MED SURG HESI LATEST EXAM AND STUDY GUIDE 2024 | ALL QUESTIONS AND CORRECT ANSWERS WITH RATIONALES | VERIFIED ANSWERS | ALREADY GRADED A+ MED SURG HESI LATEST EXAM The nurse is receiving report from surgery about a client with a penrose drain who is to be admitted to the pos toperative unit. Before choosing a room for this client, which information is most important for the nurse to obtain? A) If suctioning will be needed for drainage of the wound. B) If the family would prefer a private or semi -private room. C) If the clien t also has a Hemovac® in place. D) If the client's wound is infected. ------CORRECT ANSWER --------------- D) If the client's wound is infected. Penrose drains provide a sinus tract or opening and are often used to provide drainage of an abscess. The fact that the client has a penrose drain should alert the nurse to the possibility that the client is infected. To avoid contamination of another post operative client, it is most important to place an infected client in a private room (D). A penrose drain does not require (A). Although (B) is information that should be considered, it does not have the priority of (D). (C) is used to drain fluid from a d ead space and is not important in choosing a room. The nurse is teaching a female client who uses a contraceptive diaphragm about reducing the risk for toxic shock syndrome (TSS). Which information should the nurse include? (Select all that apply.) A) Remove the diaphragm immediately after intercourse. B) Wash the diaphragm with an alcohol solution. C) Use the diaphragm to prevent conception during the menstrual cycle. D) Do not leave the diaphragm in place longer than 8 hours after intercourse. E) Contact a healthcare provider a sudden onset of fever grater than 101º F appears. F) Replace the old diaphragm every 3 months. ------CORRECT ANSWER --
------------- D) Do not leave the diaphragm in place longer than 8 hours after intercourse. E) Contact a he althcare provider a sudden onset of fever grater than 101º F appears. Correct selections are (D and E). The diaphragm needs to remain against the cervix for 6 to 8 hours to prevent pregnancy but should not remain for longer than 8 hours (D) to avoid the risk of TSS. If a sudden fever occurs, the client should notify the healthcare provider (E). (A) increases the risk of pregnancy, and (B) can reduce the integrity of the barrier contraceptive but neither prevents the risk of TSS. The diaphragm should not b e used during menses (C) because it obstructs the menstrual flow and is not indicated because conception does not occur during this time. (F) is not necessary. A 58-year-old client, who has no health problems, asks the nurse about the Pneumovax vaccine. The nurse's response to the client should be based on which information? A) The vaccine is given annually before the flu season to those over 50 years of age. B) The immunization is administered once to older adults or persons with a history of chronic i llness. C) The vaccine is for all ages and is given primarily to those persons traveling overseas to areas of infection. D) The vaccine will prevent the occurrence of pneumococcal pneumonia for up to five years. ------CORRECT ANSWER --------------- B) The immunization is administered once to older adults or persons with a history of chronic illness. It is usually recommended that persons over 65 years of age and those with a history of chronic illness receive the vaccine once in a lifetime (B). (Some reso urces recommend obtaining the vaccine at 50 years of age.) The influenza vaccine is given once a year, not the Pneumovax (A). Although the vaccine might be given to a person traveling overseas, that is not the main rationale for administering the vaccine ( C). It is usually given once in a lifetime (D), but with immunosuppressed clients or clients with a history of pneumonia re -
vaccination is sometimes required. The nurse is assessing a client who has a history of Parkinson's disease for the past 5 years. What symptoms should this client most likely exhibit? A) Loss of short -term memory, facial tics and grimaces, and constant writhing movements. B) Shuffling gait, masklike facial expression, and tremors of the head. C) Extreme muscular weakness, easy fatigability, and ptosis. D) Numbness of the extremities, loss of balance, and visual disturbances. -
-----CORRECT ANSWER --------------- B) Shuffling gait, masklike facial expression, and tremors of the head. (B) are com mon clinical features of Parkinsonism. (A) are symptoms of chorea, (C) of myasthenia gravis, and (D) of multiple sclerosis. A postmenopausal client asks the nurse why she is experiencing discomfort during intercourse. What response is best for the nurse to provide? A) Estrogen deficiency causes the vaginal tissues to become dry and thinner. B) Infrequent intercourse results in the vaginal tissues losing their elasticity. C) Dehydration from inadequate fluid intake causes vulva tissue dryness. D) Lack of adequate stimulation is the most common reason for dyspareunia. ------CORRECT ANSWER --------------- A) Estrogen deficiency causes the vaginal tissues to become dry and thinner. Estrogen deprivation decreases the moisture -secreting capacity of vaginal c ells, so vaginal tissues tend to become thinner, drier (A), and the rugae become smoother which reduces vaginal stretching that contributes to dyspareunia. Dyspareunia is not related to (B or C). While (D) can contribute to discomfort during intercourse, t he primary cause is hormone -related. An adult client is admitted to the hospital burn unit with partial -thickness and full -thickness burns over 40% of the body surface area. In assessing the potential for skin regeneration, what should the nurse remembe r about full-thickness burns? A) Regenerative function of the skin is absent because the dermal layer has been destroyed. B) Tissue regeneration will begin several days following return of normal circulation. C) Debridement of eschar will delay the body' s ability to regenerate normal tissue. D) Normal tissue formation will be preceded by scar formation for the first year. ------CORRECT ANSWER --------------- A) Regenerative function of the skin is absent because the dermal layer has been destroyed. Full-thickness burns destroy the entire dermal layer. Included in this destruction is the regenerative tissue. For this reason, tissue regeneration does not occur, and skin grafting is necessary (A). (B, C, and D) are simply false. Which symptoms should the nurse expect a client to exhibit who is known to have a pheochromocytoma? A) Numbness, tingling, and cramps in the extremities. B) Headache, diaphoresis, and palpitations. C) Cyanosis, fever, and classic signs of shock. D) Nausea, vomiting, and muscular weakness. ------CORRECT ANSWER --
------------- B) Headache, diaphoresis, and palpitations. (B) is the typical triad of symptoms of tumors of the adrenal medulla (symptoms depend on the relative proportions of epinephrine a nd norepinephrine secretion). (A) lists the signs of latent tetany, exhibited by clients diagnosed with hypoparathyroidism. (C) lists the signs of an Addisonian (adrenal) crisis. (D) lists the signs of hyperparathyroidism.
