Question

While caring for a client with full-thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the health care provider, the nurse should evaluate which laboratory value?

Answer 1

Correct Answers:

Neutrophil count.

Rationale :

◈ A client with full-thickness burns is at high risk for infection due to impaired skin integrity.

◈ The presence of purulent drainage suggests a potential wound infection, and evaluating the neutrophil count helps assess for systemic inflammatory response.

◈ Neutrophils are the body’s primary defense against infection, and an elevated or severely decreased count indicates sepsis or immune suppression.

◈ Prompt reporting of abnormal neutrophil values can facilitate early antimicrobial intervention.

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Answer 2

Correct Answers:

Teach the client breathing exercises.
Perform chest physiotherapy.
Encourage use of incentive spirometer.

Rationale :

🔹 ALS progressively weakens respiratory muscles, leading to complications such as atelectasis and pneumonia.

🔹 Breathing exercises, incentive spirometry, and chest physiotherapy help mobilize secretions and improve lung expansion.

🔹 These interventions support respiratory function and delay mechanical ventilation need.

🔹 Bladder routines and passive ROM are important but do not directly address pulmonary risks.

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Answer 3

Correct Answers:

Hematuria.

Rationale :

♦ In systemic lupus erythematosus (SLE), hematuria is a sign of lupus nephritis, a serious complication affecting renal function.

♦ Early identification and reporting are critical for preserving kidney function and adjusting immunosuppressive therapy.

♦ Other symptoms like joint pain or low-grade fever are common in SLE but do not indicate organ damage.

♦ Hematuria requires immediate provider notification and further renal evaluation.

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Answer 4

Correct Answers:

Has everyone at home already had varicella?

Rationale :

🟣 Herpes zoster (shingles) is caused by reactivation of varicella-zoster virus and is contagious to individuals who have not had chickenpox or the varicella vaccine.

🟣 Determining the exposure risk to non-immune contacts helps guide isolation education and transmission precautions.

🟣 Antifungal creams are irrelevant because shingles is viral, and dry patches or comb sharing are unrelated to zoster transmission.

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Answer 5

Correct Answers:

Begin a weight loss program.

Rationale :

🟩 Obesity is a key risk factor for obstructive sleep apnea (OSA), and weight loss significantly improves airway patency during sleep.

🟩 While CPAP is the standard therapy, weight reduction can decrease severity or eliminate the need for long-term CPAP use.

🟩 Alcohol and sedatives relax airway muscles and worsen apnea; sleeping flat also aggravates symptoms.

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Answer 6

Correct Answers:

Demonstrate the use of visual scanning during meals to the client and family.

Rationale :

🟨 Post-stroke clients may experience unilateral neglect or visual-perceptual deficits, leading to incomplete food intake.

🟨 Teaching visual scanning techniques helps them recognize and attend to the entire tray, promoting adequate nutrition.

🟨 Reassurance, feeding assistance, or bringing food from home don’t address the underlying perceptual issue.

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Answer 7

Correct Answers:

Demonstrate the use of visual scanning during meals to the client and family.

Rationale :

🔳 Stroke-related visual perception issues like hemianopsia often lead to clients ignoring one side of their tray.

🔳 Training in visual scanning improves awareness and food intake.

🔳 It addresses the root cause rather than offering compensatory measures that reinforce dependency.

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Answer 8

Correct Answers:

Washes the radiation site with antibacterial soap and water.

Rationale :

🟥 Radiation therapy sites should be treated gently to avoid irritation.

🟥 Antibacterial soaps are harsh and may worsen skin damage at the portal site.

🟥 Gentle cleansing with mild soap and water, patting dry, and using prescribed lotions is recommended.

🟥 This client action indicates a need for re-education to prevent skin breakdown.

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Answer 9

Correct Answers:

Insert a nasogastric tube (NGT) and attach to low intermittent suction.

Rationale :

💠Vomiting with epigastric pain in peptic ulcer disease suggests gastric retention or bleeding, requiring decompression via NGT.

⚠️ This relieves pressure, prevents aspiration, and allows monitoring of gastric contents.

⚠️ Other interventions are supportive but do not address the acute risk of gastric distension or perforation.

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Answer 10

Correct Answers:

Restrict physical activities.

Rationale :

🔵 After transurethral needle ablation (TUNA), clients are at risk for bleeding and urinary irritation, so activity restriction is essential to promote healing.

🔵 Clients should avoid lifting, straining, or strenuous exercise until cleared.

🔵 Hematuria is expected early on and doesn’t require reporting unless it worsens.

🔵 Incentive spirometry is not relevant post-TUNA.

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RN-Hesi Medical Surgical Exam III

No.

1 :
While caring for a client with full-thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the health care provider, the nurse should evaluate which laboratory value?

2 :
To reduce the risk for pulmonary complications for a client with Amyotrophic Lateral Sclerosis (ALS), which interventions should the nurse implement? (Select all that apply)

3 :
A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important to report which assessment finding to the health care provider?

4 :
The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?

5 :
A client with obstructive sleep apnea (OSA) calls the clinic to report difficulty wearing the continuous positive air pressure (CPAP) mask because it is uncomfortable. The client asks the nurse for an alternative way to manage sleep apnea. Which recommendation should the nurse provide?

6 :
An older client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half of the food on the meal tray. The client's family expresses concern about the client's nutritional status. How should the nurse respond to the family's concern?

7 :
An older client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half of the food on the meal tray. The client's family expresses concern about the client's nutritional status. How should the nurse respond to the family's concern?

8 :
The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action about skin care indicates a need for further teaching?

9 :
A client admitted to the emergency department with an acute exacerbation of peptic ulcer disease is vomiting and describing epigastric pain and nausea. After obtaining vital sign measurements, which prescription should the nurse implement first?

10 :
A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?

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RN-Hesi Medical Surgical Exam III

No.

1 : While caring for a client with full-thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the health care provider, the nurse should evaluate which laboratory value?

2 : To reduce the risk for pulmonary complications for a client with Amyotrophic Lateral Sclerosis (ALS), which interventions should the nurse implement? (Select all that apply)

3 : A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important to report which assessment finding to the health care provider?

4 : The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?

5 : A client with obstructive sleep apnea (OSA) calls the clinic to report difficulty wearing the continuous positive air pressure (CPAP) mask because it is uncomfortable. The client asks the nurse for an alternative way to manage sleep apnea. Which recommendation should the nurse provide?

6 : An older client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half of the food on the meal tray. The client's family expresses concern about the client's nutritional status. How should the nurse respond to the family's concern?

7 : An older client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half of the food on the meal tray. The client's family expresses concern about the client's nutritional status. How should the nurse respond to the family's concern?

8 : The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action about skin care indicates a need for further teaching?

9 : A client admitted to the emergency department with an acute exacerbation of peptic ulcer disease is vomiting and describing epigastric pain and nausea. After obtaining vital sign measurements, which prescription should the nurse implement first?

10 : A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?

1 :
While caring for a client with full-thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the health care provider, the nurse should evaluate which laboratory value?

2 :
To reduce the risk for pulmonary complications for a client with Amyotrophic Lateral Sclerosis (ALS), which interventions should the nurse implement? (Select all that apply)

3 :
A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important to report which assessment finding to the health care provider?

4 :
The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?

5 :
A client with obstructive sleep apnea (OSA) calls the clinic to report difficulty wearing the continuous positive air pressure (CPAP) mask because it is uncomfortable. The client asks the nurse for an alternative way to manage sleep apnea. Which recommendation should the nurse provide?

6 :
An older client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half of the food on the meal tray. The client's family expresses concern about the client's nutritional status. How should the nurse respond to the family's concern?

7 :
An older client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half of the food on the meal tray. The client's family expresses concern about the client's nutritional status. How should the nurse respond to the family's concern?

8 :
The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action about skin care indicates a need for further teaching?

9 :
A client admitted to the emergency department with an acute exacerbation of peptic ulcer disease is vomiting and describing epigastric pain and nausea. After obtaining vital sign measurements, which prescription should the nurse implement first?

10 :
A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?