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HESI Med Surg I Test Bank
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HESI Med Surg I Test BankBased on the clinical manifestations of Cushing syndrome, which nursing
intervention would be appropriate for a client who is newly diagnosed with Cushing
syndrome?
A. Monitor blood glucose levels daily.
B. Increase intake of fluids high in potassium.
C. Encourage adequate rest between activities.
D. Offer the client a sodium-enriched menu. - ANSWER: A. Monitor Blood Glucose
Levels
Cushing syndrome results from a hypersecretion of glucocorticoids in the adrenal
cortex. Clients with Cushing syndrome often develop diabetes mellitus. Monitoring
of serum glucose levels assesses for increased blood glucose levels so that treatment
can begin early. A common finding in Cushing syndrome is generalized edema.
Although potassium is needed, it is generally obtained from food intake, not by
offering potassium-enhanced fluids. Fatigue is usually not an overwhelming factor in
Cushing syndrome, so an emphasis on the need for rest is not indicated A low-
calorie, low-carbohydrate, low-sodium diet is not recommended.
The nurse is assessing a male client with acute pancreatitis. Which finding requires
the most immediate intervention by the nurse?
A. The client's amylase level is three times higher than the normal level.
B.While the nurse is taking the client's blood pressure, he has a carpal spasm.
C.On a 1 to 10 scale, the client tells the nurse that his epigastric pain is at 7.
D.The client states that he will continue to drink alcohol after going home. -
ANSWER: B.While the nurse is taking the client's blood pressure, he has a carpal
spasm.
Rationale:
A positive Trousseau sign indicates hypocalcemia and always requires further
assessment and intervention, regardless of the cause (40% to 75% of those with
acute pancreatitis experience hypocalcemia, which can have serious, systemic
effects). A key diagnostic finding of pancreatitis is serum amylase and lipase levels
that are two to five times higher than the normal value. Severe boring pain is an
expected symptom for this diagnosis, but dealing with the hypocalcemia is a priority
over administering an analgesic. Long-term planning and teaching do not have the
same immediate importance as a positive Trousseau sign.
The nurse is completing an admission interview for a client with Parkinson disease.
Which question will provide additional information about manifestations that the
client is likely to experience?
A. "Have you ever experienced any paralysis of your arms or legs?"
B. "Do you have frequent blackout spells?"
, C."Have you ever been frozen in one spot, unable to move?"
D. "Do you have headaches, especially ones with throbbing pain?" - ANSWER: C.
Have you ever been frozen in one spot, unable to move?"
Rationale:
Clients with Parkinson disease frequently experience difficulty in initiating,
maintaining, and performing motor activities. They may even experience being
rooted to the spot and unable to move. Parkinson disease does not typically cause
option A, B, or D.
The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12
hours after chest tube insertion for hemothorax. What is the best initial action for
the nurse to take?
A. Document this expected decrease in drainage.
B. Clamp the chest tube while assessing for air leaks. C. Milk the tube to remove any
excessive blood clot buildup.
D. Assess for kinks or dependent loops in the tubing. - ANSWER: D.Assess for kinks or
dependent loops in the tubing.
Rationale:
The least invasive nursing action should be performed first to determine why the
drainage has diminished. Option A is completed after assessing for any problems
causing the decrease in drainage. Option B is no longer considered standard protocol
because the increase in pressure may be harmful to the client. Option C is an
appropriate nursing action after the tube has been assessed for kinks or dependent
loops.
A 77-year-old female client is admitted to the hospital with confusion and anorexia
of several days' duration. She has symptoms of nausea and vomiting and is currently
complaining of a headache. The client's pulse rate is 43 beats/min. The nurse is most
concerned about the client's history related to which medication?
A. Warfarin (Coumadin)
B. Ibuprofen (Motrin)
C. Nitroglycerin (Nitrostat)
D. Digoxin (Lanoxin) - ANSWER: D. Digoxin
Rationale:
Older persons are particularly susceptible to the buildup of cardiac glycosides, such
as digoxin or digitoxin (medications derived from digitalis), to a toxic level in their
systems. Toxicity can cause anorexia, nausea, vomiting, diarrhea, headache, and
fatigue. Options A, B, and C are unlikely to result in the symptoms described.
The nurse is observing an unlicensed assistive personnel (UAP) performing morning
care for a bedridden client with Huntington disease. Which care measure is most
important for the nurse to supervise?
A. Oral care
B.Bathing
,C. Foot care
D. Catheter care - ANSWER: A. Oral care
Rationale:
The client with Huntington disease experiences problems with motor skills such as
swallowing and is at high risk for aspiration, so the highest priority for the nurse to
observe is the UAP's ability to perform oral care safely. Options B, C, and D do not
necessarily require registered nurse (RN) supervision because they do not ordinarily
pose life-threatening consequences.
A client who is receiving an angiotensin-converting enzyme (ACE) inhibitor for
hypertension calls the clinic and reports the recent onset of a cough to the nurse.
Which action should the nurse implement?
A. Advise the client to come to the clinic immediately for further assessment.
B. Instruct the client to discontinue use of the drug and to make an appointment at
the clinic.
C. Suggest that the client learn to accept the cough as a side effect to a necessary
prescription.
D. Encourage the client to keep taking the drug until seen by the health care
provider. - ANSWER: D. Encourage the client to keep taking the drug until seen by
the health care provider.
Rationale:
Coughing is a common side effect of ACE inhibitors and is not an indication to
discontinue the medication. Immediate evaluation is not needed. Antihypertensive
medications should not be stopped abruptly because rebound hypertension may
occur. Option C is demeaning because the cough may be very disruptive to the client,
and other antihypertensive medications may produce the desired effect without the
adverse effect.
When assigning clients on a medical-surgical floor to an RN and a PN, it is best for
the charge nurse to assign which client to the PN?
A. A young adult with bacterial meningitis with recent seizures
B. An older adult client with pneumonia and viral meningitis
C. A female client in isolation with meningococcal meningitis
D. A male client 1 day postoperative after drainage of a brain abscess - ANSWER: B.
An older adult client with pneumonia and viral meningitis
Rationale:
The most stable client is option B. Options A, C, and D are all at high risk for
increased intracranial pressure and require the expertise of the RN for assessment
and management of care.
In assessing a client diagnosed with primary aldosteronism, the nurse expects the
laboratory test results to indicate a decreased serum level of which substance?
A.Sodium
B.Phosphate
, C.Potassium
D.Glucose - ANSWER: C. Potassium
Rationale:
Clients with primary aldosteronism exhibit a profound decline in serum levels of
potassium; hypokalemia; hypertension is the most prominent and universal sign. The
serum sodium level is normal or elevated, depending on the amount of water
resorbed with the sodium. Option B is influenced by parathyroid hormone (PTH).
Option D is not affected by primary aldosteronism.
A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid
ventricular response. Based on this finding, the nurse anticipates assisting the
physician with which treatment?
A.Administer lidocaine, 75 mg intravenous push.
B.Perform synchronized cardioversion.
C.Defibrillate the client as soon as possible.
D.Administer atropine, 0.4 mg intravenous push. - ANSWER: B.Perform synchronized
cardioversion.
Rationale:
With uncontrolled atrial fibrillation, the treatment of choice is synchronized
cardioversion to convert the cardiac rhythm back to normal sinus rhythm. Option A
is a medication used for ventricular dysrhythmias. Option C is not for a client with
atrial fibrillation; it is reserved for clients with life-threatening dysrhythmias, such as
ventricular fibrillation and unstable ventricular tachycardia. Option D is the drug of
choice in symptomatic sinus bradycardia, not atrial fibrillation.
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 mm Hg. Which action should the nurse take?
A.Administer the prescribed dose at the scheduled time.
B.Hold the dose and contact the health care provider.
C.Hold the dose and recheck the blood pressure in 1 hour.
D.Check the health care provider's prescription to clarify the dose. - ANSWER: A.
Administer the prescribed dose at the scheduled time
Rationale:
The client's blood pressure is within normal limits, indicating that the ramipril, an
antihypertensive, is having the desired effect and should be administered. Options B
and C would be appropriate if the client's blood pressure was excessively low (<100
mm Hg systolic) or if the client were exhibiting signs of hypotension such as
dizziness. This prescribed dose is within the normal dosage range, as defined by the
manufacturer; therefore, option D is not necessary.
Which consideration is most important when the nurse is assigning a room for a
client being admitted with progressive systemic sclerosis (scleroderma)?
A.Provide a room that can be kept warm.
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