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MED-SURG HESI COMPILATION Test, Answered, Latest Spring 2022.
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MED-SURG HESI COMPILATION Test, Answered, Latest Spring 2022.
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MED-SURG HESI COMPILATIONTEST BANK.
A female client with a nasogastric tube attached to low suction states that she is
nauseated. The nurse assesses that there has been no drainage through the
nasogastric tube in the last 2 hours. Which action should the nurse take first?
A. Irrigate the nasogastric tube with sterile normal saline.
B. Reposition the client on her side.
C. Advance the nasogastric tube 5 cm.
D. Administer an intravenous antiemetic as prescribed.
✅ - B. The priority is to determined if the tube is functioning correctly, which would
relieve the client's nausea. The least invasive intervention is to reposition the client (B),
should be attempted first, followed by (A & C) if these are unsuccessful then (D).
When assigning clients on a medical-surgical floor to a RN and a LPN, it is best for the
charge nurse to assign which client to the LPN?
A. A child with bacterial meningitis with recent seizures.
B. An older adult client with pneumonia and viral meningitis.
C. A female client in isolation wiht meningococcal meningitis.
D. A male client 1 day post-op after drainage of a brain abscess
.✅ - B. Is the most stable. A, C, D have an increased risk for elevated ICP.
Which description of symptoms is characteristic of a client with diagnosed with
trigeminal neuralgia (tic douloureux)?
A. Tinnitus, vertigo, and hearing difficulties.
B. Sudden, stabbing, severe pain over the lip and chin.
C. Unilateral facial weakness and paralysis.
D. Difficulty in talking, chewing, and swallowing
.✅ - B. Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric
shock, in the area innervated by one or more branches of the trigeminal nerve.
A. Characteristic of Meniere's
C. Characteristic of Bell palsey
D. Characteristic of disorders of the hypoglossal (12th cranial nerve)
Which abnormal lab finding indicates that a client with diabetes needs further evaluation
for diabetic nephropathy?
A. Hypokalemia
B. Microalbuminauria
C. Elevated serum lipids
D. Ketonuria
✅ - B. Microalbuminuria is the earliest sign of nephropathy and indicates the need for
follow-up evaluation. Hyperkalemia (A) is associated with end stage renal disease
,caused by diabetic nephropathy. (C) may be elevated in end stage renal disease. (D)
may signal the onset of DKA.
An older male client comes to the geriatric screening clinic complaining of pain in his left
calf. The nurse notices a reddened area on the calf of his right leg that is warm to touch
and the nurse suspects that the client may have thrombophlebitis. Which addition
assessment is most important for the nurse to perform?
A. Measure calf circumference.
B. Auscultate the client's breath sounds.
C. Observe for ecchymosis and petechiae.
D. Obtain the client's blood pressure.
✅ - B. Since the client may have a pulmonary embolus secondary to the
thrombophlebitis.
A. Would support the nurses assessment.
C. Least helpful since bruising is not associated with thrombophlebitis.
D. Less important then auscultation.
The nurse know that a client taking diuretics must be assessed for the development of
hypokalemia, and that hypokalemia will create changes in the client's normal ECG
tracing. Which ECG change would be an expected finding in the client with
hypokalemia?
A. Tall, spiked T waves
B. A prolonged QT interval
C. A widening QRS complex
D. Presence of a U wave
✅ - D. A U wave is a positive deflection following the T wave and is often present with
hypokalemia. A, B, C indicate hyperkalemia.
An older client is admitted with a diagnosis of bacterial pneumonia. The nurse's
assessment of the client will most likely reveal which S/SX?
A. Leukocytosis and febrile.
B. Polycythemia and crackles.
C. Pharyngitis and sputum production.
D. Confusion and tachycardia.
✅ - D. The onset of pneumonia is the older may be signaled by general deterioration,
confusion, increased heart rate or increased respiratory rate.
(A, B, C) are often absent in the older with bacterial pneumonia.
The nurse observes ventricular fibrillation on telemetry and upon entering the clients
bathroom finds the client unconscious on the floor. What intervention should the nurse
implement first?
A. Administer an antidysrhythmic medication.
B. Start cardiopulmonary resuscitation.
,C. Defibrillate the client at 200 joules.
D. Assess the client's pulse oximetry.
✅ - B. Ventricular fibrillation is a life-threatening dysrhythmia and CPR should be
started immediately. A & C are appropriate but B is the priority. D does not address the
seriousness of the situation.
An older female client with dementia is transferred from a long term care unit to an
acute care unit. The client's children express concern that their mother's confusion is
worsening. How should the nurse respond?
A. "It is to be expected that older people will experience progressive confusion."
B. "Confusion in an older person often follows relocation to new surroundings."
C. "The dementia is progressing rapidly, but we will do everything we can to keep your
mother safe."
D. "The acute care staff is not as experienced as the long-term care staff at dealing with
dementia."
✅ - B. Relocation often results in confusion among older clients and is stressful to
clients of all ages. (A) is an inaccurate stereotype. (C) is most likely false there are
many factors that cause increased temporary confusion. (D) may be true but does not
offer the family a sense of security about the care.
The nurse plans to help an 18-year-old developmentally disabled female client ambulate
on the first postoperative day. When the nurse tells her it is time to get out of bed, the
client becomes angry and yells at the nurse. "Get out of here! I'll get up when I'm
ready." Which response should the nurse provide?
A. "Your healthcare provider has prescribed ambulation on the first postoperative day."
B. "You must ambulate to avoid serious complications that are much more painful."
C. "I know how you feel; you're angry about having to do this, but it is required."
D. "I'll be back in 30 minutes to help you get out of bed and walk around the room."
✅ - D. Returning in 30 minutes provides a cooling off period, is firm, direct,
nonthreatening, and avoids argument with the client. B is threatening. C. assumes what
the client is feeling. A. avoids the nurse's responsibility to ambulate the client.
The nurse is performing hourly neurological check for a client with a head injury. Which
new assessment finding warrants the most immediate intervention by the nurse?
A. A unilateral pupil that is dilated and nonreactive to light.
B. Client cries out when awakened by a verbal stimulus.
C. Client demonstrates a loss of memory to the events leading up to the injury.
D. Onset of nausea, headache, and vertigo.
✅ - A. Any changes in pupil size and reactivity is an indication of increasing ICP and
should be reported immediately. (B) is normal for being awakened. (C & D) are common
manifestations of head injury and less of an immediacy than (A).
, A male client with arterial peripheral vascular disease (PVD) complains of pain in his
feet. Which instruction should the nurse give to the UPA to quickly relieve the client's
pain?
A. Help the client to dangle his legs.
B. Apply compression stockings.
C. Assist with passive leg exercises.
D. Ambulate three times daily.
✅ - A. A client who has arterial PVD may benefit from a dependent position which can
be achieved by dangling by improving blood flow and relieving pain. (B) is indicated for
venous insufficiency and (C) is indicated for bed rest. (D) is indicated to facilitate
collateral circulation and may improve long term complaints of pain.
A 58-year-old client, who has no health problems, asks the nurse about taking the
pneumococcal vaccine (Pneumovax). Which statement give by the nurse would offer
the client accurate information about this vaccine?
A. "The vaccine is given annually before the flue season to those over 50 years of age."
B. "The immunization is administered once to older adults or persons with a history of
chronic illness."
C. "The vaccine is for all ages and is given primarily to those person traveling overseas
to infected areas."
D. "The vaccine will prevent the occurrence of pneumococcal pneumonia for up to 5
years."✅ - B. It is usually recommended that persons over 65 years of age and those
with a history of chronic illness should receive the vaccine once in a lifetime. (A) the
influenza vaccine is given annually. (C) travel is not the main rationale for the vaccine.
(D) The vaccine is usually given once in a lifetime.
A client with hypertension has been receiving ramipril (Altace) 5 mg PO daily for 2
weeks and is scheduled to receive a dose at 0900. At 0830 the client's blood pressure is
120/70. Which action should the nurse take?
A. Administer the dose as prescribed.
B. Hold the dose and contact the healthcare provider.
C. Hold the dose and recheck the blood pressure in 1 hour.
D. Check the healthcare provider's prescription to clarify the dose. ✅ - A. The BP is
WNL and indicates that the medication is working. (B & C) would be indicated if the BP
was low (systole below 100). (D) is not required because the dose is within
manufacture's recommendations.
The nurse know that normal lab values expected for an adult may vary in an older client.
Which data would the nurse expect to find when reviewing laboratory values of an 80-
year-old man who is in good overall health.
A. Complet blood count reveals increased WBC and decreased RBC counts.
B. Chemistries reveal an increased serum bilirubin with slightly increased liver enzymes.
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