MED SURG 2 HESI TEST BANK REAL EXAM 231 QUESTIONS
AND CORRECT ANSWERS ALREADY A+GRADE ASSURED
PASS!!!!!!!!!!!!!
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 - ANS... -c. The
clients daily blood pressure will be less than 140/80 this month
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 - ANS... -b.
A change has recently occurred in his handwriting
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 breakdown"
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"
- ANS... -b. "I can use a mirror to check the bottoms of my feet for any signs of
breakdown"
,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 - ANS... -d.
Consult with the occupational therapist for a functional assessment
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: heart rate 140 bpm, respirations 26 breaths/minute and blood pressure
140/90. Which intervention is most important for the nurse to implement?
a. Medicate for pain and monitor vital signs according to protocol
b. Adminsted intravenous fluid bolus as prescribed by the HCP
c. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter.
d. Encourage the client to splint the incision with a pillow to cough and deep
breathe - ANS... -a. Medicate for pain and monitor vital signs
An adult is diagnosed with restless leg syndrome and is referred to the sleep clinic.
The HCP prescribed ferrous sulfate 325 PO daily. Which laboratory values should
the nurse monitor ?
a. Platelet count and hematocrit
b. Serum electrolytes
c. Serum iron and ferritin
d. Neutrophils and eosinophils - ANS... -c. Serum iron and ferritin
While caring for a client with a full thickness burn covering 40% of the body, the
nurse observes purulent drainage at the wound. Before reporting this finding to the
HCP , the nurse should review which of the client's laboratory values?
a. White blood cell count
b. Platelet count
c. Blood pH level
d. Hematocrit - ANS... -a. White blood cell count
,A client with a history of type 1 diabetes mellitus (DM) and asthma is readmitted
to the unit for the third time in two months with a current fasting blood sugar of
325 mg/dl. The client describes to the nurse of not understanding why the blood
glucose level continues to be out of control. Which interventions should the nurse
implement? Select all that apply.
a. Have the client describe a typical day at work, home, and social activities
b. Determine if the client is using a new insulin needle each administration
c. Evaluate the clients asthma medications that can elevate the blood glucose
d. Ask the client if they want a different manufactures glucose monitoring device
e. Have the client demonstrate techniques used to monitor blood glucose levels -
ANS... -a. Have the client describe a typical day at work, home, and social
activities
e. Have the client demonstrate techniques used to monitor blood glucose levels
The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and
legs, and massive ascites. Which mechanism contributes to edema and ascites in
clients with cirrhosis?
a. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules
b. Decreased portcaval pressure with greater collateral circulation
c. Decreased renin-angiotensin response related to an increase in renal blood flow
d. Hypoalbuminemia that results in a decreased colloid oncotic pressure - ANS... -
d. Hypoalbuminemia that results in a decreased colloid oncotic pressure
An older client with long term type 2 diabetes mellitus (DM) is seen in the clinic
for a routine health assessment. Which assessments would the nurse complete if a
patient with type 2 diabetes mellitus (DM) is experiencing long term
complications? Select all that apply.
a. Signs of respiratory tract infection
b. Sensation in feet and legs
c. Skin condition of lower extremities
d. Serum creatinine and BUN
e. Visual acuity - ANS... -b. Sensation in feet and legs
c. Skin condition of lower extremities
e. Visual acuity
, The nurse is caring for a client who is receiving teletherapy radiation for a
malignant tumor. Which instructions regarding skin of the portal site should the
nurse provide?
a. Protect the skin of the radiation portal site from sunlight exposure
b. Apply moisture lotions daily to the radiation portal site
c. Avoid washing the skin inside the radiation portal site
d. Remove the ink marks of the portal after each radiation treatment - ANS... -a.
Protect the skin of the radiation portal site from sunlight exposure
When conducting discharge teaching for a client diagnosed with diverticulitis,
which diet instruction should the nurse include?
a. Have a small frequent meals and sit up for at least two hours after meals
b. Eat a bland diet and avoid spicy foods
c. Eat a high-fiber diet and increase fluid intake
d. Eat a soft diet with increased intake of milk and milk products - ANS... -c. Eat a
high-fiber diet and increase fluid intake
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 - ANS... -b. Irregular apical pulse
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 - ANS... -b. Administer a narcotic antagonist
AND CORRECT ANSWERS ALREADY A+GRADE ASSURED
PASS!!!!!!!!!!!!!
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 - ANS... -c. The
clients daily blood pressure will be less than 140/80 this month
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 - ANS... -b.
A change has recently occurred in his handwriting
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 breakdown"
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"
- ANS... -b. "I can use a mirror to check the bottoms of my feet for any signs of
breakdown"
,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 - ANS... -d.
Consult with the occupational therapist for a functional assessment
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: heart rate 140 bpm, respirations 26 breaths/minute and blood pressure
140/90. Which intervention is most important for the nurse to implement?
a. Medicate for pain and monitor vital signs according to protocol
b. Adminsted intravenous fluid bolus as prescribed by the HCP
c. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter.
d. Encourage the client to splint the incision with a pillow to cough and deep
breathe - ANS... -a. Medicate for pain and monitor vital signs
An adult is diagnosed with restless leg syndrome and is referred to the sleep clinic.
The HCP prescribed ferrous sulfate 325 PO daily. Which laboratory values should
the nurse monitor ?
a. Platelet count and hematocrit
b. Serum electrolytes
c. Serum iron and ferritin
d. Neutrophils and eosinophils - ANS... -c. Serum iron and ferritin
While caring for a client with a full thickness burn covering 40% of the body, the
nurse observes purulent drainage at the wound. Before reporting this finding to the
HCP , the nurse should review which of the client's laboratory values?
a. White blood cell count
b. Platelet count
c. Blood pH level
d. Hematocrit - ANS... -a. White blood cell count
,A client with a history of type 1 diabetes mellitus (DM) and asthma is readmitted
to the unit for the third time in two months with a current fasting blood sugar of
325 mg/dl. The client describes to the nurse of not understanding why the blood
glucose level continues to be out of control. Which interventions should the nurse
implement? Select all that apply.
a. Have the client describe a typical day at work, home, and social activities
b. Determine if the client is using a new insulin needle each administration
c. Evaluate the clients asthma medications that can elevate the blood glucose
d. Ask the client if they want a different manufactures glucose monitoring device
e. Have the client demonstrate techniques used to monitor blood glucose levels -
ANS... -a. Have the client describe a typical day at work, home, and social
activities
e. Have the client demonstrate techniques used to monitor blood glucose levels
The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and
legs, and massive ascites. Which mechanism contributes to edema and ascites in
clients with cirrhosis?
a. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules
b. Decreased portcaval pressure with greater collateral circulation
c. Decreased renin-angiotensin response related to an increase in renal blood flow
d. Hypoalbuminemia that results in a decreased colloid oncotic pressure - ANS... -
d. Hypoalbuminemia that results in a decreased colloid oncotic pressure
An older client with long term type 2 diabetes mellitus (DM) is seen in the clinic
for a routine health assessment. Which assessments would the nurse complete if a
patient with type 2 diabetes mellitus (DM) is experiencing long term
complications? Select all that apply.
a. Signs of respiratory tract infection
b. Sensation in feet and legs
c. Skin condition of lower extremities
d. Serum creatinine and BUN
e. Visual acuity - ANS... -b. Sensation in feet and legs
c. Skin condition of lower extremities
e. Visual acuity
, The nurse is caring for a client who is receiving teletherapy radiation for a
malignant tumor. Which instructions regarding skin of the portal site should the
nurse provide?
a. Protect the skin of the radiation portal site from sunlight exposure
b. Apply moisture lotions daily to the radiation portal site
c. Avoid washing the skin inside the radiation portal site
d. Remove the ink marks of the portal after each radiation treatment - ANS... -a.
Protect the skin of the radiation portal site from sunlight exposure
When conducting discharge teaching for a client diagnosed with diverticulitis,
which diet instruction should the nurse include?
a. Have a small frequent meals and sit up for at least two hours after meals
b. Eat a bland diet and avoid spicy foods
c. Eat a high-fiber diet and increase fluid intake
d. Eat a soft diet with increased intake of milk and milk products - ANS... -c. Eat a
high-fiber diet and increase fluid intake
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 - ANS... -b. Irregular apical pulse
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 - ANS... -b. Administer a narcotic antagonist
