HESI MEDICAL -SURGICAL NURSING EXIT EXAM II WITH 160 ACTUAL EXAM QUESTIONS AND ANSWERS| LATEST UPDATE 2024 TEST 1 Multiple Choice Identify the letter of the choice that best completes the statement or answers the question. 1. While assessing a client with diabetes mellitus, the nurse observes an absence of hair growth on the client's legs. What additional assessment provides further data to support this finding? a. Palpate for the presence of femoral pulses bilaterally. b. Assess for the presence of a positive Homan's sign. c. Observe the appearance of the skin on the client's legs. d. Watch the client's posture and balance during ambulation. 2. The healthcare provider prescribes 15 mg/kg of Streptomycin for an infant weighing 4 pounds. The drug is diluted in 25 ml of D5W to run over 8 hours. How much Streptomycin will the infant receive? a. 9 mg. b. 18 mg. c. 27 mg. d. 36 mg. 3. In assessing a client with preeclampsia who is receiving magnesium sulfate, the nurse determines that her deep tendon reflexes are 1+; respiratory rate is 12 breaths/minute; urinary output is 90 ml in 4 hours; magnesium sulfate level is 9 mg/dl. Based on these findings, what intervention should the nurse implement? a. Continue the magnesium sulfate infusion as prescribed. b. Decrease the magnesium sulfate infusion by one-half. c. Stop the magnesium sulfate infusion immediately. d. Administer calcium gluconate immediately. 4. A client is on a mechanical ventilator. Which client response indicates that the neuromuscular blocker tubocurarine chloride (Tubarine) is effective? a. The client’s expremities are paralyzed. b. The peripheral nerve stimulator causes twitching. c. The client clinches fist upon command. d. The client’s Glagow Coma Scale score is 14. 5. An elderly female client comes to the clinic for a regular check -up. The client tells the nurse that she has increased her daily doses of acetaminophen (Tylenol) for the past month to control joint pain. Based on this client's comment, what previous lab values should the nurse compare with today's lab report? a. Look at last quarter's hemoglobin and hematocrit, expecting an increase today due to dehydration. b. Look for an increase in today's LDH compared to the previous one to assess for possible liver damage. c. Expect to find an increase in today's APTT as compared to last quarter's due to bleeding. d. Determine if there is a decrease in serum potassium due to renal compromise. Name: ID: A 2 6. Aspirin is prescribed for a 9 -year -old child with rheumatic fever to control the inflammatory process, promote comfort, and reduce fever. What intervention is most important for the nurse to implement? a. Instruct the parents to hold the aspirin until the child has first had a tepid sponge bath. b. Administer the aspirin with at least two ounces of water or juice. c. Notify the healthcare provider if the child complains of ringing in the ears. d. Advise the parents to question the child about seeing yellow halos around objects. 7. Which signs or symptoms are characteristic of an adult client diagnosed with Cushing's syndrome? a. Husky voice and complaints of hoarseness. b. Warm, soft, moist, salmon -colored skin. c. Visible swelling of the neck, with no pain. d. Central -type obesity, with thin extremities. 8. A charge nurse agrees to cover another nurse’s assignment during a lunch break. Based on the status report prov ided by the nurse who is leaving for lunch, which client should be checked first by the charge nurse? The client a. admitted yesterday with diabetec ketoacidosis whose blood glucose level is now 195 mg/dl. b. with an ileal conduit created two days ago with a scant amount of blood in the drainage pouch. c. post -triple coronary bypass four days ago who has serosanguinous drainage in the chest tube. d. with a pneumothorax secondary to a gunshot wound with a current pulse oximeter reading of 90%. 9. An outcome for treatment of peripheral vascular disease is, "The client will have decreased venous congestion." What client behavior would indicate to the nurse that this outcome has been met? a. Avoids prolonged sitting or standing. b. Avoids trauma and irritation to skin. c. Wears protective shoes. d. Quits smoking. 10. The healthcare provider performs a paracentesis on a client with ascites and 3 liters of fluid are removed. Which assessment parameter is most critical for the nurse to monitor following the procedure? a. Pedal pulses. b. Breath sounds. c. Gag reflex. d. Vital signs. Name: ID: A 3 11. The nurse is administering sevelamer (RenaGel) during lunch to a client with end stage renal disease (ESRD). The client asks the nurse to bring the medication later. The nurse should describe which action of RenaGel as an explanation for taking it with meals? a. Prevents indigestion associated with ingestion of spicy foods. b. Binds with phosphorus in foods and prevents absorption. c. Promotes stomach emptying and prevents gastric reflux. d. Buffers hydrochloric acid and prevents gastric erosion. 12. The nurse formulates a nursing diagnosis of, "High risk for ineffective airway clearance" for a client with myasthenia gravis. What is the most likely etiology for this nursing diagnosis? a. Pain when coughing. b. Diminished cough effort. c. Thick dry secretions. d. Excessive inflammation. 13. Following a CVA, the nurse assess that a client developed dysphagia, hypoactive bowel sounds and firm, distended abdomen. Which prescription for the client should the nurse question? a. Continous tube feeding at 65 ml/hr via gastrostomy. b. Total parenteral nutrition to be infused at 125 ml/hour. c. Nasogastric tube connected to low intermittent suction. d. Metoclopramide (Reglan) intermittent piggyback. 14. A client's telemetry monitor indicates the sudden onset of ventricular fibrillation. Which assessment finding should the nurse anticipate? a. Bounding erratic pulse. b. Regularly irregular pulse. c. Thready irregular pulse. d. No palpable pulse. 15. In assessing a 70-year -old female client with Alzheimer's disease, the nurse notes that she has deep inflamed cracks at the corners of her mouth. What intervention should the nurse include in this client's plan of care? a. Scrub the lesions with warm soapy water. b. Encourage the client to drink orange juice for added vitamin C. c. Notify the healthcare provider of the need for oral antibiotics. d. Ensure that the client gets adequate B vitamins in foods or supplements. 16. A young adult female client is seen in the emergency department for a minor injury following a motor vehicle collision. She states she is very angry at the person who hit her car. What is the best nursing response? a. "You are lucky to be alive. Be grateful no one was killed." b. "I understand your car was not seriously damaged." c. "You are upset that this incident has brought you here." d. "Have you ever been in the emergency department before?" Name: ID: A 4 17. An 85-year -old male resident of an extended care facility reaches for the hand of the unlicensed assistive personnel (UAP) and tries to kiss her hand several times during his morning care. The UAP reports the incident to the charge nurse. What is the best assessment of the situation? a. This is sexual harassment and needs to be reported to the administration immediately. b. The UAP needs to be reassigned to another group of residents, preferably females only. c. The client may be suffering from touch deprivation and needs to know appropriate ways to express his need. d. The resident needs to know the rules concerning unwanted touching of the staff and the consequences. 18. The parents of a newborn infant with hypospadias are concerned about when the surgical correction should occur. What information should the nurse provide? a. Repair should be done by one month to prevent bladder infections. b. Repairs typically should be done before the child is potty -trained. c. Delaying the repair until school age reduces castration fears. d. To form a proper urethra repair, it should be done after sexual maturity. 19. In evaluating teaching of a client about wearing a Holter monitor, which statement made by the client would indicate to the nurse that the client understands the procedure? a. “I must record any symptoms occurring with my activity.” b. “I am not looking forward to staying in bed for 24 hours.” c. “I really am dreading the frequent blood drawing.” d. “I know that I shouldn’t get close to my microwave oven.” 20. A 9-year -old female client was recently diagnosed with diabetes mellitus. Which symptom will her parents most likely report? a. Refuses to eat her favorite meals at home. b. Drinks more soft drinks than previously. c. Voids only one or two times per day. d. Gained 10 pounds within one month. 21. The nurse is caring for four clients: Client A, who has emphysema and whose oxygen saturation is 94%; Client B, with a postoperative hemoglobin of 8.7 mg/dl; Client C, newly admitted with a potassium level of 3.8 mEq/L; and Client D, scheduled for an appendectomy who has a white blood cell count of 15,000 mm 3. What intervention should the nurse implement? a. Increase Client A's oxygen to 4 liters per minute via nasal cannula. b. Determine if Client B has two units of packed cells available in the blood bank. c. Ask the dietician to add a banana to Client C's breakfast tray. d. Inform Client D that surgery is likely to be delayed until the infection is treated. Name: ID: A 5
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