MEDSURG HESI Ans Key.
• 1 Which milestone indicates to the nurse successful achievement of young adulthood?
• Demonstrates a conceptualization of death and dying.
• Completes education and becomes self-supporting. Correct
• Creates a new definition of self and roles with others.
• Develops a strong need for parental support and approval.
• 2.ID: 311205638
The nurse working on a telemetry unit finds a client unconscious and in pulseless ventricular tachycardia
(VT). The client has an implanted automatic defibrillator. What action should the nurse implement?
• Prepare the client for transcutaneous pacemaker.
• Shock the client with 200 joules per hospital policy. Correct
• Use a magnet to deactivate the implanted pacemaker.
• Observe the monitor until the onset of ventricular fibrillation.
• 3.ID: 311255986
How should the nurse position the electrodes for modified chest lead one (MCL I) telemetry monitoring?
• Positive polarity right shoulder, negative polarity left shoulder, ground left chest nipple line.
• Positive polarity left shoulder, negative polarity right chest nipple line, ground left chest nipple
line.
• Positive polarity right chest nipple line, negative polarity left chest nipple line, ground left
shoulder.
• Negative polarity left shoulder, positive polarity right chest nipple line, ground left chest nipple
line. Correct
• 4.ID: 311196177
Based on the analysis of the client's atrial fibrillation, the nurse should prepare the client for which
treatment protocol?
• Diuretic therapy.
• Pacemaker implantation.
• Anticoagulation therapy. Correct
• Cardiac catheterization.
• 5.ID: 311205684
In preparing to administer intravenous albumin to a client following surgery, what is the priority nursing
intervention? (Select all that apply.)
,MEDSURG HESI Ans Key.
• Set the infusion pump to infuse the albumin within four hours. Correct
• Compare the client's blood type with the label on the albumin.
• Assign a UAP to monitor blood pressure q15 minutes.
• Administer through a large gauge catheter. Correct
• Monitor hemoglobin and hematocrit levels. Correct
• Assess for increased bleeding after administration. Correct
• 6.ID: 311189053
A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L. Which action is
most important for the nurse to implement?
• Give 20 mEq of potassium chloride.
• Initiate continuous cardiac monitoring. Correct
• Arrange a consultation with the dietician.
• Teach about the side effects of diuretics.
• 7.ID: 311192005
The nurse is teaching a female client about the best time to plan sexual intercourse in order to conceive.
Which information should the nurse provide?
• Two weeks before menstruation. Correct
• Vaginal mucous discharge is thick.
• Low basal temperature.
• First thing in the morning.
• 8.ID: 311205646
A 49-year-old female client arrives at the clinic for an annual exam and asks the nurse why she becomes
excessively diaphoretic and feels warm during nighttime. What is the nurse’s best response?
• Explain the effect of the follicle-stimulating and luteinizing hormones.
• Discuss perimenopause and related comfort measures. Correct
• Assess lung fields and for a cough productive of blood-tinged mucous.
• Ask if a fever above 101º F has occurred in the last 24 hours.
• 9.ID: 311264322
Which client should the nurse recognize as most likely to experience sleep apnea?
• Middle-aged female who takes a diuretic nightly.
, MEDSURG HESI Ans Key.
• Obese older male client with a short, thick neck. Correct
• Adolescent female with a history of tonsillectomy.
• School-aged male with a history of hyperactivity disorder.
• 10.ID: 311194999
The nurse is planning care for a client with newly diagnosed diabetes mellitus that requires insulin.
Which assessment should the nurse identify before beginning the teaching session?
• Present knowledge related to the skill of injection.
• Intelligence and developmental level of the client.
• Willingness of the client to learn the injection sites. Correct
• Financial resources available for the equipment.
• 11.ID: 311205688
The nurse is assessing a client's laboratory values following administration of chemotherapy. Which lab
value leads the nurse to suspect that the client is experiencing tumor lysis syndrome (TLS)?
• Serum PTT of 10 seconds.
• Serum calcium of 5 mg/dl. Correct
• Oxygen saturation of 90%.
• Hemoglobin of 10 g/dl.
• 12.ID: 311232352
During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving.
What action should the nurse take first?
• Use a laryngoscope to check for a foreign body lodged in the esophagus.
• Reposition the head to validate that the head is in the proper position to open the airway.
Correct
• Turn the client to the side and administer three back blows.
• Perform a finger sweep of the mouth to remove any vomitus.
• 13.ID: 311240002
A client has undergone insertion of a permanent pacemaker. When developing a discharge teaching
plan, the nurse writes a goal of, "The client will verbalize symptoms of pacemaker failure." Which
symptoms are most important to teach the client?
• Facial flushing.
• Fever.
• 1 Which milestone indicates to the nurse successful achievement of young adulthood?
• Demonstrates a conceptualization of death and dying.
• Completes education and becomes self-supporting. Correct
• Creates a new definition of self and roles with others.
• Develops a strong need for parental support and approval.
• 2.ID: 311205638
The nurse working on a telemetry unit finds a client unconscious and in pulseless ventricular tachycardia
(VT). The client has an implanted automatic defibrillator. What action should the nurse implement?
• Prepare the client for transcutaneous pacemaker.
• Shock the client with 200 joules per hospital policy. Correct
• Use a magnet to deactivate the implanted pacemaker.
• Observe the monitor until the onset of ventricular fibrillation.
• 3.ID: 311255986
How should the nurse position the electrodes for modified chest lead one (MCL I) telemetry monitoring?
• Positive polarity right shoulder, negative polarity left shoulder, ground left chest nipple line.
• Positive polarity left shoulder, negative polarity right chest nipple line, ground left chest nipple
line.
• Positive polarity right chest nipple line, negative polarity left chest nipple line, ground left
shoulder.
• Negative polarity left shoulder, positive polarity right chest nipple line, ground left chest nipple
line. Correct
• 4.ID: 311196177
Based on the analysis of the client's atrial fibrillation, the nurse should prepare the client for which
treatment protocol?
• Diuretic therapy.
• Pacemaker implantation.
• Anticoagulation therapy. Correct
• Cardiac catheterization.
• 5.ID: 311205684
In preparing to administer intravenous albumin to a client following surgery, what is the priority nursing
intervention? (Select all that apply.)
,MEDSURG HESI Ans Key.
• Set the infusion pump to infuse the albumin within four hours. Correct
• Compare the client's blood type with the label on the albumin.
• Assign a UAP to monitor blood pressure q15 minutes.
• Administer through a large gauge catheter. Correct
• Monitor hemoglobin and hematocrit levels. Correct
• Assess for increased bleeding after administration. Correct
• 6.ID: 311189053
A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L. Which action is
most important for the nurse to implement?
• Give 20 mEq of potassium chloride.
• Initiate continuous cardiac monitoring. Correct
• Arrange a consultation with the dietician.
• Teach about the side effects of diuretics.
• 7.ID: 311192005
The nurse is teaching a female client about the best time to plan sexual intercourse in order to conceive.
Which information should the nurse provide?
• Two weeks before menstruation. Correct
• Vaginal mucous discharge is thick.
• Low basal temperature.
• First thing in the morning.
• 8.ID: 311205646
A 49-year-old female client arrives at the clinic for an annual exam and asks the nurse why she becomes
excessively diaphoretic and feels warm during nighttime. What is the nurse’s best response?
• Explain the effect of the follicle-stimulating and luteinizing hormones.
• Discuss perimenopause and related comfort measures. Correct
• Assess lung fields and for a cough productive of blood-tinged mucous.
• Ask if a fever above 101º F has occurred in the last 24 hours.
• 9.ID: 311264322
Which client should the nurse recognize as most likely to experience sleep apnea?
• Middle-aged female who takes a diuretic nightly.
, MEDSURG HESI Ans Key.
• Obese older male client with a short, thick neck. Correct
• Adolescent female with a history of tonsillectomy.
• School-aged male with a history of hyperactivity disorder.
• 10.ID: 311194999
The nurse is planning care for a client with newly diagnosed diabetes mellitus that requires insulin.
Which assessment should the nurse identify before beginning the teaching session?
• Present knowledge related to the skill of injection.
• Intelligence and developmental level of the client.
• Willingness of the client to learn the injection sites. Correct
• Financial resources available for the equipment.
• 11.ID: 311205688
The nurse is assessing a client's laboratory values following administration of chemotherapy. Which lab
value leads the nurse to suspect that the client is experiencing tumor lysis syndrome (TLS)?
• Serum PTT of 10 seconds.
• Serum calcium of 5 mg/dl. Correct
• Oxygen saturation of 90%.
• Hemoglobin of 10 g/dl.
• 12.ID: 311232352
During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving.
What action should the nurse take first?
• Use a laryngoscope to check for a foreign body lodged in the esophagus.
• Reposition the head to validate that the head is in the proper position to open the airway.
Correct
• Turn the client to the side and administer three back blows.
• Perform a finger sweep of the mouth to remove any vomitus.
• 13.ID: 311240002
A client has undergone insertion of a permanent pacemaker. When developing a discharge teaching
plan, the nurse writes a goal of, "The client will verbalize symptoms of pacemaker failure." Which
symptoms are most important to teach the client?
• Facial flushing.
• Fever.
