HESI RN MED SURG

1 | P a g e HESI RN MED SURG 1. A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the best initial nursing action? Answer: Administer the first dose of prescribed antibiotic therapy 2. A client is brought to the Emergency Department by ambulation in cardiac arrest with cardiopulmonary resuscitation (CPR) in progress. The client isintubated and receiving 100% oxygen per self‐inflating (ambu) bag. The nurse determines that the client is cyanotic, cold, and diaphoretic. Which assessment is most important for the nurse to obtain? Answer: deep tendon reflexes. 3. After hospitalization for Syndrome of Inappropriate Antidiuretic hormone (SIADH), a client develops myelinolysis. Which intervention should the nurse implement first? Answer: Reorient client to hisroom. 4. A male client with heart failure (HF) calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain? Answer: Has his weight changed in the lastseveral days? 5. An older adult woman with a long history of COPD is admitted with progressive shortness of breath and a persistent cough. She is anxious and is complaining of a dry mouth. Which intervention should the nurse implement? Answer: Apply a high‐flow venturi mask. 6. A client with a history of asthma and bronchitis arrives at the clinic with SOB, productive cough with thickened, tenacious mucous, and the inability to walk up flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self‐care? Answer: Increase the daily intake of oral fluids to liquefy secretions. 7. A cardiac catheterization of a client with heart disease indicates the following blockages: 95% LAD, 99% proximal circumflex, and 95% proximal RCA. The client later asks the nurse “what does all that mean for me?” Answer: Three main arteries have major blockage with only 1 to 5% of the blood flow getting through to the heart muscle. 8. A client who weighs 175 pounds is receiving an IV bolus dose of heparin 80 units/kg. The heparin is available in a 2 mL vial, labeled 10,000 units/mL. How many mL should the nurse administer? (enter numeric value only. If rounding, round to nearest tenth.) Answer: 1.3 mL after calculations: the calculator willshow 1., but you must round to the nearest tenth. So, the answer is 1.3 mL. 9. What information should the nurse include in the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD)? 2 | P a g e Answer: minimize symptoms by wearing loose, comfortable clothing. 10. The nurse is caring for a client with a lower left lobe pulmonary abscess. Which position should the nurse instruct the client to maintain? Answer: Left Lateral. 11. A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider? Answer: Yellow Sclera 12. While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse? Answer: Increasing anxiety. 13. The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft to promote burn healing. Which information should the nurse provide this client? Answer: The xenograft is taken from nonhuman sources. 14. A male client who had colon surgery 3 days ago is anxious and request assistance to reposition. The wound dehiscences and eviscerates. The nurse moistens an available sterile dressing and palaces it over the wound. Which intervention should the nurse implement next? answer: prepare the client to return to the operating room. 15. A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117 mEq/L. Which nursing problem should the nurse include in this client’s plan of care? answer: fluid volume excess 16.A female client enters the clinic and insists on being seen. She is weak, nervous, and reports a racing heart beat and recent weight loss of 15 pounds. After ruling out substance withdrawal, the healthcare provider suspects hyperthyroidism. Which action should the nurse implement? answer:space the client’s care to provide periods of rest 17. The nurse isteaching a client with glomerulonephritis aboutself‐care. Which dietary recommendations should the nurse encourage the client to follow? answer:restrict intake by limiting meats and other high‐protein foods. 18. An overweight, young adult male who has recently diagnosed with type diabetes mellitus is admitted for a hernia repair. He tells the nurse he is feeling very weak and jittery. Which actions should the nurse implement? (select all that apply). Assess hisskin temperature and moisture. Document anxiety on the surgical checklist. Administer a PRN dose of regular insulin 3 | P a g e 19. A client with Cushing’ssyndrome isrecovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse? answer: irregular apical pulse 20. An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red and the client reports a burning sensation. What action should the nurse take? answer:secure a pulse oximeter to monitor the client’s oxygen saturation. 21. A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 101° F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood pressure 122/82, which intervention is most important for the nurse to implement first? Answer: assess lower extremity circulation. 22.The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomy under general anesthesia. Which finding warrants notification ofthe healthcare provider prior to proceeding with the scheduled procedure? answer: the client’s blood pressure is 184/88 mm Hg. 23. A client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse? answer: hematocrit of 30% 24. Following surgical repair of the bladder, a female client is being discharged from the hospital to home with an indwelling urinary catheter. Which instruction is most important for the nurse to provide to this client? answer: keep the drainage bag lower than the level of the bladder 25. Which client has the highest risk for developing skin cancer? answer: a 65‐year‐old fairskinned male who is a construction worker. 26. When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain? answer: level of consciousness 27. A female client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). (select all that apply). Verify pedal pulses using a doppler pulse device. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure. Evaluate the application of the splint to the left leg. 28. A male client with herpeszoster (shingles) on his thorax tells the nurse that he is having difficulty sleeping. What is the probably etiology of this problem? 4 | P a g e answer: pain 5 | P a g e 29. When planning care for a client newly diagnosed with open angle glaucoma, the nurse identifies a priority nursing diagnosis of, “visual sensory/perceptual alterations.” This diagnosis is based on which etiology? answer: decreased peripheral vision. 30. A client who is newly diagnosed with emphysema is being prepared for discharge. Which instruction is best for the nurse to provide the client to assist them with dyspnea self‐management? answer: Allow additional time to complete physical activities to reduce oxygen demand. 31. A client with cancer is receiving chemotherapy with a known vesicant. The client’s IV has been in place for 72 hours. The nurse determines that a new IV site cannot be obtained, and leaves the present IV in place. What is the greatest clinical risk related to this situation? answer: impaired skin integrity. 32. A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the post anesthesia unit. Before selecting which medication to administer, which action should the nurse implement? answer: Compare the client’s pain scale rating with the prescribed dosing. 33. While assisting a female client to the toilet, the client begins to have a seizure and the nurse eases her to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first? answer: Observe for prolonged periods of apnea. 34. A male client with diabetes mellitus istransferred from the hospital to a rehabilitation facility following treatment for a stroke with resulting right hemiplegia. He tells the nurse that his feet are always uncomfortable cool at night, preventing him from falling asleep. Which Action should the nurse implement? answer: Use a bed cradle to old the covers off feet. 35. During a home visit, the nurse assessesthe skin of a client with eczema who reportsthat an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms? answer: a grandson and his new dog recently visited. 36. While planning care for a client with carpal tunnelsyndrome, the nurse identifies a collaborative problem of pain. What is the etiology of this problem? answer: irritation of nerve endings. 37. The nurse assesses a client being treated for Herpes zoster (shingles). Which assessments should the nurse include when evaluating the effectiveness of treatment? (select all that apply). Skin integrity Functional ability Pain scale 6 | P a g e 38. A male client tells the clinic nurse that he is experiencing burning on urination, and assessment reveals that he had sexual intercourse four days ago with a woman he casually met. Which action should the nurse implement? answer: obtain a specimen of urethral drainage for culture 39.A client with Addison’s disease started taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor which serum laboratory value? answer: Glucose 40. A client with acquired immunodeficiency syndrome (AIDS) has impaired gas exchange from a respiratory infection. Which assessment finding warrants immediate intervention by the nurse? answer: elevated temperature 41. An older male client tells the nurse that he is losing sleep because he has to get up several times at night to go to the bathroom, that he has trouble starting his urinary stream, and that he does not feel like his bladder is ever empty. Which intervention should the nurse implement? answer: collect a urine specimen for culture analysis. 42. Fluids are restricted to 1,500 mL daily for a male client with acute kidney injury (AKI). He is frustrated and complaining of constant thirst, and the nurse discovers that the family is providing the client with additional fluids. Which intervention of the nurse implement? answer: provide the client with oralswabs to moisten his mouth. 43. During a paracentesis, two liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed, and 50 mL of clear, straw‐colored fluid drains within the first hour. What action should the nurse implement? answer: Continue to monitor the fluid output. 44. While assessing a client with degenerative joint disease, the nurse observes Heberden’s nodes large prominences on the client’s fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take? answer: discuss approaches to chronic pain control with the client. 45. A client who took a camping vacation two weeks ago in a country with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse report to the healthcare provider? answer: jaundiced sclera. 46. Ten hours following thrombolysis for an ST elevation myocardial infarction (STEMI), a client isreceiving a lidocaine infusion for isolated runs of ventricular tachycardia (VT). Which finding should the nurse document in the electronic medical record as a therapeutic response to the lidocaine infusion? answer: Cessation of chest pain 47. After a computer tomography (CT) scan with intravenous contrast medium, a client returns to the room complaining of SOB and itching. Which intervention should the nurse implement? answer: prepare a dose of epinephrine (adrenalin). 7 | P a g e 8 | P a g e 48. The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding? answer: Nuchal rigidity 49. The nurse is preparing to administer enoxaparin (lovenox) 135 mg subcutaneously. The medication is available in a cartridge labeled 150 mg/mL. How many mL should the nurse administer? answer: 0.9 mL After calculations, the answer willshow 0.9 mL. If you have to round forsome reason in this answer, simply round to the nearest tenth. 50. The nurse is obtaining a client’s fingerstick glucose level. After gently milking the client’s finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take? answer: collect the blood sample 51.A client admitted to a surgical unit is being evaluated for an intestinal obstruction. The healthcare provider prescribes a nasogastric tube (NGT) to be inserted and placed to intermittent low wallsuction. Which intervention should the nurse implemented to facilitate proper tube placement? answer: insert tube with client’s head tilted back. 52. A young female client with seven children is having frequent morning headaches, dizziness, and blurred vision. Her blood pressure (BP) is 168/104 mm Hg. The client reports that her husband recently lost his job and she is not sleeping well. After administering a STAT dose of an antihypertensive IV medication, which intervention is most important for the nurse to implement? answer: Use an automated BP machine to monitor for hypotension. 53. The wife of a client with Parkinson’s disease expresses concern because her husband has lost so much weight. Which teaching is best for the nurse to provide? answer: Invite friends over regularly to share in meal times. 54. A client who was discharge 8 months ago with cirrhosis and ascites is admitted with anorexia and recent hemoptysis. The client is drowsy but responds to verbal stimuli. The nurse programs a blood pressure monitor to take readings every 15 minutes. Which assessment should the nurse implement first? answer: Palpate the abdomen for tenderness and rigidity. 55. A client with urolithiasis is preparing for discharge afterlithotripsy. Which intervention should the nurse include in the client’s postoperative discharge instructions? answer: monitor urinary stream for decreases in output.