HESI ONL: HU NSG527 Med Surg Nursing II Exam 2 Summer C
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Free HESI ONL: HU NSG527 Med Surg Nursing II Exam 2 Summer C Questions
74-year-old male client comes to emergency department (ED) with symptoms of feeling weak, extreme tiredness and lack of appetite for 4 days.
Nurses' Notes:
0800 — Client has a diagnosis of end stage renal disease (ESRD) and was supposed to go to the hospital to start dialysis but did not have transportation. Peripheral IV (PIV) access device inserted, and STAT laboratory specimens drawn. Connected to continuous cardiac monitoring.
0810 — Mucous membranes dry. Capillary refill greater than 3 seconds. Able to void, but urinary output less than 100 mL/24 hours. Weight 188 lb (85.45 kg).
Laboratory Results:
Basic Metabolic Panel (BMP):
- Potassium: 6.6 mEq/L (6.6 mmol/L) — Reference range: 3.5 to 5 mEq/L (3.5 to 5 mmol/L)
- Sodium: 130 mEq/L (130 mmol/L) — Reference range: 136 to 145 mEq/L (136 to 145 mmol/L)
- Creatinine: 1.4 mg/dL (123.8 μmol/L) — Reference range: 0.5 to 1.1 mg/dL (44 to 97 μmol/L)
- Blood urea nitrogen (BUN): 20 mg/dL (7.14 mmol/L) — Reference range: 7 to 20 mg/dL (2.5 to 7.1 mmol/L)
Arterial Blood Gas (ABG):
- pH: 7.33 — Reference range: 7.35 to 7.45
- PaCO2: 25 mm Hg — Reference range: 35 to 45 mm Hg
- HCO3-: 18 mEq/L (18 mmol/L) — Reference range: 21 to 28 mEq/L (21 to 28 mmol/L)
PaO2: 80 mm Hg — Reference range: 80 to 100 mm Hg
Flow Sheet (0810) — Vital Signs:
- Heart rate: 126 beats/minute and irregular
- Respirations: 24 breaths/minute and shallow
- Blood pressure: 166/104 mm Hg
- Oxygen saturation: 92% on room air
Orders (0800):
- Admit to hospital for insertion of subclavian dialysis catheter. Send to interventional radiology for insertion STAT
- Begin hemodialysis as soon as catheter in place and verified by x-ray
- Repeat basic metabolic panel (BMP) and complete blood count (CBC) at the end of first dialysis and every six hours thereafter
- Weigh daily
The nurse is reviewing the client's assessment data to prepare the plan of care (POC).
For each finding click to highlight the emergency department (ED) notation that requires immediate follow up. Each finding may support more than one ED notation. Each category must have at least one response option selected.
Findings: Arterial Blood Gas (ABG) ☐ pH 7.33 ☐ PaCO2 25 mm Hg ☐ PaO2 80 mm Hg
Findings: Laboratory Basic Metabolic Panel (BMP) ☐ Creatinine 1.4 mg/dL (0.23 mmol/L) ☐ Blood urea nitrogen (BUN) 20 mg/dL (7.14 mmol/L) ☐ Potassium 6.6 mEq/L (6.6 mmol/L)
Findings: Vital Signs ☐ Capillary refill greater than 3 seconds ☐ Blood pressure 166/104 mm Hg ☐ Heart rate 126 beats/minute and irregular
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pH 7.33
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PaCO2 25 mm Hg
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PaO2 80 mm Hg
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Creatinine 1.4 mg/dL (0.23 mmol/L)
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Blood urea nitrogen (BUN) 20 mg/dL (7.14 mmol/L)
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Potassium 6.6 mEq/L (6.6 mmol/L)
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Capillary refill greater than 3 seconds
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Blood pressure 166/104 mm Hg
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Heart rate 126 beats/minute and irregular
Explanation
Correct Answer:
- Arterial Blood Gas (ABG) — pH 7.33
- Laboratory Basic Metabolic Panel (BMP) — Potassium 6.6 mEq/L (6.6 mmol/L)
- Vital Signs — Capillary refill greater than 3 seconds and Heart rate 126 beats/minute and irregular
Why Other Findings Are Not Immediate Priorities:
PaCO2 25 mm Hg and PaO2 80 mm Hg. The low PaCO2 reflects expected respiratory compensation for metabolic acidosis rather than a primary respiratory problem, and the PaO2 is within normal limits.
Creatinine 1.4 mg/dL and BUN 20 mg/dL. These values are elevated or at the upper limit consistent with known ESRD and are expected findings rather than acute, immediate concerns.
Blood pressure 166/104 mm Hg. While elevated, likely due to fluid overload from missed dialysis, this is a chronic and expected finding in ESRD rather than the most urgent, immediately life-threatening concern.
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Give IV analgesia.
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Administer tetanus immunization.
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Start IV antibiotics.
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Give an IV bolus of normal saline.
Explanation
Correct Answer: (D) Give an IV bolus of normal saline. Full thickness burns cause massive fluid loss through damaged skin and capillary leak, placing the client at high risk for hypovolemic shock. The priority intervention is to initiate aggressive IV fluid resuscitation with a bolus of normal saline to maintain adequate circulating volume and organ perfusion.
Why Other Options are Incorrect:
A. Give IV analgesia. While pain management is important, it is not the priority over addressing the client's immediate risk for hypovolemic shock from significant fluid loss.
B. Administer tetanus immunization. Tetanus prophylaxis is appropriate for burn wound care but is not the priority intervention in the acute phase compared to fluid resuscitation.
C. Start IV antibiotics. Prophylactic antibiotics are not a priority intervention in the immediate management of burns and are not routinely indicated unless infection is present.
A client is receiving an intermittent infusion of erythromycin lactobionate for injection, USP, 1 gram in 250 mL of normal saline over two hours. The nurse should program the infusion pump to deliver how many mL/hour? (Enter numeric value only.)
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125
Explanation
To calculate the infusion rate, divide the total volume by the total time: 250 mL ÷ 2 hours = 125 mL/hour.
A client with chronic syndrome of inappropriate antidiuretic hormone (SIADH) reports to the nurse that they feel constantly thirsty. Which action should the nurse take?
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Encourage the client to use hard candy frequently to help relieve thirst.
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Withhold the next diuretic dose until contacting the healthcare provider (HCP).
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Provide the client with additional oral fluids of her preference.
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Measure the client's capillary glucose reading at regular intervals.
Explanation
Correct Answer: (A) Encourage the client to use hard candy frequently to help relieve thirst. Clients with SIADH retain excess water, requiring fluid restriction as a primary treatment measure. To help manage the client's sensation of thirst without increasing fluid intake, the nurse should encourage non-fluid comfort measures, such as sucking on hard candy, which stimulates saliva production and helps relieve dry mouth and thirst without contributing to further fluid overload.
Why Other Options are Incorrect:
B. Withhold the next diuretic dose until contacting the healthcare provider (HCP). There is no indication that the diuretic dose needs to be withheld based on the client's report of thirst; this action is not warranted by the data provided.
C. Provide the client with additional oral fluids of her preference. Providing additional fluids would worsen the client's fluid overload, as fluid restriction is essential in the management of SIADH.
D. Measure the client's capillary glucose reading at regular intervals. Thirst in this client is related to fluid restriction for SIADH management, not a concern related to blood glucose levels.
A client fell 20 feet from a ladder and fractured the right tibia. After a plaster cast was applied, the client was admitted for observation. Which assessment finding warrants immediate intervention by the nurse?
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Toes exhibit 1+ edema.
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Pain reported 7 on a 0 to 10 scale.
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Bruising on exposed right foot.
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Onset of paresthesia of foot.
Explanation
Correct Answer: (D) Onset of paresthesia of foot. New onset paresthesia (numbness or tingling) is a critical sign of neurovascular compromise and may indicate compartment syndrome, a limb-threatening emergency caused by increased pressure within the cast or surrounding tissue. This finding requires immediate intervention to prevent permanent nerve damage or tissue necrosis.
Why the other options are incorrect:
A. Toes exhibit 1+ edema. Mild edema is an expected finding after a fracture and cast application and does not, by itself, indicate an emergency.
B. Pain reported 7 on a 0 to 10 scale. Pain is expected after a fracture; while it should be managed, it is not as urgent as a new neurological finding suggesting nerve compromise.
C. Bruising on exposed right foot. Bruising is an expected finding following trauma and does not indicate an acute neurovascular emergency on its own.
A client with Cushing's disease is admitted to the medical unit with uncontrolled hypertension. Which interventions should the nurse implement for this client? Select all that apply.
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Monitor serum glucose.
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Obtain daily weights.
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Encourage increased fluid intake.
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Promote verbalization of feelings.
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Assess for signs of hypoglycemia.
Explanation
Correct Answer: (A) Monitor serum glucose, (B) Obtain daily weights, (D) Promote verbalization of feelings.
Excess cortisol in Cushing's disease causes hyperglycemia due to increased gluconeogenesis and insulin resistance, so monitoring serum glucose is essential. Cortisol excess also causes sodium and fluid retention, leading to weight gain and hypertension, making daily weights an important monitoring tool. Additionally, clients with Cushing's disease often experience significant body image changes and mood disturbances, so promoting verbalization of feelings supports their emotional and psychological well-being.
Why the other options are incorrect:
C. Encourage increased fluid intake. Clients with Cushing's disease already retain excess sodium and fluid, contributing to hypertension; increasing fluid intake would worsen fluid overload and blood pressure.
E. Assess for signs of hypoglycemia. Cushing's disease causes hyperglycemia, not hypoglycemia, due to elevated cortisol levels, so this assessment is not appropriate.
The nurse is working with a client who has a new cast for a fractured elbow. Which outcome is the priority?
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Experiences no peripheral neurovascular dysfunction.
-
Demonstrates appropriate care of cast.
-
Reports satisfactory relief of pain.
-
Maintains maximum mobility within limitations.
Explanation
Correct Answer: (A) Experiences no peripheral neurovascular dysfunction.
A new cast can cause swelling that compromises circulation and nerve function in the affected limb, potentially leading to compartment syndrome, a limb-threatening emergency. Preventing peripheral neurovascular dysfunction is the priority because unaddressed compromise can result in permanent nerve damage, tissue necrosis, or loss of limb function within hours.
Why the other options are incorrect:
B. Demonstrates appropriate care of cast. This is important patient education but is not as urgent or life/limb-threatening as neurovascular status.
C. Reports satisfactory relief of pain. Pain control matters for comfort, but pain itself can also be a warning sign of neurovascular compromise, making assessment of circulation and sensation the higher priority.
D. Maintains maximum mobility within limitations. Mobility is a long-term goal for recovery but is secondary to ensuring the limb remains viable and properly perfused.
A client who is receiving normal saline IV at 75 mL/hour has dry, sticky mucous membranes and diminished skin turgor. Which action should the nurse implement?
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Slow the normal saline to a keep open rate while contacting the healthcare provider (HCP).
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Instruct the client to withhold oral fluids and report the symptoms to the healthcare provider (HCP).
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Review the client's medications to see if the client can be given a PRN diuretic.
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Continue the normal saline IV at 75 mL/hour and encourage increased oral fluid intake.
Explanation
Correct Answer: (D) Continue the normal saline IV at 75 mL/hour and encourage increased oral fluid intake. This client's dry, sticky mucous membranes and diminished skin turgor are signs of fluid volume deficit. Since the current IV rate is not adequately meeting the client's fluid needs, the nurse should continue the prescribed normal saline infusion and encourage additional oral fluid intake to further supplement hydration and correct the deficit.
Why the other options are incorrect:
A. Slow the normal saline to a keep open rate while contacting the healthcare provider (HCP). Slowing the IV fluids would worsen this client's existing fluid volume deficit and is contraindicated given the signs of dehydration.
B. Instruct the client to withhold oral fluids and report the symptoms to the healthcare provider (HCP). Withholding oral fluids would further exacerbate the client's dehydration and is not an appropriate action for a client with signs of fluid volume deficit.
C. Review the client's medications to see if the client can be given a PRN diuretic. Administering a diuretic would worsen this client's fluid volume deficit by increasing fluid loss, which is contraindicated in this situation.
74-year-old male client comes to emergency department (ED) with symptoms of feeling weak, extreme tiredness and lack of appetite for 4 days.
Nurses' Notes:
0800 — Client has a diagnosis of end stage renal disease (ESRD) and was supposed to go to the hospital to start dialysis but did not have transportation. Peripheral IV (PIV) access device inserted, and STAT laboratory specimens drawn. Connected to continuous cardiac monitoring.
0810 — Mucous membranes dry. Capillary refill greater than 3 seconds. Able to void, but urinary output less than 100 mL/24 hours. Weight 188 lb (85.45 kg).
Laboratory Results:
Basic Metabolic Panel (BMP):
- Potassium: 6.6 mEq/L (6.6 mmol/L) — Reference range: 3.5 to 5 mEq/L (3.5 to 5 mmol/L)
- Sodium: 130 mEq/L (130 mmol/L) — Reference range: 136 to 145 mEq/L (136 to 145 mmol/L)
- Creatinine: 1.4 mg/dL (123.8 μmol/L) — Reference range: 0.5 to 1.1 mg/dL (44 to 97 μmol/L)
- Blood urea nitrogen (BUN): 20 mg/dL (7.14 mmol/L) — Reference range: 7 to 20 mg/dL (2.5 to 7.1 mmol/L)
Arterial Blood Gas (ABG):
- pH: 7.33 — Reference range: 7.35 to 7.45
- PaCO2: 25 mm Hg — Reference range: 35 to 45 mm Hg
- HCO3-: 18 mEq/L (18 mmol/L) — Reference range: 21 to 28 mEq/L (21 to 28 mmol/L)
PaO2: 80 mm Hg — Reference range: 80 to 100 mm Hg
Flow Sheet (0810) — Vital Signs:
- Heart rate: 126 beats/minute and irregular
- Respirations: 24 breaths/minute and shallow
- Blood pressure: 166/104 mm Hg
- Oxygen saturation: 92% on room air
Orders (0800):
- Admit to hospital for insertion of subclavian dialysis catheter. Send to interventional radiology for insertion STAT
- Begin hemodialysis as soon as catheter in place and verified by x-ray
- Repeat basic metabolic panel (BMP) and complete blood count (CBC) at the end of first dialysis and every six hours thereafter
- Weigh daily
Imaging Studies: Tunneled subclavian 16 French (Fr) triple lumen dialysis catheter placed in interventional radiology. Placement confirmed via chest x-ray.
The nurse is reviewing the client's assessment data to prepare the plan of care (POC).
Select 3 prescriptions the nurse should perform prior transferring the client.
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Assess peripheral IV (PIV) site for patency
-
Reassess pain level
-
Educate client about dialysis procedure
-
Administer second dose of labetalol
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Prepare the client for dialysis
Explanation
Correct Answer: (A, B, E) Assess peripheral IV (PIV) site for patency; Reassess pain level; Prepare the client for dialysis. Prior to transferring the client, the nurse should assess the PIV site for patency to ensure it remains functional and free from complications such as infiltration prior to transfer. The nurse should also reassess pain level, since the client reported chest pain related to the cardiac dysrhythmia caused by severe hyperkalemia, to evaluate whether the pain has resolved or requires further intervention before transfer. Finally, the nurse should prepare the client for dialysis, as the tunneled dialysis catheter placement has been confirmed and hemodialysis is the priority treatment ordered to correct this client's life-threatening hyperkalemia and metabolic acidosis.
Why the other options are incorrect:
C. Educate client about dialysis procedure. While client education is important, it is not a priority nursing action prior to transfer in this acute, unstable situation and can be provided by the dialysis team.
D. Administer second dose of labetalol. There is no data indicating labetalol has been ordered or administered for this client, making this option unsupported by the case information.
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Warm the dialysate solution before initiating the exchange.
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Check the blood pressure, pulse, respirations, and temperature.
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Plan to increase the dwell time of the next dialysis exchange.
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Report the assessment findings to the nephrologist.
Explanation
Correct Answer: (B) Check the blood pressure, pulse, respirations, and temperature. This client's abdominal pain, diminished bowel sounds, and report of not feeling well are concerning for peritonitis, a serious complication of peritoneal dialysis. Following the nursing process, the nurse should further assess the client by obtaining a full set of vital signs, since fever and hemodynamic changes are key indicators of infection, before proceeding with any intervention or notification.
Why Other Options are Incorrect:
A. Warm the dialysate solution before initiating the exchange. Proceeding with the dialysis exchange is inappropriate before further assessing the client's concerning symptoms, which may indicate a complication requiring different management.
C. Plan to increase the dwell time of the next dialysis exchange. This intervention does not address the client's current symptoms and assessment is needed before making changes to the dialysis regimen.
D. Report the assessment findings to the nephrologist. While the HCP will need to be notified, the nurse should first gather complete assessment data, including vital signs, to provide a thorough report.
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