Samuel merrit University, hesi med surg
Total Questions : 45
Showing 25 questions, Sign in for moreThe nurse is preparing to administer Tylenol to a client admitted with urination issues who also has difficulty sleeping (OSA).
Which interaction is most important for the nurse to implement before leaving the client?
Explanation
The client has difficulty sleeping due to obstructive sleep apnea (OSA), and using a positive airway pressure device can help keep their airway open and prevent dangerous pauses in breathing while they sleep 1.
Choice A is not the answer because elevating the head of the bed to a 45-degree angle may provide some relief for OSA, but it is not as effective as using a positive airway pressure device 1.
Choice C is not the answer because lifting and locking the side rails in place is a safety measure but does not directly address the client’s OSA 1.
Choice D is not the answer because removing dentures or other oral appliances may provide some relief for OSA, but it is not as effective as using a positive airway pressure device 1.
The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies.
Which of the following is most useful for the nurse to include?
Explanation
Simulation activities provide a safe and controlled environment for young adult clients to practice problem-solving strategies and learn from their experiences .
Choice A is not the answer because providing a physical demonstration may be helpful in teaching a skill, but it does not actively engage the clients in problem-solving .
Choice C is not the answer because incorporating verbal analogies can help clients understand concepts, but it does not actively engage them in problem-solving .
Choice D is not the answer because offering positive reinforcement can encourage and motivate clients, but it does not actively engage them in problem-solving .
The nurse is providing postoperative care for a client who complains of severe pain after receiving codeine 30 mg orally one hour ago.
Which intervention should the nurse implement next?
Explanation
The nurse should reassess the client’s pain level and determine if additional interventions are needed to manage the pain.
Choice A is not the answer because while a back rub may provide some temporary relief, it does not address the underlying cause of the pain.
Choice C is not the answer because while deep breathing can help with relaxation, it does not address the underlying cause of the pain.
Choice D is not the answer because telling the client that the medication needs more time to work does not address their current pain level or provide any immediate relief.
The healthcare provider prescribes ear drops to an adult client with an ear infection.
Which exacting should the nurse follow?
Explanation
The correct answer is choice D.
When administering ear drops to an adult client with an ear infection, the nurse should keep the patient in a supine position to administer the drops.
This position allows the medication to flow into the ear canal and reach the site of infection.
Choice A is not correct because it is not necessary to swab and shake the bottle before administering the drops.
Choice B is not correct because tilting the head upright would cause the medication to flow out of the ear canal instead of reaching the site of infection.
Choice C is not correct because lowering the edge of the dropper into the canal of the ear could cause injury or discomfort to the patient.
How should the nurse document the finding of pain, numbness, and tingling sensations in the lower legs?
Explanation
The symptoms of pain, numbness, and tingling sensations in the lower legs are consistent with neuropathic pain.
Neuropathic pain is a complex type of pain initiated or caused by a primary lesion or dysfunction in the nervous system1.
Therefore, the nurse should document the finding as neuropathic pain.
Choice A is not correct because acute pain is a general term that does not specify the type of pain experienced by the patient.
Choice C is not correct because visceral pain refers to pain that originates from internal organs.
Choice D is not correct because nociceptive pain refers to pain caused by tissue damage or injury.
The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration.
Which action by the UAP should the nurse recognize indicates the need for additional teaching?
Explanation
When feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration, the head of the bed should be elevated 45 to 90 degrees to prevent aspiration1.
Therefore, if the UAP raises the head of the bed to only 80 degrees, it indicates the need for additional teaching.
Choice A is not correct because placing food on the unaffected side of the mouth is an appropriate action when feeding a client with a CVA.
Choice C is not correct because positioning the head with the chin tilted slightly downward can help prevent aspiration.
Choice D is not correct because allowing 30 minutes of rest before feeding can help improve digestion and reduce the risk of aspiration.
The nurse observes the skin over a client's greater trochanter, as seen in the picture with pressure sores.
What actions should the nurse implement?
Explanation
Pressure redistribution is an important part of preventing and treating pressure sores1.
Choice A is not the answer because offering oral fluids does not directly address the issue of pressure sores.
Choice C is not the answer because debridement is a surgical procedure that removes dead tissue from a wound and may not be necessary in this case.
Choice D is not the answer because checking for anemia and sensitivity does not directly address the issue of pressure
A client who had emergency gallbladder surgery yesterday is getting ready to be discharged.
The nurse knows that the client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client's understanding of self-care at home?
Explanation
The best way to evaluate the client’s understanding of self-care at home is to have the client demonstrate prescribed wound care.
This allows the nurse to directly observe the client’s ability to perform the necessary tasks and provide feedback and clarification as needed.
Choice B, providing written instructions in the client’s native language, may be helpful but does not allow the nurse to directly evaluate the client’s understanding.
Choice C, asking the client if he/she understands after each instruction, may not be effective if the client is not comfortable expressing confusion or misunderstanding.
Choice D, having an interpreter repeat the wound care instructions, may be helpful but still does not allow for direct observation of the client’s ability to perform the necessary tasks.
After a long bed rest, a client with a Foley catheter and wrist restraints has repeatedly removed the antibiotic (G) tube and NG tube.
At checking the restraints, which action is most important for the nurse to take?
Explanation
When checking the restraints, the most important action for the nurse to take is to assess capillary refill distal to the restraints.
This helps to ensure that the restraints are not too tight and that blood flow to the extremities is not compromised.
Choice B, verifying that the restraints can be quickly released, is important for safety but does not directly address the client’s physical well-being.
Choice D, replacing the nasogastric tube, may also be necessary but is not the most important action in this situation.
After a week of bed rest, a client is being assisted to a chair for the first time.
The nurse raises the head of the bed and moves the client to a sitting position. What should the nurse implement next?
Explanation
After moving the client to a sitting position, the next step the nurse should implement is to determine how the client feels.
This allows the nurse to assess for any dizziness, lightheadedness, or other symptoms that may indicate orthostatic hypotension or other issues.
Choice B, supporting the client when rising, is important but should be done after assessing how the client feels.
Choice C, offering a pair of non-skid socks, may be helpful for safety but is not the most important action in this situation.
Choice D, placing the chair by the bed, should be done before moving the client to a sitting position.
The nurse is caring for a client who has only months predicted to live. The client avoids questions regarding plans for care.
What is the next approach for the nurse to use when discussing end of life issues with the client?
Explanation
Nurses who provide end of life care are trained to communicate in a way that is concise, yet sensitive.
A personalized approach is often taken to meet the unique communication needs of each patient and to recognize when a person may be in pain or distressed 1.
Choice A is not the answer because asking questions in a vague, nonspecific format can lead to confusion and misunderstanding.
Choice B is not the answer because getting the most difficult questions over with first can be overwhelming for the client.
Choice D is not the answer because sharing personal values may not put the client at ease and may even make them feel uncomfortable.
What equipment should the nurse use to most accurately measure a 2ml dose of a viscous liquid solution to be given orally?
Explanation
A tuberculin syringe is designed to measure small volumes of liquid accurately and is commonly used to measure doses of medication.
Choice A is not the answer because a sterile needle is not necessary for measuring an oral dose of medication.
Choice B is not the answer because a one-ounce medicine cup is not precise enough to accurately measure a 2 mL dose.
Choice C is not the answer because a 3 mL syringe may not be precise enough to accurately measure a 2 mL dose of a viscous liquid solution.
The nurse is using guided imagery with a client who is experiencing chronic pain.
What should the nurse direct the client's attention on during the session?
Explanation
Guided imagery involves creating a specific imagined reality for yourself.
These techniques can be self-taught or guided by a professional.
The more you’re able to use your imagination and engage your senses, the greater the benefits 1.
Choice B is not the answer because motivational phrases may not be as effective as positive external places in reducing chronic pain through guided imagery.
Choice C is not the answer because tranquil sounds may not be as effective as positive external places in reducing chronic pain through guided imagery.
Choice D is not the answer because emotional reflection may not be as effective as positive external places in reducing chronic pain through guided imagery.
The nurse is preparing to give an emergency sedative injection to an agitated client.
Which action by the nurse is inappropriate?
Explanation
Placing a client in restraints without having a healthcare provider’s order.
It is inappropriate for a nurse to place a client in restraints without having a healthcare provider’s order.
Choice B is not the answer because administering the medication to a client behind a closed curtain is not necessarily inappropriate.
Choice C is not the answer because enlisting security personnel to assist with restraining the client may be necessary in some situations.
Choice D is not the answer because informing a client that the medication being administered is a sedative is not necessarily inappropriate.
Two days after surgery, a male client experiences incisional pain while dangling his feet at the bedside and he refuses to ambulate as prescribed.
The nurse establishes a problem of 'Activity intolerance related to pain'. Based on this problem, which outcome statement is best for the nurse to include in his care plan?
Explanation
The goal of the care plan should be to help the client overcome his activity intolerance related to pain.
This can be achieved by helping him to ambulate without discomfort.
Choice B is not the answer because taking analgesics as prescribed may help manage the pain but does not address the problem of activity intolerance.
Choice C is not the answer because showing evidence of incision healing is important but does not address the problem of activity intolerance.
Choice D is not the answer because avoiding pain-causing activity may help manage the pain but does not address the problem of activity intolerance.
The nurse observes that a client is using accessory muscles. Which vital sign should the nurse obtain first?
Explanation
If a nurse observes that a client is using accessory muscles, it indicates an obstruction of the airways, which reduces oxygen saturation.
Accessory muscles help in the act of forced expiration to wash out carbon dioxide and improve oxygen saturation 1.
Therefore, the nurse should obtain the respiratory rate first.
Choice A is not the answer because determining pulse pressure will not provide any significant indication of respiratory distress 1.
Choice C is not the answer because temperature does not provide any significant data about the use of accessory muscles in respiration 1.
Choice D is not the answer because pulse rate does not provide any significant data about the use of accessory muscles in respiration 1.
While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively.
Which action should the nurse implement?
Explanation
Sensory overload happens when an individual is getting more input from their senses than their brain can sort through and process 1.
Therefore, reducing the stimuli in the area can help the client’s brain to better process the information being taught.
Choice A is not the answer because demonstrating the skill speaking slowly and using simple terms does not address the issue of sensory overload 1.
Choice B is not the answer because reassuring the client that the skill is not difficult to learn does not address the issue of sensory overload 1.
Choice D is not the answer because providing step-by-step written instruction does not address the issue of sensory overload 1.
An accident arrives at the emergency department (ED) with severe right lower quadrant abdominal pain.
To assess the intensity of the client's pain, which approach should the nurse use?
Explanation
The assessment of pain intensity by a validated pain scale is a critical initial step, and a patient’s self-reporting is widely considered as the key to effective pain management 1.
According to good practice guidelines, clinicians must accept a patient’s statement, regardless of their own opinions 1.
Choice A is not the answer because asking the client to describe the pain does not provide an objective measure of pain intensity 1.
Choice C is not the answer because identifying effective pain relief measures does not assess the intensity of the client’s pain 1.
Choice D is not the answer because observing body language and movement does not provide an objective measure of pain intensity 1.
The nurse is caring for a male client with decreased circulation in the lower extremities. The client washes his feet in the shower but is unable to bend safely to dry the feet.
While drying the client's feet, the nurse should emphasize the need to thoroughly dry which area of the feet?
Explanation
While drying the client’s feet, the nurse should emphasize the need to thoroughly dry between the toes.
Moisture between the toes can create a breeding ground for bacteria and fungi, which can lead to infections such as athlete’s foot 1.
Choice C is not the answer because drying over the heels is not as important as drying between the toes 1.
Choice D is not the answer because drying around the ankles is not as important as drying between the toes 1.
The nurse is planning to provide mouth care to an unconscious client.
Which statement is accurate for implementing mouth care to this client?
Explanation
Cleaning the inner cheeks and outer gum surfaces with a gauze pad is appropriate for an unconscious client.
When mouth care is provided, an unconscious patient is placed in the side-lying position because this prevents secretions from pooling at the back of the oral cavity, lowering the risk of aspiration1.
Choice A is incorrect because brushing an unconscious client’s teeth should not be avoided.
In fact, it is recommended that you brush your teeth at least once every four hours1.
Choice C is incorrect because unconscious clients need regular mouth care just like conscious clients2.
Choice D is incorrect because positioning the unconscious client upright is not the best method.
Instead, they should be placed in a side-lying position to prevent aspiration1.
The nurse observes a new employee, an uncertified nursing assistant (UAP), checking the temperature using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer.
Which action should the nurse implement?
Explanation
The UAP is correctly pulling the client’s auricle up and back and preparing to insert the thermometer1.
Choice A is incorrect because it is not necessary to remind the UAP to locate the thermometer before gently inserting it into the ear.
Choice B is incorrect because the UAP is already demonstrating the correct technique for pulling the client’s auricle up and back1.
Choice C is incorrect because it is not necessary to advise the UAP to hold the thermometer securely in place to obtain the measurement.
A client is in contact isolation due to a stage IV coccyx wound infected with MRSA. The nurse plans interventions to prevent multiple infections.
Which intervention is most appropriate to prevent the spread of MRSA to others?
Explanation
Restate the vital importance of performing hand hygiene. The most effective way to prevent MRSA is frequent hand washing1.
Choice A is incorrect because changing the coccyx dressing after performing routine care does not necessarily prevent the spread of MRSA to others.
Choice B is incorrect because changing the coccyx dressing before performing routine care does not necessarily prevent the spread of MRSA to others.
Choice D is incorrect because performing a coccyx dressing change in the nursing station does not necessarily prevent the spread of MRSA to others.
An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert and requests that no heroic measures be implemented if her breathing stops.
What actions should the nurse take first?
Explanation
The nurse should first discuss with the client her meaning of heroic measures.
This will help the nurse to understand the client’s wishes and preferences for her care.
Choice A is incorrect because obtaining a do not resuscitate prescription should be done after discussing the client’s wishes and preferences.
Choice B is incorrect because setting up a family conference to discuss the client’s wishes should be done after discussing the client’s wishes and preferences with her.
Choice D is incorrect because consulting the palliative care team about the client’s care should be done after discussing the client’s wishes and preferences with her.
A client arrives at the emergency department (ED) with severe right upper quadrant pain.
To assess the quality of the client's pain, which approach should the nurse use?
Explanation
To assess the quality of the client’s pain, the nurse should ask the client to describe the pain.
This will help the nurse to understand the characteristics of the pain and how it is affecting the client.
Choice B is incorrect because providing a numeric pain scale only assesses the intensity of the pain, not its quality.
Choice C is incorrect because identifying effective pain relief measures does not assess the quality of the pain.
Choice D is incorrect because observing body language and movement only provides indirect information about the quality of the pain.
A client arrives at the emergency department (ED) with severe right upper quadrant pain.
To assess the quality of the client's pain, which approach should the nurse use?
Explanation
To assess the quality of the client’s pain, the nurse should ask the client to describe the pain.
This will help the nurse to understand the characteristics of the pain and how it is affecting the client.
Choice B is incorrect because providing a numeric pain scale only assesses the intensity of the pain, not its quality.
Choice C is incorrect because identifying effective pain relief measures does not assess the quality of the pain.
Choice D is incorrect because observing body language and movement only provides indirect information about the quality of the pain.
Sign Up or Login to view all the 45 Questions on this Exam
Join over 100,000+ nursing students using Nursingprepexams’s science-backend flashcards, practice tests and expert solutions to improve their grades and reach their goals.
Sign Up Now
