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Samuel merrit University, hesi med surg
Samuel merrit University, hesi med surg
Total Questions : 45
Showing 10 questions Sign up 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
A. Placing food on the unaffected side of the mouth is appropriate for a client who has had a CVA and may have unilateral weakness. This technique helps the client chew and swallow effectively, reducing the risk of aspiration.
B. Raising the head of the bed to 80 degrees is too high and can increase the risk of choking or aspiration by making it harder for the client to control the food bolus during swallowing. A more appropriate position is raising the head of the bed to 45–60 degrees, which facilitates safe swallowing while maintaining comfort. This action requires additional teaching.
C. Positioning the head with the chin tilted slightly downward, known as the chin-tuck position, is a recommended strategy to prevent aspiration. This position helps close the airway during swallowing, reducing the risk of food or liquid entering the trachea.
D. Allowing 30 minutes of rest before feeding is appropriate because it ensures the client is not fatigued, which can compromise swallowing ability and increase 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.
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