Question

Following a motor vehicle accident, a client with chest trauma receives a chest tube to relieve a hemothorax. Two hours following the chest tube insertion, the nurse observes the water level in the water-seal chamber is rising during inspiration and falling during expiration. Which action should the nurse implement?

Answer 1

Correct Answers:

Continue to monitor the drainage system.

Rationale :

🔹 In a chest tube system, tidaling—a rise in the water-seal chamber during inspiration and fall during expiration—is a normal finding, indicating that the system is patent and the chest tube is functioning properly.

🔹 No interventions are needed unless there is absence of tidaling, continuous bubbling, or other signs of obstruction or disconnection.

🔹 Continuous monitoring is appropriate in this stable situation.

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Answer 2

Correct Answers:

An acutely distended bladder.

Rationale :

♦ Autonomic dysreflexia in clients with spinal cord injuries above T6, such as C7, is often triggered by bladder distention, bowel impaction, or skin irritation.

♦ It is a life-threatening hypertensive emergency caused by an exaggerated sympathetic response.

♦ Identifying and relieving the precipitating cause—commonly a full bladder—should be done immediately to prevent complications.

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Answer 3

Correct Answers:

10

Rationale :

🧮 The prescribed dose is 10 units/hour, and the solution concentration is 100 units in 100 mL, which simplifies to 1 unit per mL.

🧮 Therefore, to deliver 10 units/hour, the pump should be set to 10 mL/hour.

🧮 Accurate conversion of IV medication dosages is critical to ensure safe and effective insulin administration.

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Answer 4

Correct Answers:

Sputum culture positive for Mycobacterium tuberculosis.

Rationale :

🦠 While chest x-rays and skin tests are suggestive, a definitive diagnosis of active tuberculosis is made through positive sputum culture for Mycobacterium tuberculosis.

🦠 It confirms the presence of the organism, allowing for appropriate isolation and treatment decisions.

🦠 PPD and imaging support the diagnosis but cannot confirm active infection.

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Answer 5

Correct Answers:

Continue the prescribed dose of lactulose.

Rationale :

🔸 Lactulose works by increasing ammonia excretion through the stool, which is essential in treating hepatic encephalopathy.

🔸 The goal is to reduce elevated ammonia levels, even if this results in frequent loose stools.

🔸 Holding the medication would worsen encephalopathy. Instead, fluid replacement may be considered, but lactulose must be continued.

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Answer 6

Correct Answers:

Upper mid abdominal pain described as gnawing and burning.

Rationale :

🔶 Peptic ulcer disease (PUD) typically presents as gnawing, burning epigastric pain, often related to meals or occurring at night.

🔶 Other symptoms like antacid use and weight loss may be present but are nonspecific.

🔶 The character and location of the pain are hallmark features that guide further diagnostic testing.

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Answer 7

Correct Answers:

Restrict physical activities.

Rationale :

🟩 After a transurethral needle ablation (TUNA) for BPH, the client is at risk for bleeding or urinary irritation, and activity restrictions help prevent complications.

🟩 Clients should avoid heavy lifting or strenuous activities post-discharge until cleared by their provider.

🟩 Pink-tinged hematuria is expected; physical rest supports optimal healing.

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Answer 8

Correct Answers:

Risk for injury related to effects of thrombolysis.

Rationale :

🔴 Thrombolytic therapy (e.g., for MI) carries a high risk of bleeding, including intracranial hemorrhage.

🔴 The priority nursing concern is preventing injury from internal or external bleeding.

🔴 Activity intolerance and medication education are important but are not immediate safety priorities.

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Answer 9

Correct Answers:

High-pitched sound heard upon inspiration.

Rationale :

🟦 A high-pitched inspiratory sound (stridor) indicates upper airway obstruction, which can be life-threatening.

🟦 This finding requires immediate intervention to protect the airway.

🟦 Pain and incision site changes are common post-op findings but do not take priority over airway compromise.

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Answer 10

Correct Answers:

Fatigue.

Rationale :

🟣 In left ventricular dysfunction, the heart cannot effectively pump blood forward, resulting in poor perfusion and oxygen delivery, leading to fatigue.

🟣 Other signs include pulmonary congestion (e.g., rales, dyspnea), but fatigue is a systemic effect and common early symptom.

🟣 JVD and hepatomegaly are more associated with right-sided heart failure.

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RN-Hesi Medical Surgical Exam IV

No.

2 :
A client with a cervical spinal injury (C7) is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor?

3 :
The healthcare provider prescribes regular insulin 10 units/hr IV. The IV solution contains 100 units of regular insulin in 100 mL of 0.9% normal saline. How many mL/hr should the nurse program the infusion pump? (Enter numerical value only.)

4 :
The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB?

6 :
The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this disease process?

7 :
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?

8 :
The nurse is caring for a client receiving thrombolytic therapy following an acute myocardial infarction (MI). Which nursing problem should the nurse identify as priority for this client?

9 :
The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?

10 :
An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding is the nurse likely to obtain?

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RN-Hesi Medical Surgical Exam IV

No.

2 : A client with a cervical spinal injury (C7) is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor?

3 : The healthcare provider prescribes regular insulin 10 units/hr IV. The IV solution contains 100 units of regular insulin in 100 mL of 0.9% normal saline. How many mL/hr should the nurse program the infusion pump? (Enter numerical value only.)

4 : The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB?

6 : The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this disease process?

7 : 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?

8 : The nurse is caring for a client receiving thrombolytic therapy following an acute myocardial infarction (MI). Which nursing problem should the nurse identify as priority for this client?

9 : The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?

10 : An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding is the nurse likely to obtain?

2 :
A client with a cervical spinal injury (C7) is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor?

3 :
The healthcare provider prescribes regular insulin 10 units/hr IV. The IV solution contains 100 units of regular insulin in 100 mL of 0.9% normal saline. How many mL/hr should the nurse program the infusion pump? (Enter numerical value only.)

4 :
The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB?

6 :
The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this disease process?

7 :
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?

8 :
The nurse is caring for a client receiving thrombolytic therapy following an acute myocardial infarction (MI). Which nursing problem should the nurse identify as priority for this client?

9 :
The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?

10 :
An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding is the nurse likely to obtain?