Hesi Med Surg | Nurselytic

Questions 34

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Hesi Med Surg Questions

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Question 1 of 5

A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?

Correct Answer: A

Rationale: Elevated rheumatoid factor is a marker of the autoimmune process in rheumatoid arthritis, confirming the diagnosis and indicating disease severity, not specific organ involvement or decline.

Question 2 of 5

An adult woman with Grave's disease is admitted with severe dehydration and malnutrition. She is currently restless and refusing to eat. Which action is most important for the nurse to implement?

Correct Answer: C

Rationale: Maintaining a patent IV site allows administration of fluids, electrolytes, and nutrients, addressing the critical dehydration and malnutrition in Grave's disease, which takes precedence over other supportive measures.

Question 3 of 5

The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action about skin care indicates a need for further teaching?

Correct Answer: B

Rationale: Washing with antibacterial soap can dry and irritate the sensitive skin at the radiation site, increasing the risk of damage. Mild, unscented soap is recommended, indicating a need for further teaching.

Question 4 of 5

The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?

Correct Answer: C

Rationale: A high-pitched sound (stridor) indicates potential airway obstruction, a life-threatening emergency requiring immediate intervention to ensure airway patency.

Question 5 of 5

A client admitted to the emergency department with an acute exacerbation of peptic ulcer disease is vomiting and describing epigastric pain and nausea. After obtaining vital sign measurements, which prescription should the nurse implement first?

Correct Answer: A

Rationale: Inserting an NGT with low intermittent suction decompresses the stomach, removes gastric contents, and relieves vomiting and pain, addressing the acute symptoms of peptic ulcer exacerbation first.

Similar Questions

While completing a health assessment for a young adult female with acute appendicitis, the client informs the nurse that there is a chance that she may be pregnant. The operating team is preparing to take the client to surgery. Which intervention should the nurse implement immediately?
An adult client, a smoker, has had chronic obstructive pulmonary disease (COPD) for twelve years. When conducting discharge teaching, what should the nurse advise the client to avoid in order to prevent exacerbation of COPD?
Which admission assessment findings should the nurse document related to a client who has been diagnosed with Cushing's syndrome?
On the third postoperative day, a client who has had a hip replacement surgery becomes anxious and diaphoretic, and begins to experience auditory hallucinations. The client denies having any pain. The client's vital signs are pulse rate is 125 beats/minute, respiratory rate is 36 breaths/minute, and blood pressure is 166/88 mmHg. Which nursing interventions should the nurse implement? (Select all that apply.)
A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?

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