HESI MED SURG V1 2022 Questions and Answers

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HESI MED SURG V1 2022 Questions and Answers 1.The nurse is preparing to assist a client with a cuffed tracheostomy tube to eat. What intervention is the priority before the client is permitted to drink or eat✔✔ Inflate the cuff

Rationale: If a client with a tracheostomy is allowed to eat and the

tracheostomy has a cuff, the nurse should inflate the cuff to prevent aspiration of food or fluids. The cuff would not be deflated because of the risk of aspiration.

2.The nurse has implemented a bowel maintenance program for an un- conscious client. The nurse would evaluate the plan as best meeting the needs of the client if which method was successful in stimulating a bowel movement✔✔ Glycerin suppository

Rationale: The least amount of invasiveness needed to produce a bowel

movement is best. Use of glycerin suppositories is the least invasive method and usually stimulates bowel evacuation within a half-hour.

3.A client is readmitted to the hospital with dehydration after surgery for creation of an ileostomy. The nurse assesses that the client has lost

• lb of weight, has poor skin turgor, and has concentrated urine. The

nurse interprets the client's clinical picture as correlating most closely with re- 1 / 3

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cent intake of which medication, which is contraindicated for the ileostomy client✔✔ Biscodyl

Rationale: The client with an ileostomy is prone to dehydration

because of the location of the ostomy in the gastrointestinal tract and should not take laxatives 4.The client is complaining of skin irritation from the edges of a cast applied the previous day. Which action should the nurse take✔✔ The nurse petals the edges of the cast with tape

Rationale: minimize skin irritation.

5.The nurse is taking a health history for a client with hyperparathyroidism. Which question would elicit information about this client's condition✔✔ "Are you experiencing pain in your joints?"

Rationale: Hyperparathyroidism is associated with over secretion of

parathyroid hormone (PTH), which causes excessive osteoblast growth and activity within the bones.When bone reabsorption is increased, calcium is released from the bones into the blood, causing hypercalcemia. The 2 / 3

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bones suffer demineralization as a result of calcium loss, leading to bone and joint pain 6.A client with type 2 diabetes mellitus has a blood glucose level greater than 600 mg/dL (34.3 mmol/L) and is complaining of polydipsia, polyuria, weight loss, and weakness. The nurse reviews the health care provider's documentation and expects to note which diagnosis✔✔ Hyperosmolar hyper- glycemic syndrome (HHS)

Rationale: HHS is seen primarily in clients with type 2 diabetes mellitus,

who experience a relative deficiency of insulin. The onset of signs and symptoms may be gradual.Manifestations may include polyuria, polydipsia, dehydration, mental status alter- ations, weight loss, and weakness.

7.The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse develops the plan, expecting that the health care provider (HCP) will most likely prescribe which option✔✔ Maintain activity level as prescribed.

Rationale: Standard management for the client with DVT includes

maintaining the activity level as prescribed by the health care provider; limb elevation; relief of discomfort with warm, moist heat; and analgesics as needed. Recent research is showing that ambulation, as previously thought, does not cause pulmonary

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