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HESI MED SURGE ACTUAL EXAM 2023-
2024 VERSION 1 & 2 (2 VERSIONS)
EACH VERSION CONTAINS 55
QUESTIONS AND ANSWERS ALREADY
GRADED A+
HESI MED SURG version 1
- A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the best initial nursing action? A. Administer the first dose of antibiotic therapy B. Observe the color, consistency, and amount of sputum C. Encourage the client to consume plenty of warm liquids D. Send the specimen to the lab for analysis - ANSWER-B. Observe the color, consistency, and amount of sputum
- A client is brought to the ED by ambulance in cardiac arrest with cardiopulmonary resuscitation (CPR) in progress. The client is intubated and is 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? A. Breath sounds over bilateral lung fields. B. Carotid pulsation during compressions C. Deep tendon reflexes D. Core body temperature - ANSWER-A. Breath sounds over bilateral lung fields.
- After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a client develops pontine myselinolysis. Which intervention should the nurse implement first? A. Reorient client to his room B. Place a patch on one eye C. Evaluate client's ability to swallow D. Perform range of motion exercises - ANSWER-A. Reorient client to his room
- 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? A. What time did he take his last medications? B. Has his weight changed in the last several days? C. Is he still able to tighten his belt buckle? D. How many hours did he sleep last night? - ANSWER-B. Has his weight changed in the last several days?
- An older adult woman with a long history of chronic obstructive pulmonary disease (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? A. Administer a prescribed sedative B. Encourage client to drink water C. Apply a high-flow venturi mask D. Assist her to an upright position - ANSWER-D. Assist her to an upright position
- A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened tenacious mucous, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care? A. Increase the daily intake of oral fluids to liquefy secretions B. Avoid crowded enclosed areas to reduce pathogen exposure C. Call the clinic if undesirable side effects of mediations occur D. Teach anxiety reduction methods for feelings of suffocation - ANSWER- A. Increase the daily intake of oral fluids to liquefy secretions
- A cardiac catherterization of a client with heart disease indicates the following blockages: 95% proximal left anterior descending (LAD), 99% proximal circumflex, and? % proximal right coronary artery (RCA). The client later asks the nurse "what does all this mean for me?" What information should the nurse provide? A. Blood supply to the heart is diminished by artherosclerotic lesions, which necessitate lifestyle changes. B. Blood vessels supplying the pumping chamber have blockages indicating a past heart attack.
D. Asymmetrical weakness - ANSWER-C. Weakened cough effort
- The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client? A. Grafting increases the risk for bacterial infections B. The xenograft is taken from nonhuman sources C. Grafts are later removed by a debriding procedure D. As the burn heals, the graft permanently attaches - ANSWER-B. The xenograft is taken from nonhuman sources
- A male client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning him, the wound dehiscences and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. What intervention should the nurse implement next? A. Bring additional sterile dressing supplies to the room B. Prepare the client to return to the operating room C. Obtain a sample of the drainage to send to the lab D. Auscultate the abdomen for bowel sound activity - ANSWER-B. Prepare the client to return to the operating room
- 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? A. Altered urinary elimination B. Impaired gas exchange C. Fluid volume excess D. Decreased cardiac output - ANSWER-C. Fluid volume excess
- 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 and admits her for further testing. Which action should the nurse implement? A. Begin preparing client for thyroidectomy procedure B. Space the client's care to provide periods of rest C. Assess the client for hyperactive bowel sounds D. Provide warm blankets to prevent heat loss - ANSWER-B. Space the client's care to provide periods of rest
- The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendations should the nurse encourage the client to follow? A. Increase intake of high-fiber foods, such as bran cereal B. Restrict protein intake by limiting meats and other high-protein foods C. Limit oral fluid intake to 500 ml per day D. Increase intake of potassium-rich foods such as bananas or cantaloupe
- ANSWER-B. Restrict protein intake by limiting meats and other high- protein foods
- An overweight, young adult made who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions should the nurse implement? (Select all that apply.) A. Check his fingerstick glucose level B. Assess his skin temperature and moisture C. Measure his pulse and blood pressure D. Document anxiety on the surgical checklist E. Administer a PRN dose of regular insulin - ANSWER-A. Check his fingerstick glucose level B. Assess his skin temperature and moisture C. Measure his pulse and blood pressure
- A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse? A. Irregular apical pulse B. Purple marks on the skin of the abdomen C. Quarter size blood spot on dressing D. Pitting ankle edema - ANSWER-A. Irregular apical pulse
- 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? A. Apply a cool compress to the affected fingers for 20 minutes B. Secure a pulse oximeter to monitor the client's oxygen saturation C. Report the finding to the healthcare provider as soon as possible
D. Drink 1,000 ml of fluids daily to irrigate catheter - ANSWER-C. Keep the drainage bag lower than the level of the bladder
- Which client has the highest risk for developing skin cancer? A. A 16-year old dark-skinned female who tans in tanning beds once a week B. A 65 year-old fair-skinned male who is a construction worker C. A 25 year-old dark-skinned male whose mother had skin cancer D. A 70 year-old fair-skinned female who works as a secretary - ANSWER- B. A 65 year-old fair-skinned male who is a construction worker
- When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain? A. Daily weight B. Vital signs C. Level of consciousness D. Bowel sounds - ANSWER-A. Daily weight
- 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). The nurse determines that her distal pulses are diminished in the left foot. Which interventions should the nurse implement? (Select all that apply.) A. Offer ice chips and oral clear liquids B. Verify pedal pulses using a doppler pulse device C. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure D. Evaluate the application of the splint to the left leg E. Administer oral antispasmodics and narcotic analgesics - ANSWER-B. Verify pedal pulses using a doppler pulse device C. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure D. Evaluate the application of the splint to the left leg
- A male client with Herpes zoster (shingles) on his thorax tells the nurse that he is having difficulty sleeping. What is the probable etiology of this problem? A. Pain B. Nocturia C. Dyspnea D. Frequent cough - ANSWER-A. Pain
- 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? A. Limited eye movement B. Decreased peripheral vision C. Blurred distance vision D. Photosensitivity - ANSWER-B. Decreased peripheral vision
- 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? A. Allow additional time to complete physical activities to reduce oxygen demand B. Practice inhaling through the nose and exhaling slowly through pursed lips C. Use a humidifier to increase home air quality humidity between 30-50% D. Strengthen abdominal muscles by alternating leg raises during exhalation - ANSWER-B. Practice inhaling through the nose and exhaling slowly
- 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? A. Impaired skin integrity B. Fluid volume excess C. Acute pain and anxiety D. Peripheral neurovascular dysfunction - ANSWER-A. Impaired skin integrity
- A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the postanasthesia unit. Before selecting which medication to administer, which action should the nurse implement? A. Document the client's report of pain in the electronic medical record B. Determine which prescription will have the quickest onset of action C. Compare the client's pain scale rating with the prescribed dosing D. Ask the client to choose which mediation is needed for pain - ANSWER- C. Compare the client's pain scale rating with the prescribed dosing
- 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) A. Skin integrity B. Functional ability C. Heart sounds D. Pain scale E. Bowel sounds - ANSWER-A. Skin integrity B. Functional ability D. Pain scale
- 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? A. Observe the perineal area for a chancroid-like lesion B. Obtain a specimen of urethral drainage for culture C. Assess for perineal itching, erythema and excoriation D. Identify all sexual partners in the last four days - ANSWER-B. Obtain a specimen of urethral drainage for culture
- 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? A. Osmolarity B. Glucose C. Albumin D. Platlets - ANSWER-B. Glucose
- A client with acquired immunodeficiency syndrome (AIDS) has impaired gas exchange from a respiratory infection. Which assessment finding warrants immediate intervention by the nurse? A. Elevated temperature B. Generalized weakness C. Diminished lung sounds D. Pain when swallowing - ANSWER-D. Pain when swallowing
- 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 completely empty. Which intervention should the nurse implement? A. Collect a urine specimen for culture analysis B. Review the client's fluid intake prior to bedtime C. Palpate the bladder above the symphysis pubis D. Obtain a fingerstick blood glucose level - ANSWER-C. Palpate the bladder above the symphysis pubis
- 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 should the nurse implement? A. Remove all sources of liquids from the client's room B. Allow family to give client a measured amount of ice chips C. Restrict family visiting until the client's condition is stable D. Provide the client with oral swabs to moisten his mouth - ANSWER-D. Provide the client with oral swabs to moisten his mouth
- 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? A. Palpate for abdominal distention B. Send fluid to the lab for analysis C. Continue to monitor the fluid output D. Clamp the drainage tube for 5 minutes - ANSWER-C. Continue to monitor the fluid output
- 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? A. Review the client's dietary intake of high-protein foods B. Notify the healthcare provider of the finding immediately C. Discuss approaches to the chronic pain control with the client D. Assess the client's radial pulses and capillary refill time - ANSWER-C. Discuss approaches to the chronic pain control with the client
- A client who took a camping vacation two weeks ago in a county with a tropical climate comes to the clinic describing vague symptoms and
- 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? A. Collect the blood sample B. Assess radial pulse volume C. Apply pressure to the site D. Select another finger - ANSWER-A. Collect the blood sample
- 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 wall suction. Which intervention should the nurse implement to facilitate proper tube placement? A. Soak nasogastric tube in warm water B. Insert tube with client's head tilted back C. Apply suction while inserting tube D. Elevate head of bed 60 to 90 degrees - ANSWER-D. Elevate head of bed 60 to 90 degrees
- A young female client with seven children is having frequent morning headaches, dizziness, and blurred vision. Her blood pressure (BP) is 168/104 mmHg. 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? A. Measure urine output hourly to assess for rental perfusion B. Request a prescription for pain medication C. Use an automated BP machine to monitor for hypotension D. Provide a quiet environment with low lighting - ANSWER-C. Use an automated BP machine to monitor for hypotension
- 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? A. Invite friends over regularly to share in meal times B. Encourage the client to drink clear liquids between meals C. Coach the client to make an intentional effort to swallow D. Talk to the healthcare provider about prescribing an appetite stimulant - ANSWER-A. Invite friends over regularly to share in meal times
- A client who was discharged 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? A. Evaluate distal capillary refill for delayed perfusion B. Check the extremities for bruising and petechiae C. Examine the pretibial regions for pitting edema D. Palpate the abdomen for tenderness and rigidity - ANSWER-D. Palpate the abdomen for tenderness and rigidity ...
- A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions? A. Report when hematuria becomes pink tinged B. Use incentive spirometer C. Restrict physical activities D. Monitor urinary stream for decrease in output - ANSWER-D. Monitor urinary stream for decrease in output
HESI MED SURGE VERSION 2
An ER nurse is completing an assessment on a patient that is alert but struggles to answer questions. When she attempts to talk, she slurs her speech and appears very frightened. What additional clinical manifestation does the nurse expect to find if nacy's sysmptoms have been caused by a brain attack (stroke)? A. A carotid bruit B. A hypotensive blood pressure C. hyperreflexic deep tendon relexes. D. Decreased bowel sounds - ANSWER-A) A carotid bruit. Rationale: the carotid artery (artery to the brain) is narrowed in clients with a brain attack. A bruit is an abnormal sound heard on auscultation resulting from interference with normal blood flow. Usually the blood pressure is
A neurologist prescribes a magnetic resonance imaging (MRI) of the head STAT for a patient. Which data warrants immediate intervention by the nurse concerning this diagnostic test? A) Elevated blood pressure. B) Allergy to shell fish. C) Right hip replacement. D) History of atrial fibrillation. - ANSWER-C) Right hip replacement. The magnetic field generated by the MRI is so strong that metal-containing items are strongly attracted to the magnet. Because the hip joint is made of metal, a lead shield must be used during the procedure. Elevated blood pressure, an allergy to shell fish, and a history of atrial fibrillation would not affect the MRI. A client's daughter is sitting by her mother's bedside who was recently transferred to the Intermediate Care Unit. She states "I don't understand what a brain attack is. The healthcare provider told me my mother is in serious condition and they are going to run several tests. I just don't know what is going on. What happened to my mother?" What is the best response by the nurse? A) "I am sorry, but according to the Health Insurance Portability and Accounting Act (HIPAA), I cannot give you any information." B) "Your mother has had a stroke, and the blood supply to the brain has been blocked." C) "How do you feel about what the healthcare provider said?" D) "I will call the healthcare provider so he/she can talk to you about your mother's serious condition." - ANSWER-B) "Your mother has had a stroke, and the blood supply to the brain has been blocked." Rationale: The nurse can discuss what a diagnosis means. Nancy is unable to make decisions, so the next of kin, her daughter, Gail, needs sufficient information to make informed decisions. The nurse has the knowledge, and the responsibility, to explain Nancy's condition to Gail. The nurse should give facts first, and then address her feelings after the information is provided.
What is the normal range for cardiac output? - ANSWER-The normal range for cardiac output to ensure cerebral blood flow and oxygen delivery is 4 to 8 L/min. A client was admitted with the diagnosis of a brain attack. Their symptoms began 24 hours before being admitted. Why would this client not be a candidate for for thrombolytic therapy? - ANSWER-Thrombolytic therapy is contraindicated in clients with symptom onset longer than 3 hours prior to admission. This client had symptoms for 24 hours before being brought to the medical center What are plate guards? - ANSWER-Plate guards prevent food from being pushed off the plate. Using plate guards and other assistive devices will encourage independence in a client with a self-care deficit. Which condition is considered a non-modifiable risk factor for a brain attack? A) High cholesterol levels. B) Obesity. C) History of atrial fibrillation. D) Advanced age. - ANSWER-D) Advanced age. Rationale: People over age 55 are a high-risk group for a brain attack because the incidence of stroke more than doubles in each successive decade of life. Non-modifiable means the client cannot do anything to change the risk factor. All the other options are modifiable risk factors. A client is experiencing homonymous hemianopsia as the result of a brain attack. Which nursing intervention would the nurse implement to address this condition? A) Turn Nancy every two hours and perform active range of motion exercises. B) Place the objects Nancy needs for activities of daily living on the left side of the table. C) Speak slowly and clearly to assist Nancy in forming sounds to words. D) Request that the dietary department thicken all liquids on Nancy's meal and snack trays. - ANSWER-B) Place the objects Nancy needs for activities of daily living on the left side of the table.
C) Request a prescription for sodium bicarbonate from the health care provider. D) Inform the charge nurse that no changes in therapy are needed. - ANSWER-A) Encourage the client to use the incentive spirometer and to cough. Rationale: Respiratory acidosis is caused by CO2 retention and impaired chest expansion secondary to anesthesia. The nurse takes steps to promote CO2 elimination, including maintaining a patent airway and expanding the lungs through breathing techniques. O2 is not indicated because Po2 and oxygen saturation are within the normal range. Sodium bicarbonate is not indicated because the bicarbonate level is in the normal range; promoting excretion of respiratory acids is the priority in respiratory acidosis. Post anesthesia, the client will need interventions as described in A above or may progress to a state of somnolence and unresponsiveness. The nurse is providing dietary instructions to a 68-year-old client who is at high risk for development of coronary heart disease (CHD). Which information should the nurse include? A) Limit dietary selection of cholesterol to 300 mg per day B) Increase intake of soluble fiber to 10 to 25 grams per day. C) Decrease plant stanols and sterols to less than 2 grams/day. D) Ensure saturated fat is less than 30% of total caloric intake. - ANSWER- B) Increase intake of soluble fiber to 10 to 25 grams per day. Rationale: To reduce risk factors associated with coronary heart disease, the daily intake of soluble fiber (B) should be increased to between 10 and 25 gm. Cholesterol intake (A) should be limited to 180 mg/day or less. Intake of plant stanols and sterols is recommended at 2 g/day (C). Saturated fat (D) intake should be limited to 7% of total daily calories. A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which statement by the nurse provides the most accurate explanation for use of the splints? A) Prevention of deformities. B) Avoidance of joint trauma. C) Relief of joint inflammation. D) Improvement in joint strength. - ANSWER-A) Prevention of deformities.
Rationale: Splints may be used at night by clients with rheumatoid arthritis to prevent deformities (A) caused by muscle spasms and contractures. Splints are not used for (B). (C) is usually treated with medications, particularly those classified as non-steroidal antiinflammatory drugs (NSAIDs). For (D), a prescribed exercise program is indicated. A 32-year-old female client complains of severe abdominal pain each month before her menstrual period, painful intercourse, and painful defecation. Which additional history should the nurse obtain that is consistent with the client's complaints? A) Frequent urinary tract infections. B) Inability to get pregnant. C) Premenstrual syndrome. D) Chronic use of laxatives. - ANSWER-B) Inability to get pregnant. Rationale: Dysmenorrhea, dyspareunia, and difficulty or painful defecation are common symptoms of endometriosis, which is the abnormal displacement of endometrial tissue in the dependent areas of the pelvic peritoneum. A history of infertility (B) is another common finding associated with endometriosis. Although (A, C, and D) are common, nonspecific gynecological complaints, the most common complaints of the client with endometriosis are pain and infertility. A client with a 16-year history of diabetes mellitus is having renal function tests because of recent fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels. Which finding should the nurse conclude as an early symptom of renal insufficiency? A) Dyspnea. B) Nocturia. C) Confusion. D) Stomatitis. - ANSWER-B) Nocturia. Rationale: As the glomerular filtration rate decreases in early renal insufficiency, metabolic waste products, including urea, creatinine, and other substances, such phenols, hormones, electrolytes, accumulate in the blood. In the early stage of renal insufficiency, polyuria results from the
