Med-Surg II HESI Test Bank_ Complete Updated fall
- A nurse is collecting data from a client who has a possible cataract. Which of the following manifestations should the nurse expect the client to report?
1) Decreased color perception
2) Loss of peripheral vision
3) Bright flashes of light
...
a nurse is collecting data from a client who has a possible cataract which of the following manifestations should the nurse expect the client to report
Med-Surg II HESI Test Bank_ Complete Updated fall 2022-2023.
✔️A - A nurse is collecting data from a client who has a possible cataract. Which of the following
manifestations should the nurse expect the client to report?
1) Decreased color perception
2) Loss of peripheral vision
3) Bright flashes of light
4) Eyestrain
✔️A, B - A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of
the following actions should the nurse take? (Select all that apply.)
1) Encourage fluid intake.
2) Monitor the puncture site for hematoma.
3) Insert a urinary catheter.
4) Elevate the client's head of bed.
5) Apply a cervical collar to the client.
✔️A, B, C - A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical
manifestations should the nurse expect to observe? (Select all that apply.)
1) Buffalo hump
2) Purple striations
3) Moon face
4) Tremors
5) Obese extremities
✔️A, B, C, D - A nurse is collecting data from a client who has an exacerbation of gout. Which of the
following findings should the nurse expect? (Select all that apply.)
1) Edema
2) Erythema
3) Tophi
4) Tight skin
5) Symmetrical joint pain
✔️A, B, C, D - A nurse is collecting data from a client who has emphysema. Which of the following
findings should the nurse expect? (Select all that apply.)
1) Dyspnea
2) Barrel chest
3) Clubbing of the fingers
4) Shallow respirations
5) Bradycardia
,✔️A, B, E - A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is to
take hydroxyzine preoperatively. Which of the following effects of the medication should the nurse
include in the teaching? (Select all that apply.)
1) Decreasing anxiety 2) Controlling emesis
3) Relaxing skeletal muscles
4) Preventing surgical site infections
5) Reducing the amount of narcotics needed for pain relief
✔️A, D - A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of
the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse notes there
has not been any urinary output in the last hour. Which of the following actions should the nurse
perform first?
1) Notify the provider.
2) Administer a prescribed analgesic.
3) Offer oral fluids.
4) Determine the patency of the tubing.
✔️A. - A nurse in a provider's office is reinforcing teaching with a client who has anemia and has been
taking ferrous gluconate for several weeks. Which of the following instructions should the nurse
include?
1) Take this medication between meals.
2) Limit intake of Vitamin C while taking this medication.
3) Take this medication with milk.
4) Limit intake of whole grains while taking this medication.
✔️A. - A nurse in a provider's office is reinforcing teaching with a client who has anemia and has been
taking ferrous gluconate for several weeks. Which of the following instructions should the nurse
include?
1) Take this medication between meals.
2) Limit intake of Vitamin C while taking this medication.
3) Take this medication with milk.
4) Limit intake of whole grains while taking this medication.
✔️A. - A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge resection
of the left lung and has a chest tube to suction. Which of the following is the priority finding the nurse
should report to the provider?
1) Abdomen is distended
2) Chest tube drainage of 70 mL in the last hour
3) Subcutaneous emphysema is noted to the left chest wall
4) Pain level of 6 on a 0 to 10 scale
✔️A. - A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should monitor
the client for which of the following manifestations?
1) Hypotension
, 2) Polyphagia
3) Hyperglycemia
4) Bradycardia
✔️A. - A nurse is assisting with the care of a client who is postoperative and has a closed-wound drainage
system in place. Which of the following actions should the nurse take?
1) Fully recollapse the reservoir after emptying it.
2) Empty the reservoir once per day.
3) Replace the drainage plug after releasing hand pressure on the device.
4) Irrigate the tubing with sterile normal saline solution at least once every 8 hr.
✔️A. - A nurse is caring for a client during the immediate postoperative period following thoracic surgery.
When administering an opioid analgesic for pain, the nurse should explain that the medication should
have which of the following effects?
1) Reducing anxiety
2) Increasing blood pressure
3) Increasing coughing
4) Increasing the client's respiratory rate
✔️A. - A nurse is caring for a client following an open reduction and internal fixation of a fractured femur.
Which of the following findings is the nurse's priority?
1) Altered level of consciousness
2) Oral temperature of 37.7° C (100° C)
3) Muscle spasms
4) Headache
✔️A. - A nurse is caring for a client immediately following a cardiac catheterization with a femoral artery
approach. Which of the following actions should the nurse take?
1) Check pedal pulses every 15 min.
2) Perform passive range-of-motion for the affected extremity.
3) Remind the client not to turn from side to side.
4) Keep the client in high-Fowler's position for 6 hr.
✔️A. - A nurse is caring for a client newly diagnosed with ovarian cancer. Which of the following
reactions from the client should the nurse initially expect?
1) Denial
2) Bargaining
3) Acceptance
4) Anger
✔️A. - A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for
a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of
the hypothermia blanket?
A. Shivering
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