencing a common life-threatening complication associated with basal skull fracture?

A. Bilateral jugular vein distention.
B. Oral temperature of 102 degrees F.
C. Intermittent focal motor seizures.
D. Intractable pain in the cervical region.

B. Increased temp indicates meningitis. (C & D) these symptoms may be exhibited but are not life threatening. (A) JVD is not a typical complication of basal skull fractures.

Seconal 0.1 gram PRN at bedtime is prescribed for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer?
A. 1/2 tablet
B. 1 tablet
C. 1 1/2 tablet
D. 2 tablets

B. 15 gr = 1 g, 0.1 x 15 = 1.5 grains

Which content about self-care should the nurse include in the teaching plan of a client who has genital herpes? (Select all that apply.)

A. Encourage annual physical and Pap smear.
B. Take antiviral medication as prescribed.
C. Use condoms to avoid transmission to others.
D. Warm sitz baths may relieve itching.
E. Use Nystatin suppositories to control itching.
F. Douche with weak vinegar solutions to decrease itching.

A,B,C,D. (E) is specific for Candida infections and (F) is used to treat Trichomonas.

A client with chronic asthma is admitted to postanesthesia complaining of pain at level 8 of 10, with a BP of 124/78, pulse of 88 beats/min, and respirations of 20 breaths/min. The postanesthesia recovery prescription is, "Morphine 2 to 4 mg IV push while in recovery for pain level over 5." What intervention should the nurse implement?

A. Give the medication as prescribed to decrease the client’s pain.
B. Call the anesthesia provider for a different medication for pain.
C. Use nonpharmacologic techniques before giving the medication.
D. Reassess pain level in 30 Minutes and medicate if it remains elevated.

B. Call for a different medication because morphine and meperidine (Demerol) have histamine-releasing narcotics and should be avoided when a client has asthma. (A) puts the client at risk for asthma attack. (C & D) disregard the clients prescription and pain relief.

During report, the nurse learns that a client with tumor lysis syndrome is receiving an IV infusion containing insulin. Which assessment should the nurse complete first?

A. Review the client’s history for diabetes mellitus.
B. Observe the extremity distal to the IV site.
C. Monitor the client’s serum potassium and blood glucose.
D. Evaluate the client’s oxygen saturation and breath sounds.

C. The client with tumor lysis syndrome may experience hyperkalemia, therefor it is important to monitor serum potassium and blood glucose levels. (A, B, D) are not as priority.

During assessment of a client in the intensive care unit, the nurse notes that the client’s breath sounds are clear upon auscultation, but jugular vein distention and muffled heart sounds are present. Which intervention should the nurse implement?

A. Prepare the client for a pericardial tap.
B. Administer intravenous furosemide (Lasix).
C. Assist the client to cough and deep breathe.
D. Instruct the client to restrict oral fluid intake.

A. The client is exhibiting symptoms of cardiac tamponade that results in reduced cardiac output. Treatment is pericardial tap. (B) is not a treatment. (C) is not priority. (D) Fluids are frequently increased but this is not as priority as (A).

In assessing an older client with dementia for sundowning syndrome, what assessment technique is best for the nurse to use?

A. Observe for tiredness at the end of the day.
B. Perform a neurologic exam and mental status exam.
C. Monitor for medication side effects.
D. Assess for decreased gross motor movement.

A. Sundowning syndrome is a pattern of agitated behavior in the evening, believed to be associated with tiredness at the end of the day combined with fewer orienting stimuli, such as activities and interactions. (B, C, & D) with not provide information about this syndrome.

Which condition should the nurse anticipate as a potential problem in a female client with a neurogenic bladder?

A. Stress incontinence.
B. Infection.
C. Painless, gross hematuria.
D. Peritonitis.

B. Infection is the major complication resulting from stasis of urine and subsequent catheterization. (A) is the involuntary loss of urine through an intact urethra as a result of suddenly increased pressure. (C) is the most common symptom of bladder cancer. (D) is the most common and serious complication of peritoneal dialysis.

The nurse is interviewing a client who is taking interferon-alfa-2a (Roferon-A) and ribavirin (Virazole) combination therapy for hepatitis C. The client reports experiencing overwhelming feelings of depression. What action should the nurse implement first?

A. Recommend mental health counseling.
B. Review the medications actions and interactions.
C. Assess for the client’s daily activity level.
D. Provide information regarding a support group.

B. Alpha-interferon and ribavirin combination therapy can cause severe depression. (A, B, C) may be implemented after physiological aspect of the situation are assessed.

The nurse is assessing a 75-year-old male client for symptoms of hyperglycemia. Which symptom of hyperglycemia is an older adult most likely to exhibit?

A. Polyuria
B. Polydipsia
C. Weight loss
D. Infection

D. S/Sx of hyperglycemia in older adults may include fatigue, infection, and neuropathy (such as sensory changes). (A, B, C) are classic symptoms and may be absent in the older adult.

A client who is receiving an ACE inhibitor for hypertension calls the clinic and reports the recent onset of a cough to the nurse. What action should the nurse implement?

A. Advise the client to come to the clinic immediately for further assessment.
B. Instruct the client to discontinue use of the drug, and make an appointment at the clinic.
C. Suggest that the client lear to accept the cough as a side effect to a necessary prescription.
D. Encourage the client to keep taking the drug until seen by the HCP.

D. Cough is a common s/e of ACE inhibitors and is not an indication to discontinue the medication. (A) immediate evaluation is not needed. (B) an antihypertensive should not be stopped abruptly. (C) is demeaning since the cough may be disruptive to the client and other medications may produce results without the s/e.

The nurse is observing an unlicensed assistive personnel (UPA) who is performing morning care for a bedfast client with Huntington disease. Which care measure is most important for the nurse to supervise?

A. Oral care
B. Bathing
C. Foot care
D. Catheter care

A. A client with Huntington disease experiences problems with motor skills such as swallowing and is at high risk for aspiration. (B, C, D) do not pose life-threatening consequences.

A client with alcohol-related liver disease is admitted to the unit. Which prescription should the nurse question as possibly inappropriate for the client?

A. Vitamin K1 (AquaMEPHYTON) 5 mg IM daily
B. High-calorie, low-sodium diet
C. Fluid restriction to 1500 ml/day
D. Pentobarbital (Nembutal sodium) 50 mg at bedtime for rest

D. Sedatives such as Nembutal are contraindicated for clients with liver damage and can have dangerous consequences. (A) is often prescribed since normal clotting mechanism is damaged. (B) is needed to restore energy. (C) Fluids are restricted to decrease ascites which often accompanies cirrhosis, particularly in later stages of the disease.

A client diagnosed with chronic kidney disease (CDK) 2 years ago is regularly treated at a community hemodialysis facility. In assessing the client 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 due to chronic hyperphosphatemia not (A). (C & D) incorrect you would find hypernatremia and hyperkalemia

Debilitating anginal pain can be decreased in some clients by the administration of beta-blocking agents such as nadolol (Corgard). Which client requires the nurse to use extreme caution when administering Corgard?
A. A 56-year-old air traffic controller who had bypass surgery 2 years ago.
B. A 47-year-old kindergarten teacher diagnosed with asthma 40 years ago
C. A 52-year-old unemployed stock broker who refuses treatment for alcoholism
D. A 60-year-old retired librarian who takes a diuretic daily for hypertension.

B. asthma must be carefully monitored because beta blockers because it can induce cardiogenic shock and reduce bronchodilation efforts. (A & D) this medication is indicated and (C) it is not contraindicated.

A male client who has never smoked but has had COPD for the past 5 years is now being assessed for cancer of the lung. The nurse knows that he is most likely to develop which type of lung cancer?

A. Adenocarcinoma
B. Oat-cell carcinoma
C. Malignant melanoma
D. Squamous-cell carcinoma

A. is the only lung cancer not related to cigarette smoking related to lung scarring and fibrosis from preexisting pulmonary diseases such as TB and COPD. (B& D) are related to smoking. (C) is a skin cancer

The nurse is caring for a client with a chest tube to water seal drainage that was inserted 10 days ago because of a ruptured bullae and pneumothorax. Which finding should the nurse report to the healthcare provider before the chest tube is removed?
A. Tidal of water in the water seal chamber
B. Bilateral muffled breath sounds at bases
C. Temperature of 101 degrees F
D. Absence of chest tube drainage for 2 days.

A. Tidal in the water seal chamber should be reported to the HPC to show that the chest tube is working properly. (B) may indicate hypoventilation from the chest tube and usually improves when the tube is removed. (C) indicates infection (D) is an expected finding.

A central venous catheter has been inserted via a jugular vein and a radiography has confirmed placement of the catheter. A prescription has been received for stat medication but IV fluids have not yet been started. What action should the nurse take prior to administering the prescribed medication?

A. Assess for signs of jugular vein distention.
B. Obtain the needed intravenous solution.
C. Administer a bolus of normal saline solution.
D. Flush the line with heparinized saline.

C. A medication can be administered central line without IV fluids, flush with normal saline to remove heparin that may counteract with the medication. (B) is used following the medication and a second saline bolus. (A) will not impact the the med administration and is not a priority. (B) Administration of the stat medication is more of a priority than (B).

The nurse assesses a postoperative client. Oxygen is being administered at 2 L/min and a saline lock is in place. Assessment shows cool, pale, moist skin. The client is very restless and has scant urine in the urinary drainage bag. What intervention should the nurse implement first.

A. Measure urine specific gravity.
B. Obtain IV fluids for infusion protocol.
C. Prepare for insertion of a central venous catheter.
D. Auscultate the client’s breath sounds.

B. The client is at risk for hypovolemic shock and is exhibiting early signs. Start IV to restore tissue perfusion. (A, C, D) are all important but less of a priority.

A client diagnosed with angina pectoris complains of chest pain while ambulating in the hallway. Which action should the nurse implement first?

A. Support the client to a sitting position.
B. Ask the client to walk slowly back to the room.
C. Administer a sublingual nitroglycerin tablet.
D. Provide oxygen via nasal cannula.

A. Assist in safely repositioning and then administer (C & D). Then the client can be escorted back to the room via wheelchair or stretcher (B).

A 55-year-old male client is admitted to the coronary care unit having suffered an acute myocardial infarction (MI). Within 24 hours of the occurrence, the nurse can expect to find which systemic sign?

A. Elevated serum amylase level
B. Elevated CM-MB level
C. Prolonged prothrombin time (PT)
D. Elevated serum BUN and creatinine

B. Tissue damage in the myocardium causes the release of cardiac enzymes into the blood system. An elevated CM-MB is a recognized indicator of an MI. It peaks 12 – 24 hours and returns to normal within 48 – 78 hours. (A) would indicate pancreatitis or a gastric disorder. (D) Although an elevated BUN might be related to an acute MI it is usually associated with dehydration, high protein intake or gastrointestinal bleeding and creatine levels indicate renal damage. (C) Indicates effective anticoagulation therapy.

The nurse is assessing a client who presents with jaundice. Which assessment finding is the most significant indication that further follow up is needed?

A. Urine specific gravity of 1.03 with a urine output of 500 ml in 8 hours
B. Frothy, tea-colored urine
C. Clay-colored stools and complaints of pruritus
D. Serum amylase and lipase levels that are twice their normal levels

D. Obstructive cholelithiasis and alcoholism are the two major causes of pancreatitis, and an elevated serum amylase and lipase indicate pancreatic injury. (A) is a normal finding. (B & C) are expected findings for jaundice.

A client with cirrhosis states that his disease was cause by a blood transfusion. What information should the nurse obtain first to provide effective client teaching?

A. The year the blood transfusion was received
B. The amount of alcohol the client drinks
C. How long the client has had cirrhosis
D. The client’s normal coping mechanisms

A. The nurse should first verify the clients explanation (A) since it may be accurate due to prior to 1990 blood was not screened for Hep C and hep C can cause cirrhosis. Not all cirrhosis is caused is caused by alcoholism (B) (C & D) provide useful but less relevant information.

What is the correct procedure for performing an ophthalmoscopic examination on a client’s right eye?

A. Instruct the client to look at the examiner’s nose and not move his/her eyes during the exam.
B. Set ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner’s right eye.
C. From a distance of 8 to 12 inches and slightly to the side, shine the light into the client’s pupil.
D. For optimum visualization, keep the ophthalmoscope at least 3 inches for the client’s eye

C. The client should focus on a distant object in order to promote pupil dilation. The ophthalmoscope should be set on the 0 lens to begin (creates no correction) and should be held in front of the examiner’s left eye when examining the client’s right eye and kept 1" from the client’s eye for optimum visualization. (A, B, D) are incorrect procedures.

The nurse witnesses a baseball player receive a blunt trauma to the back of the head with a softball. What assessment data should the nurse collect immediately?

A. Reactivity of deep tendon reflexes, comparing upper to lower extremities.
B. Vital signs readings, excluding blood pressure if need equipment is unavailable.
C. Memory of events that occurred before and after the blow to the head.
D. Ability to spontaneously open the eyes before any tactile stimuli are given.

D. The LOC should be immediately established immediately after the head injury has occurred. Spontaneous eye opening (D) is a simple measure of LOC. (A) is not the best indicator of LOC. (B) is important but not the best indicator of LOC. (C) can be assessed after LOC has been established by assessing eye opening.

A 43-year-old homeless, malnourished female client with a history of alcoholism is transferred to the ICU. She is placed on telemetry, and the rhythm strip shown is obtained. The nurse palpates a heart rate of 160 beats/min, and the client’s blood pressure is 90/54. Based on these finding, which IV medication should the nurse administer?

A. Amiodarone (Cordarone)
B. Magnesium sulfate
C. Lidocaine (Xylocaine)
D. Procainamide (Pronestyl)

B. Because the client has chronic alcoholism, she is likely to have hypomagnesium. (B) is the recommended drug for torsades de pointes (AHA, 2005), which is a form of polymorphic ventricular tachycardia (VT), usually associated with a prolonged QT interval that occurs with hypomagnesemia. (A and D) increase the QT interval, which can cause the torsades to worsen. (C) is the antiarrhythmic of choice in most cases of drug-induced monomorphic VT, not torsades.

The nurse is caring for a critically ill client with cirrhosis of the liver who has a nasogastric tube draining bright red blood. The nurse notes that the client’s serum hemoglobin and hematocrit are decreased. What additional change in lab data should the nurse expect?

A. Increased serum albumin
B. Decreased serum creatinine
C. Decreased serum ammonia
D. Increased liver function tests

C. The breakdown of glutamine in the intestine and the increased activity of colonic bacteria from the digestion of proteins increases the ammonia levels in the clients with advanced liver disease, so removal of blood, a protein source, from the intestines results in reduced ammonia. (A, B, D) will not be significantly impacted by the removal of blood.

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 occurs
C. Withdraws the catheter while maintaining suctioning
D. Re-clears the tracheostomy after suctioning the mouth

B. indicates correct technique for performing suctioning. Suction pressure should be between -80 and -120 (A). The catheter should be withdrawn 1-2 cm at a time with intermittent suction (C). (D) introduces pathogens.

The nurse is planning the care for a client who is admitted with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which interventions should the nurse include in this client’s plan of care? (Select all that apply.)

A. Salt-free diet
B. Quiet environment
C. Deep tendon reflex assessments
D. Neurologic checks
E. Daily weights
F. Unrestricted intake of free water

B, C, D, E. SIADH results in water retention and dilutional hyponatremia, which causes neurologic change when serum sodium levels are less than 115 mEq/L. The nurse should maintain a quiet environment (B) to prevent overstimulation that can lead to periods of disorientation, assess deep tendon reflexes (C) and neurologic checks (D) to monitor for neurologic deterioration. Daily weights (E) should be monitored to assess for fluid overload: 1 kg weight gain equals 1 L of fluid retention, which further dilutes serum sodium levels. (A and F) contribute to dilutional hyponatremia.