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Hesi Med-surg exam (MCPHS University)
Total Questions : 59
Showing 10 questions, Sign in for moreThe nurse assists a client with Parkinson's disease (PD) to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. The client tells the nurse of pretending to step over a crack on the floor. How should the nurse respond?
The nurse establishes a nursing problem, "Fatigue related to inability to rest comfortably secondary to rheumatoid arthritis." Which nursing intervention should the nurse include in the plan of care (POC) for this client?
A 68-year-old male, with a history of bilateral total hip arthroplasty two years ago, presents to the emergency department (ED) by ambulance. Client said he simply slipped today and did not feel lightheaded or dizzy before the fall. He says he returned home from the store and was putting his groceries away, dropped a can, and bent over to pick it up. He says he lost his balance and fell face-forward, hitting his head on the wall and his left shoulder on the floor. Reports pain mainly in his shoulder. However, he also notes pain in his right knee. Additionally, he indicates he feels nauseated and tired.
Client is resting in bed, grimacing. Vital signs assessed. Reports intense pain and the inability to move his left arm. He appears guarded. His gown has slipped off his shoulder, swelling and bruising are present. The skin on the left arm is cool to the touch. His collarbone appears out of alignment on the left side.
1835
Peripheral IV (PIV) access is initiated with a 20 gauge in the right forearm. Assessment performed.
Neurological: Pupils equal and reactive to light. Oriented times 3. Decreased sensation noted in left forearm to fingertips.
Cardiovascular: Normal heart sounds of S1 and S2. Bilateral pedal pulses and right radial pulse are 2+ while left radial is 1+
Respiratory: Clear lung sounds in all fields.
Musculoskeletal: Normal strength observed in lower extremities. Minimal pain on palpation noted in right knee. Can still flex and extend his right leg. 1+ strength noted in the left upper extremity and 3+ strength noted in the right upper extremity. Diffuse pain noted with and without palpation on the left shoulder, and pain reported extending from the left shoulder into the neck. 3+ swelling is noted on the left shoulder and 1+ swelling on the right knee. No pain noted upon assessment of right shoulder and left knee.
Gastrointestinal: Abdomen is soft, nondistended and nontender.
Genitourinary: Last bowel movement reported today. Denies difficulty with urination.
Integumentary: The left arm is cool to touch. Bruising is noted on the left upper arm; bruise area is 0.79 in (3 cm) by 1.18 in (2 cm). Right knee skin is intact and dry.
1930
The healthcare provider (HCP) speaks to the client about surgery recommendations. Questions are answered, and the client signs the consent forms.
2310
Is transferred from surgical recovery into a surgical bed. Received a nerve block prior to surgery, Reports he feels sick to his stomach and worries that he might vomit. He reports the inability to lift or feel his left arm. A compression bandage with gauze is wrapped around the surgical area. Has 500 mL left in the 0.9% sodium chloride bag, infusing without problems.
1820
Vital signs
- Temperature: 98.1° F (36.7° C), orally
- Heart rate: 88 beats/minute
- Respirations: 18 breaths/minute
- Blood pressure: 136/90 mm Hg
- Oxygen saturation: 95% on room air
- Pain: 10 on a 0 to 10 scale, sharp and constant in the left arm; pain 3 on a 0 to 10 scale, dull and achy in the right knee
- Weight: 344 lb (156.1 kg)
- Height: 6 ft 2 in (182.8 cm)
- Body mass index (BMI): 46.67 kg/m2 (normal 18.0 to 24.9 kg/m2)
2310
Vital signs
- Temperature: 98.4° F (36.9°C), orally
- Heart rate: 78 beats/minute
- Respirations: 16 breaths/minute
- Blood pressure: 120/78 mm Hg
- Oxygen saturation: 96% on room air
- Pain: 0 on a 0 to 10 scale
1830
- Insert peripheral IV (PIV) access device
- X-ray of left shoulder and right knee, STAT
- Computed tomography (CT) of brain, STAT
1900
- Morphine 2 mg IV push (IVP), once now
- Oxycodone 7.5 mg PO every 4 hours PRN for pain rating greater than 5 on a 0 to 10 scale
- Acetaminophen 500 mg PO every 4 hours PRN for pain rating greater than 2 on a 0 to 10 scale
1930
- Complete blood count (CBC) and complete metabolic panel (CMP)
- Prepare client for surgery
2305
- Admit client to surgical unit
- Infuse 0.9% sodium chloride IV infusion at 100 mL/hour
- Enoxaparin 30 mg SUBQ every 12 hours
- Clear liquid diet, advance as tolerated to regular diet
- Do not remove surgical dressing the healthcare provider (HCP) will remove on postoperative day 1
- Ketorolac 10 mg IVP every 4 hours
- Morphine 2 mg IVP every 2 hours PRN for pain rating greater than 7 on a 0 to 10 scale
- Cefazolin 250 mg IV piggyback (IVPB) every 8 hours
- Ondansetron 4 mg IVP every 4 hours PRN for nausea
- Incentive spirometer every hour for 10 breaths, while awake
1850
Shoulder x-ray, 3 views: Fracture of left humeral head/neck junction. Bony impaction with comminution is noted. The fracture extends to the shoulder joint. Significant displacement of the fracture at the humeral head/neck junction is seen. There is a bony offset of the fracture fragment most pronounced in the neck region.
Knee x-ray, 3 views: No osseous abnormality. Osteoarthropathy of the patellofemoral compartment.
Computed tomography (CT) brain: No acute intracranial abnormality.
The nurse reviews the prescriptions and plans initial steps for caring for the client.
Explanation
Rationale:
- Administer ondansetron 4 mg IV push: The client reports nausea and a history of vomiting, likely related to trauma, surgery preparation, and opioid use. Administering ondansetron will prevent aspiration, maintain hydration, and promote comfort during recovery.
- Inspect the bandage for drainage: Observing the surgical dressing for bleeding or drainage is critical post-injury and postoperatively. It allows the nurse to identify early signs of hemorrhage, hematoma, or infection and report abnormalities promptly.
- Check capillary refill on bilateral upper extremities: The left arm shows cool skin and diminished radial pulse (1+), suggesting compromised circulation. Checking capillary refill helps monitor perfusion and detect potential neurovascular compromise early.
- Provide morphine 2 mg IV push: The client reports severe pain (10/10) from the humeral fracture. Administering prescribed opioids manages pain effectively, facilitates movement, and improves comfort, while allowing compliance with surgical positioning and procedures.
- Perform range of motion: Active or passive range-of-motion exercises on the fractured left arm are contraindicated because the client has a displaced humeral head/neck fracture. Movement could worsen displacement, compromise neurovascular status, increase pain, and impede healing. The arm should remain immobilized until surgical fixation.
- Palpate and compare radial pulses: Comparing pulses bilaterally assesses for neurovascular compromise in the injured limb. This is essential after fractures, especially with displacement, swelling, and diminished strength, to prevent ischemic complications.
The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?
The nurse is caring for a client who reports a sudden, severe headache, and facial numbness. The nurse asks the client to smile and observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. After obtaining vital signs, the nurse should implement which intervention?
While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?
The nurse has determined that a client with trigeminal neuralgia has the nursing problem, "Imbalanced nutrition, less than body requirements." Which cause is most likely contributing to the problem?
A client who has had diabetes for the past 10 years has an elevated blood pressure and bilateral ankle edema. Which laboratory result should the nurse report to the healthcare provider?
A client with chronic venous insufficiency is being discharged from the hospital, and plans to return home. Which client statement indicates an understanding of home care instructions?
The nurse is collecting a urine specimen for a client with symptoms related to urethritis. Which collection method should the nurse implement?
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