Medical-Surgical Practice HESI Exam
Study online at https://quizlet.com/_b87928
1. 1. The nurse is caring for a client re- c. Assist the client in coping with hot
ceiving tamoxifen for the treatment of flashes.
breast cancer. Which action should the
nurse include in the client's plan of Tamoxifen, an estrogen recep-
care? tor blocking agent, can cause
a. Increase fluid intake. hot flashes, so client education
b. Monitor sodium chloride intake. regarding menopausal-like symp-
c. Assist the client in coping with hot toms should be included in the plan
flashes. of care.
d. Encourage milk products to in-
crease calcium intake.
2. 2. The nurse is caring for a client who c. Teach measures to avoid the Val-
is admitted with a hemorrhagic stroke. salva maneuver.
Which nursing action should be in-
cluded in the plan of care? a. Perform The Valsalva maneuver, straining
active range of motion three times dai- with bowel movements while hold-
ly. ing one's breath, increases intrac-
b. Monitor for Battle's sign every four erebral pressure (ICP) which may
hours. induce bleeding or rupture of cere-
c. Teach measures to avoid the Valsal- bral blood vessels.
va maneuver.
d. Maintain the head of bed in a flat
position.
3. 3. The nurse is caring for a client with c. Gloves should be worn during
multiple trauma after a motor vehi- direct contact with the client's skin.
cle collision. The nurse learns that the
client has secondary syphilis. Which The secondary stage of syphilis
precaution should the nurse imple- is a systemic blood-borne disease
ment? that presents with skin lesions and
a. A mask should be worn by anyone rashes that may drain the highly
entering the client's room. contagious spirochete, so gloves
b. Handwashing is required before and should be worn during direct con-
after contact with the client. tact with the client's skin. The client
c. Gloves should be worn during direct should be placed on contact pre-
contact with the client's skin. cautions.
d. No precautions in addition to stan-
dard precautions are necessary.
1/7
, Medical-Surgical Practice HESI Exam
Study online at https://quizlet.com/_b87928
4. 4. The nurse is providing discharge in- a. "I should continue to perform
structions to a client who has under- testicular self-examination (TSE)
gone a left orchiectomy for testicular monthly on my remaining testicle."
cancer. Which statement indicates that
the client understands his post-opera- Although testicular cancer proto-
tive care and prognosis? cols, such as surgery, radiation, or
a. "I should continue to perform tes- chemotherapy, focus on the prima-
ticular self-examination (TSE) monthly ry site of testicular cancer, these
on my remaining testicle." treatments do not reduce the risk
b. "I should wear an athletic supporter of testicular cancer in the remaining
and cup to prevent testicular cancer in testicle, so early recognition is the
my remaining testicle." best prevention. The client's under-
c. "I should always use a condom be- standing is reflected in the state-
cause I am at increased risk for acquir- ment to perform monthly TSE for
ing a sexually transmitted disease." changes in size, shape, or consis-
d. "I should make sure my sons know tency of the testis that may indicate
how to perform TSE because they are early cancer.
at increased risk for this type of can-
cer."
5. 5. A client with heart failure is pre- a. Administer the medication.
scribed digoxin 0.125 mg PO. The
client's apical heart rate is70 beats Obtaining the apical heart rate is
per minute, blood pressure is 125/75 a common parameter prior to ad-
mmHg, and respirations are 18 breaths ministering digoxin, which may in-
per minute. Which action should the dicate early digoxin toxicity if the
nurse implement next? heart rate is less than 60 beats
a. Administer the medication. per minute, so the dose should be
b. Inform the healthcare provider. administered since the client is not
c. Review the vital sign flowsheet. demonstrating any signs of toxicity.
d. Reassess the apical heart rate.
6. 6. When teaching a client with breast a. Dry, itchy skin changes may oc-
cancer about the prescribed radiation cur.
therapy for treatment, what informa-
tion is important to include? Side effects from radiation to the
a. Dry, itchy skin changes may occur. breast most often include tempo-
b. There is a possibility of long bone rary skin changes such as dryness,
2/7
Study online at https://quizlet.com/_b87928
1. 1. The nurse is caring for a client re- c. Assist the client in coping with hot
ceiving tamoxifen for the treatment of flashes.
breast cancer. Which action should the
nurse include in the client's plan of Tamoxifen, an estrogen recep-
care? tor blocking agent, can cause
a. Increase fluid intake. hot flashes, so client education
b. Monitor sodium chloride intake. regarding menopausal-like symp-
c. Assist the client in coping with hot toms should be included in the plan
flashes. of care.
d. Encourage milk products to in-
crease calcium intake.
2. 2. The nurse is caring for a client who c. Teach measures to avoid the Val-
is admitted with a hemorrhagic stroke. salva maneuver.
Which nursing action should be in-
cluded in the plan of care? a. Perform The Valsalva maneuver, straining
active range of motion three times dai- with bowel movements while hold-
ly. ing one's breath, increases intrac-
b. Monitor for Battle's sign every four erebral pressure (ICP) which may
hours. induce bleeding or rupture of cere-
c. Teach measures to avoid the Valsal- bral blood vessels.
va maneuver.
d. Maintain the head of bed in a flat
position.
3. 3. The nurse is caring for a client with c. Gloves should be worn during
multiple trauma after a motor vehi- direct contact with the client's skin.
cle collision. The nurse learns that the
client has secondary syphilis. Which The secondary stage of syphilis
precaution should the nurse imple- is a systemic blood-borne disease
ment? that presents with skin lesions and
a. A mask should be worn by anyone rashes that may drain the highly
entering the client's room. contagious spirochete, so gloves
b. Handwashing is required before and should be worn during direct con-
after contact with the client. tact with the client's skin. The client
c. Gloves should be worn during direct should be placed on contact pre-
contact with the client's skin. cautions.
d. No precautions in addition to stan-
dard precautions are necessary.
1/7
, Medical-Surgical Practice HESI Exam
Study online at https://quizlet.com/_b87928
4. 4. The nurse is providing discharge in- a. "I should continue to perform
structions to a client who has under- testicular self-examination (TSE)
gone a left orchiectomy for testicular monthly on my remaining testicle."
cancer. Which statement indicates that
the client understands his post-opera- Although testicular cancer proto-
tive care and prognosis? cols, such as surgery, radiation, or
a. "I should continue to perform tes- chemotherapy, focus on the prima-
ticular self-examination (TSE) monthly ry site of testicular cancer, these
on my remaining testicle." treatments do not reduce the risk
b. "I should wear an athletic supporter of testicular cancer in the remaining
and cup to prevent testicular cancer in testicle, so early recognition is the
my remaining testicle." best prevention. The client's under-
c. "I should always use a condom be- standing is reflected in the state-
cause I am at increased risk for acquir- ment to perform monthly TSE for
ing a sexually transmitted disease." changes in size, shape, or consis-
d. "I should make sure my sons know tency of the testis that may indicate
how to perform TSE because they are early cancer.
at increased risk for this type of can-
cer."
5. 5. A client with heart failure is pre- a. Administer the medication.
scribed digoxin 0.125 mg PO. The
client's apical heart rate is70 beats Obtaining the apical heart rate is
per minute, blood pressure is 125/75 a common parameter prior to ad-
mmHg, and respirations are 18 breaths ministering digoxin, which may in-
per minute. Which action should the dicate early digoxin toxicity if the
nurse implement next? heart rate is less than 60 beats
a. Administer the medication. per minute, so the dose should be
b. Inform the healthcare provider. administered since the client is not
c. Review the vital sign flowsheet. demonstrating any signs of toxicity.
d. Reassess the apical heart rate.
6. 6. When teaching a client with breast a. Dry, itchy skin changes may oc-
cancer about the prescribed radiation cur.
therapy for treatment, what informa-
tion is important to include? Side effects from radiation to the
a. Dry, itchy skin changes may occur. breast most often include tempo-
b. There is a possibility of long bone rary skin changes such as dryness,
2/7
