MED Surge 2 HESI Final EXIT exam GRADED A LATEST

MED Surge 2 HESI
Final EXIT exam
GRADED A LATEST





1. A client with Cushing's syndrome is recovering from an
elective laparoscopic procedure. Which assessment finding
warrant's immediate intervention by the nurse?
a. Purple marks on skin of the abdomen
b. Irregular apical pulse
c. Quarter size blood spot on dressing
d. Pitting ankle edema - ANSWER-b. Irregular apical pulse
2. A client with lung cancer who wears a subcutaneous
morphine sulfate patch for pain is short of breath and is
difficult to arouse. When performing a head to toe assessment,
the nurse discovers four analgesic patches on the clients body.
Which intervention should the nurse implement first?
a. Remove all of the morphine patches
b. Administer a narcotic antagonist
c. Apply oxygen per face mask
d. Measure the client's blood pressure - ANSWER-b. Administer
a narcotic antagonist
3. A client receives prescriptions for a multidrug regimen for
the treatment of tuberculosis. Which information should the
nurse prioritize?
a. Adherence to the regimen is imperative
b. Medications should be taken with food
c. Serum liver panels are collected regularly
d. Enhanced sun protection measures will be needed -
ANSWER-a. Adherence to the regimen is imperative
4. The nurse is preparing a client for surgery who was admitted
to the emergency center following a motor vehicle collision.
The client has an open fracture of the femur and is bleeding
moderately from the bone protrusion site. During the
prescriptive assessment, the nurse determines that the client
currently receives heparin sodium 5,000 units subcutaneously
daily. What is the priority nursing action?
a. Notify the healthcare provider of the client's medication
history
b. Observe the heparin injections sites for signs of bruising
c. Have the client sign the surgical and transfusion permits
d. Ensure that the potential for bleeding is explained to the
client - ANSWER-a. Notify the healthcare provider of the client's
medication history
5. A client with orthopnea expresses concern about the ability
to "get enough air" during a scheduled thoracentesis. On which
information should the nurse's response be based?
a. A thoracentesis is a brief process that has minimal discomfort
b. Orthopnea is frequently caused by a client's uncontrolled
anxiety
c. The procedure is performed with the client in an upright
position
d. Extra pillows can be used if needed to elevate the client's
head - ANSWER-c. The procedure is performed with the client
in an upright position