MED SURG 2 HESI TEST BANK REAL EXAM 100+ QUESTIONS
AND CORRECT ANSWERS WITH RATIONALES|AGRADE
1. 1. A client with Cushing's syndrome is recovering from an elective laparoscopic
procedure. Which assessment finding warrant's immediate intervention by the nurse?
a. Purple marks on skin of the abdomen
b. Irregular apical pulse
c. Quarter size blood spot on dressing
d. Pitting ankle edema: b. Irregular apical pulse
2. 2. A client with lung cancer who wears a subcutaneous morphine sulfate patch for
pain is short of breath and is difficult to arouse. When performing a head to toe
assessment, the nurse discovers four analgesic patches on the clients body. Which
intervention should the nurse implement first?
a. Remove all of the morphine patches
b. Administer a narcotic antagonist
c. Apply oxygen per face mask
d. Measure the client's blood pressure: b. Administer a narcotic antagonist
3. 3. A client receives prescriptions for a multidrug regimen for the treatment of
tuberculosis. Which information should the nurse prioritize?
a. Adherence to the regimen is imperative
b. Medications should be taken with food
c. Serum liver panels are collected regularly
d. Enhanced sun protection measures will be needed: a. Adherence to the regimen is
imperative
4. 4. The nurse is preparing a client for surgery who was admitted to the
emergency center following a motor vehicle collision. The client has an open
,fracture of the femur and is bleeding moderately from the bone protrusion
site. During the prescriptive assessment, the nurse determines that the client
currently receives heparin sodium 5,000 units subcutaneously daily. What is
the priority nursing action?
a. Notify the healthcare provider of the client's medication history
b. Observe the heparin injections sites for signs of bruising
c. Have the client sign the surgical and transfusion permits
d. Ensure that the potential for bleeding is explained to the client: a. Notify the
healthcare provider of the client's medication history
5. 5. A client with orthopnea expresses concern about the ability to "get enough
air" during a scheduled thoracentesis. On which information should the nurse's
response be based?
a. A thoracentesis is a brief process that has minimal discomfort
b. Orthopnea is frequently caused by a client's uncontrolled anxiety
c. The procedure is performed with the client in an upright position
d. Extra pillows can be used if needed to elevate the client's head: c. The procedure is
performed with the client in an upright position
6. 6. What information should the nurse include in the teaching plan of a client
diagnosed with gastroesophageal reflux disease (GERD)?
a. Sleep without pillows at night to maintain neck alignment
b. Adjust food intake to three full meals per day and no snacks
c. Minimize symptoms by wearing loose, comfortable clothing
d. Avoid participation in any aerobic exercise programs: c. Minimize symptoms by
wearing loose, comfortable clothing
,MED SURG 2 HESI TEST BANK REAL EXAM 100+ QUESTIONS
AND CORRECT ANSWERS WITH RATIONALES|AGRADE
7. 7. The nurse is providing teaching to a client with Type 2 diabetes mellitus and
peripheral neuropathy. Which information should the nurse provide?
a. Family members can help with regular foot exams
b. Heating pads are useful if on the low setting
c. Aching feet may be soaked in lukewarm water for one hour or more
d. Shoes should be worn outside the house, but it is fine to be barefoot inside: a.
Family members can help with regular foot exams
8. 8. A client in the operating room received succinylcholine. The client is experiencing
muscle rigidity and has an extremely high temperature. What action should the nurse
implement?
a. Hold a prescription for dantrolene until fever is reduced
b. Prepare ice packs for placement in the clients axillary area
c. Call the PACU nurse to prepare for prolonged ventilator support
d. Determine if prescribed antibiotics were administered preoperatively: b. Prepare ice
packs for placement in the clients axillary area
9. 9. The nurse is developing a plan of care for a client who reports blurred vision and
who is newly diagnosed with cardiovascular disease. Which outcome should the nurse
include in the plan of care for this client?
a. The nurse will encourage the client to walk thirty minutes every day
b. The clients family will state signs and symptoms about the disease
c. The clients daily blood pressure will be less than 140/80 this month
d. The client blood pressure readings will be less than 160/90: c. The clients daily blood
pressure will be less than 140/80 this month
, 10. 10. The family suspects that acquired immune deficiency syndrome (AIDS) dementia
is occuring in their son who is human immunodeficiency virus (HIV) positive. Which
symptoms confirm their suspicions?
a.
He has begun to sleep 18 out of 24 hours
b.
A change has recently occurred in his handwriting
c.
He refuses to see any of his friends or to return their phone calls
d.
He exhibits angry outburst when the subject of dying is approached: b. A change has
recently occurred in his handwriting
11. 11. A hospitalized client with peripheral arterial disease (PAD) is instructed
regarding leg and foot care. Which statement by the client indicates to the nurse that
learning has occurred?
a. "Whenever I am sitting in a chair I will keep my legs up to reduce swelling"
b. "I can use a mirror to check the bottoms of my feet for any signs of break-down"
c. "I will try to keep moving if leg pain occurs to help promote good circulation"
d. "I will use my swimming pool early in the day while the water is still very
cool": b. "I can use a mirror to check the bottoms of my feet for any signs of breakdown"
12. 12. While completing a health assessment for a client with migraine headaches, the
nurse assesses bilateral weakness in the client's hand grips.
The client reports joint pain and trouble twisting a door knob due to weakness. Which
action should the nurse take in response to these findings?
a. Explain that relief of the migraine pain will reduce related symptoms
b. Gather additional assessment data about the pain and weakness
c. Implement fall precautions to reduce the client's risk for injury
d. Consult with the occupational therapist for a functional assessment: d. Consult with
the occupational therapist for a functional assessment
13. 13. The nurse is caring for a client in the post anesthesia care unit (PACU) who
underwent a thoracotomy two hours ago. The nurse observes the following vital signs:
AND CORRECT ANSWERS WITH RATIONALES|AGRADE
1. 1. A client with Cushing's syndrome is recovering from an elective laparoscopic
procedure. Which assessment finding warrant's immediate intervention by the nurse?
a. Purple marks on skin of the abdomen
b. Irregular apical pulse
c. Quarter size blood spot on dressing
d. Pitting ankle edema: b. Irregular apical pulse
2. 2. A client with lung cancer who wears a subcutaneous morphine sulfate patch for
pain is short of breath and is difficult to arouse. When performing a head to toe
assessment, the nurse discovers four analgesic patches on the clients body. Which
intervention should the nurse implement first?
a. Remove all of the morphine patches
b. Administer a narcotic antagonist
c. Apply oxygen per face mask
d. Measure the client's blood pressure: b. Administer a narcotic antagonist
3. 3. A client receives prescriptions for a multidrug regimen for the treatment of
tuberculosis. Which information should the nurse prioritize?
a. Adherence to the regimen is imperative
b. Medications should be taken with food
c. Serum liver panels are collected regularly
d. Enhanced sun protection measures will be needed: a. Adherence to the regimen is
imperative
4. 4. The nurse is preparing a client for surgery who was admitted to the
emergency center following a motor vehicle collision. The client has an open
,fracture of the femur and is bleeding moderately from the bone protrusion
site. During the prescriptive assessment, the nurse determines that the client
currently receives heparin sodium 5,000 units subcutaneously daily. What is
the priority nursing action?
a. Notify the healthcare provider of the client's medication history
b. Observe the heparin injections sites for signs of bruising
c. Have the client sign the surgical and transfusion permits
d. Ensure that the potential for bleeding is explained to the client: a. Notify the
healthcare provider of the client's medication history
5. 5. A client with orthopnea expresses concern about the ability to "get enough
air" during a scheduled thoracentesis. On which information should the nurse's
response be based?
a. A thoracentesis is a brief process that has minimal discomfort
b. Orthopnea is frequently caused by a client's uncontrolled anxiety
c. The procedure is performed with the client in an upright position
d. Extra pillows can be used if needed to elevate the client's head: c. The procedure is
performed with the client in an upright position
6. 6. What information should the nurse include in the teaching plan of a client
diagnosed with gastroesophageal reflux disease (GERD)?
a. Sleep without pillows at night to maintain neck alignment
b. Adjust food intake to three full meals per day and no snacks
c. Minimize symptoms by wearing loose, comfortable clothing
d. Avoid participation in any aerobic exercise programs: c. Minimize symptoms by
wearing loose, comfortable clothing
,MED SURG 2 HESI TEST BANK REAL EXAM 100+ QUESTIONS
AND CORRECT ANSWERS WITH RATIONALES|AGRADE
7. 7. The nurse is providing teaching to a client with Type 2 diabetes mellitus and
peripheral neuropathy. Which information should the nurse provide?
a. Family members can help with regular foot exams
b. Heating pads are useful if on the low setting
c. Aching feet may be soaked in lukewarm water for one hour or more
d. Shoes should be worn outside the house, but it is fine to be barefoot inside: a.
Family members can help with regular foot exams
8. 8. A client in the operating room received succinylcholine. The client is experiencing
muscle rigidity and has an extremely high temperature. What action should the nurse
implement?
a. Hold a prescription for dantrolene until fever is reduced
b. Prepare ice packs for placement in the clients axillary area
c. Call the PACU nurse to prepare for prolonged ventilator support
d. Determine if prescribed antibiotics were administered preoperatively: b. Prepare ice
packs for placement in the clients axillary area
9. 9. The nurse is developing a plan of care for a client who reports blurred vision and
who is newly diagnosed with cardiovascular disease. Which outcome should the nurse
include in the plan of care for this client?
a. The nurse will encourage the client to walk thirty minutes every day
b. The clients family will state signs and symptoms about the disease
c. The clients daily blood pressure will be less than 140/80 this month
d. The client blood pressure readings will be less than 160/90: c. The clients daily blood
pressure will be less than 140/80 this month
, 10. 10. The family suspects that acquired immune deficiency syndrome (AIDS) dementia
is occuring in their son who is human immunodeficiency virus (HIV) positive. Which
symptoms confirm their suspicions?
a.
He has begun to sleep 18 out of 24 hours
b.
A change has recently occurred in his handwriting
c.
He refuses to see any of his friends or to return their phone calls
d.
He exhibits angry outburst when the subject of dying is approached: b. A change has
recently occurred in his handwriting
11. 11. A hospitalized client with peripheral arterial disease (PAD) is instructed
regarding leg and foot care. Which statement by the client indicates to the nurse that
learning has occurred?
a. "Whenever I am sitting in a chair I will keep my legs up to reduce swelling"
b. "I can use a mirror to check the bottoms of my feet for any signs of break-down"
c. "I will try to keep moving if leg pain occurs to help promote good circulation"
d. "I will use my swimming pool early in the day while the water is still very
cool": b. "I can use a mirror to check the bottoms of my feet for any signs of breakdown"
12. 12. While completing a health assessment for a client with migraine headaches, the
nurse assesses bilateral weakness in the client's hand grips.
The client reports joint pain and trouble twisting a door knob due to weakness. Which
action should the nurse take in response to these findings?
a. Explain that relief of the migraine pain will reduce related symptoms
b. Gather additional assessment data about the pain and weakness
c. Implement fall precautions to reduce the client's risk for injury
d. Consult with the occupational therapist for a functional assessment: d. Consult with
the occupational therapist for a functional assessment
13. 13. The nurse is caring for a client in the post anesthesia care unit (PACU) who
underwent a thoracotomy two hours ago. The nurse observes the following vital signs:
