HESI RN MED SURG VERSION A &
VERSION B |CERTIFIED QUESTIONS
WITH ANSWERS
A client with a nasogastric tube attached to low suction states that she is
nauseated. The nurse assesses that there has been no drainage through the
nasogastric tube in the last 2 hours. Which action should the nurse take first?
A.
Irrigate the nasogastric tube with sterile normal saline.
B.
Reposition the client on her side.
C.
Advance the nasogastric tube 5 cm.
D.
Administer an intravenous antiemetic as prescribed. - correct-answer -B
Rationale:The immediate priority is to determine if the tube is functioning
correctly, which would then relieve the client's nausea. The least invasive
intervention, repositioning the client, should be attempted first, followed by
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options A and C, unless either of these interventions is contraindicated. If these
measures are unsuccessful, the client may require option D.
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. - correct-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
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decrease of bone loss. Regular sleep patterns are important to overall health but
are not identified with a decreasing risk for osteoporosis.
Which nursing action would be appropriate for a client who is newly diagnosed
with Cushing syndrome?
A.
Monitor blood glucose levels daily.
B.
Increase intake of fluids high in potassium.
C.
Encourage adequate rest between activities.
D.
Offer the client a sodium-enriched menu. - correct-answer -A
Rationale:Cushing syndrome results from a hypersecretion of glucocorticoids in
the adrenal cortex. Clients with Cushing syndrome often develop diabetes
mellitus. Monitoring of serum glucose levels assesses for increased blood glucose
levels so that treatment can begin early. A common finding in Cushing syndrome
is generalized edema. Although potassium is needed, it is generally obtained from
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food intake, not by offering potassium-enhanced fluids. Fatigue is usually not an
overwhelming factor in Cushing syndrome, so an emphasis on the need for rest is
not indicated. A low-calorie, low-carbohydrate, low-sodium diet is not
recommended.
A 58-year-old client who has no health problems asks the nurse about receiving
the pneumococcal vaccine. Which statement given by the nurse would offer the
client accurate information about this vaccine?
A.
The vaccine is given annually before the flu season to those older than 50 years.
B.
The immunization is administered once to older adults or those at risk for illness.
C.
The vaccine is for all ages and is given primarily to those persons traveling
overseas to areas of infection.
D.
The vaccine will prevent the occurrence of pneumococcal pneumonia for up to 5
years. - correct-answer -B