MED-SURG II HESI EXAM | COMPLETE
QUESTIONS WITH EXPERT SOLUTIONS|
VERIFIED & UPDATED ANSWERS
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 - Correct Answer b. Irregular apical pulse
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 - Correct Answer b. Administer a narcotic
antagonist
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 - Correct Answer a. Adherence to
the regimen is imperative
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 - Correct Answer a.
Notify the healthcare provider of the client's medication history
,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 - Correct Answer c.
The procedure is performed with the client in an upright position
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 - Correct Answer c. Minimize
symptoms by wearing loose, comfortable clothing
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 - Correct
Answer a. Family members can help with regular foot exams
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 - Correct Answer
b. Prepare ice packs for placement in the clients axillary area
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 - Correct Answer c. The
clients daily blood pressure will be less than 140/80 this month
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 - Correct Answer
b. A change has recently occurred in his handwriting
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 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" -
Correct Answer b. "I can use a mirror to check the bottoms of my feet for any signs of
breakdown"
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 - Correct Answer
d. Consult with the occupational therapist for a functional assessment
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:
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 -
Correct Answer a. Medicate for pain and monitor vital signs
, 14. 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 - Correct Answer c. Serum iron and ferritin
15. 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 - Correct Answer a. White blood cell count
16. 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 -
Correct Answer 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
17. 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 - Correct
Answer d. Hypoalbuminemia that results in a decreased colloid oncotic pressure
18. 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
QUESTIONS WITH EXPERT SOLUTIONS|
VERIFIED & UPDATED ANSWERS
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 - Correct Answer b. Irregular apical pulse
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 - Correct Answer b. Administer a narcotic
antagonist
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 - Correct Answer a. Adherence to
the regimen is imperative
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 - Correct Answer a.
Notify the healthcare provider of the client's medication history
,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 - Correct Answer c.
The procedure is performed with the client in an upright position
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 - Correct Answer c. Minimize
symptoms by wearing loose, comfortable clothing
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 - Correct
Answer a. Family members can help with regular foot exams
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 - Correct Answer
b. Prepare ice packs for placement in the clients axillary area
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 - Correct Answer c. The
clients daily blood pressure will be less than 140/80 this month
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 - Correct Answer
b. A change has recently occurred in his handwriting
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 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" -
Correct Answer b. "I can use a mirror to check the bottoms of my feet for any signs of
breakdown"
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 - Correct Answer
d. Consult with the occupational therapist for a functional assessment
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:
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 -
Correct Answer a. Medicate for pain and monitor vital signs
, 14. 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 - Correct Answer c. Serum iron and ferritin
15. 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 - Correct Answer a. White blood cell count
16. 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 -
Correct Answer 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
17. 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 - Correct
Answer d. Hypoalbuminemia that results in a decreased colloid oncotic pressure
18. 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
