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 fractu
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Medical Surgical Assignment Exam HESI Quizlet

1. 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.

Correct answer: D

Rationale: In this scenario, the priority action is to notify the healthcare provider of the client's medication history. This is important because understanding the client’s medication history, especially if they are taking anticoagulants or other medications that could affect bleeding and surgery, is crucial in ensuring safe management of the client's condition. Option A, ensuring the client is NPO and documenting the last meal, is important but not the priority in this situation. Administering pain medication (Option B) should only be done after ensuring the client's safety and stability. Applying a sterile dressing (Option C) is also important but not as critical as informing the healthcare provider of the medication history.

2. A client admitted with left-sided heart failure has a heart rate of 110 beats per minute and is becoming increasingly dyspneic. Which additional assessment finding by the nurse supports the client’s admitting diagnosis?

Correct answer: B

Rationale: The correct answer is B: Crackles in the lung bases. Crackles in the lung bases are indicative of pulmonary congestion, which is a classic sign of left-sided heart failure. Left-sided heart failure leads to a backup of blood into the lungs, causing fluid leakage into the alveoli and resulting in crackles upon auscultation. Choices A, C, and D are less specific to left-sided heart failure. Jugular vein distention can be seen in right-sided heart failure, peripheral edema can be seen in both right and left-sided heart failure, and bounding peripheral pulses are more indicative of conditions like hyperthyroidism or anemia rather than specifically supporting left-sided heart failure.

3. A client who is newly diagnosed with emphysema is being prepared for discharge. Which instruction is best for the nurse to provide the client to assist them with dyspnea self-management?

Correct answer: B

Rationale: The correct answer is B. Instructing the client to practice inhaling through the nose and exhaling slowly through pursed lips can help improve oxygenation and reduce dyspnea. This technique, known as pursed lip breathing, can help regulate breathing patterns and decrease the work of breathing in clients with emphysema. Choice A is incorrect because allowing additional time for physical activities does not directly address dyspnea management. Choice C is incorrect as using a humidifier, although beneficial for respiratory conditions, does not specifically assist with dyspnea self-management. Choice D is also incorrect as strengthening abdominal muscles through leg raises does not directly target dyspnea relief.

4. A middle-aged man who has a 35-year smoking history presents to the emergency department confused and short of breath. Before starting oxygen, these baseline arterial blood gases (ABGs) are obtained: pH=7.25, pCO2=50 mmHg, HCO3=30 mEq/L. These findings indicate to the nurse that the client is experiencing which acid-base imbalance?

Correct answer: B

Rationale: The ABG results show a low pH (acidosis) and increased pCO2, indicating respiratory acidosis. In respiratory acidosis, the lungs cannot remove enough CO2, leading to its accumulation in the blood. This often occurs in conditions like COPD and is consistent with the patient's smoking history. Metabolic acidosis (choice A) is characterized by low pH and low HCO3 levels. Metabolic alkalosis (choice C) is marked by high pH and high HCO3 levels. Respiratory alkalosis (choice D) presents with high pH and low pCO2.

5. The mother of a child with acute laryngotracheobronchitis (LTB) asks why her child must be kept NPO. Which response would be the most correct?

Correct answer: D

Rationale: The correct answer is D because rapid respirations predispose to aspiration in a child with acute laryngotracheobronchitis. Choice A is incorrect because epinephrine does not directly relate to the need for NPO status. Choice B is incorrect as hydration with IV fluids is not the primary reason for keeping the child NPO. Choice C is incorrect as the child being hungry is not the main concern when keeping a child NPO in this situation.

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