HESI Med-Surg Block 3 Questions And
Correct Answers
1. The nurse is caring for a client with a chest tube to water seal drainage that
was inserted 10 days ago because of a ruptured bullae and pneumothorax.
Which finding should the nurse report to the health care provider before the
chest tube is removed?
A. Tidaling of water in water seal chamber
B. Bilateral muffled breath sounds at bases
C. Temperature of 101°F
D. Absence of chest tube drainage for 2 days: A. Tidaling of water in water seal chamber
Rationale: Tidaling (rising and falling of water with respirations) in the water seal chamber should be reported to the
health care provider before the chest tube is removed to rule out an unresolved pneumothorax or persistent air leak,
which is characteristic of a ruptured bullae caused by abnormally wide changes in negative intrathoracic pressure.
Option B may indicate hypoventilation from chest tube discomfort and usually improves when the chest tube is removed.
Option C usually indicates an infection, which may not be related to the chest tube. Option D is an expected finding.
2. The nurse is planning care for a client with diabetes mellitus who has gan-
grene of the toes to the midfoot. Which goal should be included in this client's
plan of care?
A. Restore skin integrity.
B. Prevent infection.
C. Promote healing.
D. Improve nutrition.: B. Prevent infection.
Rationale: The prevention of infection is a priority goal for this client. Gangrene is the result of necrosis (tissue death).
If infection develops, there is insuflcient circulation to fight the infection and the infection can result in osteomyelitis or
sepsis. Because tissue death has already occurred, options A and C are unattainable goals. Option D is important but
of less priority than option B.
3. A client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly
treated at a community hemodialysis facility. Before the scheduled dialysis
treatment, which electrolyte imbalance should the nurse anticipate?
,A. Hypophosphatemia
B. Hypocalcemia
C. Hyponatremia
, D. Hypokalemia: B. Hypocalcemia
Rationale: Hypocalcemia develops in CKD because of chronic hyperphosphatemia, not option A. Increased phosphate
levels cause the peripheral deposition of calcium and resistance to vitamin D absorption needed for calcium absorption.
Prior to dialysis, the nurse would expect to find the client hypernatremic and hyperkalemic, not with option C or D.
4. The nurse is conducting an osteoporosis screening clinic at a health fair.
What information should the nurse provide to individuals who are at risk for
osteoporosis? (Select all that apply.)
A. Encourage alcohol and smoking cessation.
B. Suggest supplementing diet with vitamin E.
C. Promote regular weight-bearing exercises.
D. Implement a home safety plan to prevent falls.
E. Propose a regular sleep pattern of 8 hours nightly.: Answer: A,C,D
Rationale: Options A, C, and D are factors that decrease the risk for developing osteoporosis. Vitamin D and calcium are
important supplements to aid in the decrease of bone loss. Regular sleep patterns are important to overall health but
are not identified with a decreasing risk for osteoporosis.
5. The nurse is preparing a 45-year-old client for discharge from a cancer center
following ileostomy surgery for colon cancer. Which discharge goal should the
nurse include in this client's discharge plan?
A. Reduce the daily intake of animal fat to 10% of the diet within 6 weeks.
B. Exhibit regular, soft-formed stool within 1 month.
C. Demonstrate the irrigation procedure correctly within 1 week.
D. Attend an ostomy support group within 2 weeks.: D. Attend an ostomy support group
within 2 weeks.
Rationale: Attending a support group will be beneficial to the client and should be encouraged because adaptation to
the ostomy can be diflcult. This goal is attainable and is measurable. Option A is not specifically related to ileostomy
care. The client with an ileostomy will not be able to accomplish option B. Option C is not necessary.
6. The nurse is concerned about infection for a client after an esophagogas-
trostomy for esophageal cancer. Which actions should the nurse include in the
Correct Answers
1. The nurse is caring for a client with a chest tube to water seal drainage that
was inserted 10 days ago because of a ruptured bullae and pneumothorax.
Which finding should the nurse report to the health care provider before the
chest tube is removed?
A. Tidaling of water in water seal chamber
B. Bilateral muffled breath sounds at bases
C. Temperature of 101°F
D. Absence of chest tube drainage for 2 days: A. Tidaling of water in water seal chamber
Rationale: Tidaling (rising and falling of water with respirations) in the water seal chamber should be reported to the
health care provider before the chest tube is removed to rule out an unresolved pneumothorax or persistent air leak,
which is characteristic of a ruptured bullae caused by abnormally wide changes in negative intrathoracic pressure.
Option B may indicate hypoventilation from chest tube discomfort and usually improves when the chest tube is removed.
Option C usually indicates an infection, which may not be related to the chest tube. Option D is an expected finding.
2. The nurse is planning care for a client with diabetes mellitus who has gan-
grene of the toes to the midfoot. Which goal should be included in this client's
plan of care?
A. Restore skin integrity.
B. Prevent infection.
C. Promote healing.
D. Improve nutrition.: B. Prevent infection.
Rationale: The prevention of infection is a priority goal for this client. Gangrene is the result of necrosis (tissue death).
If infection develops, there is insuflcient circulation to fight the infection and the infection can result in osteomyelitis or
sepsis. Because tissue death has already occurred, options A and C are unattainable goals. Option D is important but
of less priority than option B.
3. A client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly
treated at a community hemodialysis facility. Before the scheduled dialysis
treatment, which electrolyte imbalance should the nurse anticipate?
,A. Hypophosphatemia
B. Hypocalcemia
C. Hyponatremia
, D. Hypokalemia: B. Hypocalcemia
Rationale: Hypocalcemia develops in CKD because of chronic hyperphosphatemia, not option A. Increased phosphate
levels cause the peripheral deposition of calcium and resistance to vitamin D absorption needed for calcium absorption.
Prior to dialysis, the nurse would expect to find the client hypernatremic and hyperkalemic, not with option C or D.
4. The nurse is conducting an osteoporosis screening clinic at a health fair.
What information should the nurse provide to individuals who are at risk for
osteoporosis? (Select all that apply.)
A. Encourage alcohol and smoking cessation.
B. Suggest supplementing diet with vitamin E.
C. Promote regular weight-bearing exercises.
D. Implement a home safety plan to prevent falls.
E. Propose a regular sleep pattern of 8 hours nightly.: Answer: A,C,D
Rationale: Options A, C, and D are factors that decrease the risk for developing osteoporosis. Vitamin D and calcium are
important supplements to aid in the decrease of bone loss. Regular sleep patterns are important to overall health but
are not identified with a decreasing risk for osteoporosis.
5. The nurse is preparing a 45-year-old client for discharge from a cancer center
following ileostomy surgery for colon cancer. Which discharge goal should the
nurse include in this client's discharge plan?
A. Reduce the daily intake of animal fat to 10% of the diet within 6 weeks.
B. Exhibit regular, soft-formed stool within 1 month.
C. Demonstrate the irrigation procedure correctly within 1 week.
D. Attend an ostomy support group within 2 weeks.: D. Attend an ostomy support group
within 2 weeks.
Rationale: Attending a support group will be beneficial to the client and should be encouraged because adaptation to
the ostomy can be diflcult. This goal is attainable and is measurable. Option A is not specifically related to ileostomy
care. The client with an ileostomy will not be able to accomplish option B. Option C is not necessary.
6. The nurse is concerned about infection for a client after an esophagogas-
trostomy for esophageal cancer. Which actions should the nurse include in the
