266 HESI MEDSURG EXAM REVIEW QUESTIONS AND ANSWERS, GRADED A+/
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266 HESI MEDSURG
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266 HESI MEDSURG
266 HESI MEDSURG EXAM REVIEW QUESTIONS AND
ANSWERS, GRADED A+/
A client with leukemia is receiving chemotherapy. The nurse observes the client is weak, pale, and
febrile. Ate reiering the client's most recent laboratory data which reveals a platelet count of
25,000/mm® (25 * 109IL), which i...
1 266 HESI PRACTICE 3/ EXAM REVIEW QUESTIONS AND
ANSWERS, GRADED A+
1- The nurse is planning care for an older adult client who experienced a cerebrovascular accident
several weeks ago. The client has expressive aphasia and becomes frustrated with the nursing staff.
Which intervention should the nurse implement?
A. Teach the client use of basic sign language
B. Ask the client simple questions
C. Encourage client use of picture charts
D. Speak slowly to the client
C. Encourage client use of picture charts
A 70-year-old male client with Type 2 diabetes mellitus (DM) is hospitalized with an infected ulcer on his
right great toe. Which instruction should the nurse emphasize during discharge teaching?
A. Open-toed shoes allow air to circulate and help prevent toenail fungus growth
B. Be sure that you only walk barefoot on soft surfaces, such as fully carpeted rooms
C. Nylon socks provide warmth without trapping excess moisture around your feet
D. Check the insides and linings of all enclosed shoes before putting the shoes on
D. Check the insides and linings of all enclosed shoes before putting the shoes on
3-A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should
the nurse respond?
A. Instruct the client to avoid foods with gluten, such as wheat bread
B. Advise the client to limit foods that are high in calcium and iron
C. Explain that the need to restrict fluids is the primary limitation
D. Describe the use of an elimination diet to find trigger foods.
D. Describe the use of an elimination diet to find trigger foods.
4- A client is receiving an IV infusion of regular insulin 60 units in 100 mL of normal saline at 5
units/hour. How many mL/hour should the nurse program the infusion pump? (round to nearest whole
number)
8
5- To reduce the risk for pulmonary complication for a client with Amyotrophic Lateral Sclerosis (ALS),
which interventions should the nurse implement? (Select all the apply)
A. Initiate passive range of motion exercises
B. Teach the client breathing exercises
C. Establish a regular bladder routine
D. Perform chest physiotherapy
E. Encourage use of incentive spirometer
,B. Teach the client breathing exercises
D. Perform chest physiotherapy
E. Encourage use of incentive spirometer
6- The nurse brings a scheduled dose of docusate calcium to a male client who has cirrhosis of the liver.
The client states he has never had bowel problems and does not need a stool softener. Which action
should the nurse take?
A. Document the client's refusal to take the prescribed medication
B. Listen to the client's bowel sounds to determine the need for the medication
C. Withhold the medication until consulting the healthcare provider
D. Explain the importance of taking measures to reduce the risk of bleeding.
C. Withhold the medication until consulting the healthcare provider
7 - An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the
priority nursing action?
A. Encourage turning and deep breathing.
B. Auscultate for presence of bowel sounds
C. Monitor hemoglobin and hematocrit
D. Administer IV antibiotics as prescribed
D. Administer IV antibiotics as prescribed
8- Which nursing problem should be included in the plan of care for the client with heart failure?
A. Ineffective tissue perfusion, peripheral, related to venous engorgement.
B. Activity intolerance related to oxygen deficit secondary to inefficient cardiac contractility
C. Pain related to myocardial ischemia secondary to cell destruction
D. Imbalance nutrition, more than body requirement, related to excessive caloric intake
B. Activity intolerance related to oxygen deficit secondary to inefficient cardiac contractility
Heart failure is a condition where the heart doesn't pump blood as well as it should. This can lead to a
lack of oxygen being delivered to the body's tissues, causing fatigue and shortness of breath, which can
limit a person's ability to perform activities - hence, activity intolerance. The phrase "secondary to
inefficient cardiac contractility" refers to the heart's reduced ability to contract and pump blood, which
is the underlying cause of the oxygen deficit and subsequent activity intolerance in heart failure
patients. The other options, while they may be relevant to other conditions, are not as directly related
to the primary symptoms and causes of heart failure.
9- An adult client is diagnosed with restless leg syndrome and is referred to the sleep clinic. The
healthcare provider prescribes ferrous sulfate 325 mg PO daily. Which laboratory values should the
nurse monitor?
A. Serum iron and ferritin
B. Platelet count and hematocrit
C. Neutrophils and eosinophils
D. Serum electrolytes.
, A. Serum iron and ferritin
Restless leg syndrome (RLS) is often associated with iron deficiency. Ferrous sulfate is an iron
supplement used to treat or prevent low blood levels of iron. Therefore, the nurse should monitor
serum iron and ferritin levels. Serum iron is a measure of the amount of iron in your blood, and ferritin is
a protein that helps your body store iron. Monitoring these levels will help the healthcare provider
determine if the ferrous sulfate is effectively increasing the client's iron levels and alleviating the
symptoms of RLS. The other options (B, C, D) are not directly related to the treatment of RLS with
ferrous sulfate, hence they are not the correct choices
10- A client enters the Emergency Department and reports a lesion caused by a human bite. The client's
injury consists of several puncture wounds and of the right hand. Which nursing intervention should the
nurse perform first?
A. Irrigation and debridement of the wounds
B. Injection of a tetanus vaccination is needed
C. Administration of antibiotic therapy as prescribed
D. Suturing and closure of the puncture wounds
C. Administration of antibiotic therapy as prescribed
Human bite wounds are at high risk of infection due to the polymicrobial nature of the oral flora, and
early administration of antibiotic therapy is crucial to prevent infection. Therefore, initiating antibiotic
therapy as prescribed is the most important initial nursing intervention to address the risk of infection
associated with human bite wounds.
11- The nurse is caring for a post-operative client following abdominal surgery with limited mobility.
Which finding is most concerning to the nurse?
A. Client does not want to perform deep breathing
B. Client denies pain
C. The right calf is 1 cm larger than the left calf
D. Oxygen saturation is 97%
C. The right calf is 1 cm larger than the left calf
This could indicate a deep vein thrombosis (DVT), a blood clot that forms in a vein deep in the body,
most commonly in the lower leg or thigh. DVT is a serious condition because the clot can break loose,
travel through the bloodstream, and block blood flow in the lungs, leading to a pulmonary embolism,
which can be fatal. Post-operative clients, especially those with limited mobility, are at increased risk for
DVT due to prolonged immobility which slows blood flow. The other options are less concerning: deep
breathing exercises are important but not immediately life-threatening, denial of pain is a positive sign,
and an oxygen saturation of 97% is within normal range.
12- In providing discharge teaching to a client with chronic obstructive disease (COPD), which instruction
is most important for the nurse to emphasize?
A. Avoid going outdoors whenever the pollen count is high
B. Stay in the house if the outdoor temperature is hot and humid
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