HESI MEDSURG RETAKE EXAM- LATEST
STUDY GUIDE
1. A client with a productive cough has obtained a sputum specimen for
culture as instructed. What is the best initial nursing action?
Observe the color, consistency, and amount of sputum.
2. A client is brought to the Emergency Department by ambulance in
cardiac arrest with cardiopulmonary resuscitation (CPR) in progress.
The client is intubated and is receiving 100% oxygen per self-inflating
(ambu) bag. The nurse determines that the client is cyanotic, cold,
and diaphoretic. Which assessment is most important for the nurse to
obtain?
Breath sounds over bilateral lung fields.
3. After a hospitalization of inappropriate antidiuretic hormone
(SIADH), a client develops positive myelinolysis. Which intervention
should the nurse implement first?
Reorient client to his room.
4. A client who is admitted to the intensive care unit with syndrome of
inappropriate antidiuretic hormone (SIADH) has developed osmotic
demyelination. Which intervention should the nurse implement first?
Evaluate swallow.
5. A male client with heart failure (HF) calls the clinic and reports that he
cannot put his shoes on because they are too tight. Which additional
information should the nurse obtain?
Has his weight changed in the last several days?
6. An older adult woman with a long history of chronic obstructive
pulmonary disease (COPD) is admitted with progressive
shortness of breath and a persistent cough. She is anxious and is
complaining of a dry mouth. Which intervention should the nurse
implement?
Apply a high-flow venturi mask.
7. Client with a history of asthma and bronchitis arrives at the clinic
with shortness of breath, productive cough with thickened, tenacious
mucous, and the inability to walk up a flight of stairs without
experiencing breathlessness. Which action is most important for the
nurse to instruct the client about self-care?
Increase the daily intake of oral fluids to liquefy secretions.
,8. A cardiac catheterization of a client with heart disease indicates the
following blockages: 95% proximal left anterior descending (LAD),
99% proximal circumflex, and ? % proximal right coronary artery
(RCA). The client later asks the nurse "what does all this mean for
me?" What information should the nurse provide?
Three main arteries have major blockages, with only 1 to 5% of blood
flow getting through to the heart muscle.
9. A client who weighs 175 pounds is receiving IV bolus dose of
heparin 80 units/kg. The heparin is available in a 2 ml vial, labeled
10,000 units/ml. How many ml should the nurse administer? (Enter
numeric value only. If rounding is required, round to the nearest
tenth.)
1.6 mL.
10. What information should the nurse include in the teaching
plan of a client diagnosed with gastroesophageal reflux disease
(GERD)?
Minimize symptoms by wearing loose, comfortable clothing.
11. The nurse is caring for a client with a lower left lobe pulmonary
abscess. Which position should the nurse instruct the client to
maintain?
Left lateral.
12. A client with cholelithiasis has a gallstone lodged in the common bile
duct and is unable to eat or drink without becoming nausea and
vomiting. Which finding should the nurse report to the healthcare
provider?
Yellow sclera.
13. The nurse is planning care for a client following an incisional
cholecystectomy for cholelithiasis. Which intervention is the highest
nursing priority for this client?
Assisting the client to turn, cough and deep breathe every 2 hours.
14. While caring for a client with Amyotrophic Lateral Sclerosis (ALS), a
nurse performs a neurological assessment every 4 hours. Which
assessment finding warrants immediate intervention by the nurse?
Weakened cough effort.
, 15. The nurse is providing preoperative education for a Jewish client
scheduled to receive a xenograft graft to promote burn healing.
Which information should the nurse provide this client?
The xenograft is taken from nonhuman sources.
16. A male client who had colon surgery 3 days ago is anxious and
requesting assistance to reposition. While the nurse is turning him,
the wound dehiscences and eviscerates. The nurse moistens an
available sterile dressing and places it over the wound. What
intervention should the nurse implement next?
Prepare the client to return to the operating room.
17. A client with carcinoma of the lung is complaining of weakness and
has a serum sodium level 117 mEq/L. Which nursing problem should
the nurse include in this client's plan of care?
Fluid volume excess.
18. A female client enters the clinic and insists on being seen. She
is weak, nervous, and reports a racing heartbeat and recent weight
loss of 15 pounds. After ruling out substance withdrawal, the
healthcare provider suspects hyperthyroidism and admits her for
further testing. Which action should the nurse implement?
Space the client's care to provide periods of rest.
19. The nurse is teaching a client with glomerulonephritis about
self-care. Which dietary recommendations should the nurse
encourage the client to follow?
Restrict protein intake by limiting meats and other high-protein foods.
20. An overweight, young adult made who was recently diagnosed
with type 2 diabetes mellitus is admitted for a hernia repair. He tells
the nurse that he is feeling very weak and jittery. Which actions
should the nurse implement? (Select all that apply.)
Check his fingerstick glucose level
Assess his skin temperature and
moisture Measure his pulse and
blood pressure
21. A client with Cushing's syndrome is recovering from an
elective laparoscopic procedure. Which assessment finding
warrants immediate intervention by the nurse?
Irregular apical pulse.
, 22. An adult woman with primary Raynaud phenomenon develops
pallor and then cyanosis of her fingers. After warming her hands,
the fingers turn red and the client reports a burning sensation.
What action should the nurse take?
Continue to monitor the fingers until color returns to normal.
23. A male client with muscular dystrophy fell in his home and is
admitted with a right hip fracture. His right foot is cool, with
palpable pedal pulses. Lungs are coarse with diminished bibasilar
breath sounds. Vital signs are temperature 101F, heart rate 128
beats/minute, respirations 28 breaths/minute, and blood pressure
122/82. Which intervention is most important for the nurse to
implement first?
Assess lower extremity circulation.
24. The nurse is completing the preoperative assessment of a client
who is scheduled for a laparoscopic cholecystectomy under general
anesthesia. Which finding warrants notification of the healthcare
provider prior to proceeding with the scheduled procedure?
The client's blood pressure reading is 184/88 mm Hg.
25. A client who has a history of hypothyroidism was initially
admitted with lethargy and confusion. Which additional finding
warrants the most immediate action by the nurse?
Further decline in level of consciousness.
26. Following surgical repair of the bladder, a female client is being
discharged from the hospital to home with an indwelling urinary
catheter. Which instruction is most important for the nurse to provide
to this client?
Keep the drainage bag lower than the level of the bladder.
27. Which client has the highest risk for developing skin cancer?
A 65-year-old fair-skinned male who is a construction worker.
28. When caring for a client with nephrotic syndrome, which
assessment is most important for the nurse to obtain?
Daily weight.
STUDY GUIDE
1. A client with a productive cough has obtained a sputum specimen for
culture as instructed. What is the best initial nursing action?
Observe the color, consistency, and amount of sputum.
2. A client is brought to the Emergency Department by ambulance in
cardiac arrest with cardiopulmonary resuscitation (CPR) in progress.
The client is intubated and is receiving 100% oxygen per self-inflating
(ambu) bag. The nurse determines that the client is cyanotic, cold,
and diaphoretic. Which assessment is most important for the nurse to
obtain?
Breath sounds over bilateral lung fields.
3. After a hospitalization of inappropriate antidiuretic hormone
(SIADH), a client develops positive myelinolysis. Which intervention
should the nurse implement first?
Reorient client to his room.
4. A client who is admitted to the intensive care unit with syndrome of
inappropriate antidiuretic hormone (SIADH) has developed osmotic
demyelination. Which intervention should the nurse implement first?
Evaluate swallow.
5. A male client with heart failure (HF) calls the clinic and reports that he
cannot put his shoes on because they are too tight. Which additional
information should the nurse obtain?
Has his weight changed in the last several days?
6. An older adult woman with a long history of chronic obstructive
pulmonary disease (COPD) is admitted with progressive
shortness of breath and a persistent cough. She is anxious and is
complaining of a dry mouth. Which intervention should the nurse
implement?
Apply a high-flow venturi mask.
7. Client with a history of asthma and bronchitis arrives at the clinic
with shortness of breath, productive cough with thickened, tenacious
mucous, and the inability to walk up a flight of stairs without
experiencing breathlessness. Which action is most important for the
nurse to instruct the client about self-care?
Increase the daily intake of oral fluids to liquefy secretions.
,8. A cardiac catheterization of a client with heart disease indicates the
following blockages: 95% proximal left anterior descending (LAD),
99% proximal circumflex, and ? % proximal right coronary artery
(RCA). The client later asks the nurse "what does all this mean for
me?" What information should the nurse provide?
Three main arteries have major blockages, with only 1 to 5% of blood
flow getting through to the heart muscle.
9. A client who weighs 175 pounds is receiving IV bolus dose of
heparin 80 units/kg. The heparin is available in a 2 ml vial, labeled
10,000 units/ml. How many ml should the nurse administer? (Enter
numeric value only. If rounding is required, round to the nearest
tenth.)
1.6 mL.
10. What information should the nurse include in the teaching
plan of a client diagnosed with gastroesophageal reflux disease
(GERD)?
Minimize symptoms by wearing loose, comfortable clothing.
11. The nurse is caring for a client with a lower left lobe pulmonary
abscess. Which position should the nurse instruct the client to
maintain?
Left lateral.
12. A client with cholelithiasis has a gallstone lodged in the common bile
duct and is unable to eat or drink without becoming nausea and
vomiting. Which finding should the nurse report to the healthcare
provider?
Yellow sclera.
13. The nurse is planning care for a client following an incisional
cholecystectomy for cholelithiasis. Which intervention is the highest
nursing priority for this client?
Assisting the client to turn, cough and deep breathe every 2 hours.
14. While caring for a client with Amyotrophic Lateral Sclerosis (ALS), a
nurse performs a neurological assessment every 4 hours. Which
assessment finding warrants immediate intervention by the nurse?
Weakened cough effort.
, 15. The nurse is providing preoperative education for a Jewish client
scheduled to receive a xenograft graft to promote burn healing.
Which information should the nurse provide this client?
The xenograft is taken from nonhuman sources.
16. A male client who had colon surgery 3 days ago is anxious and
requesting assistance to reposition. While the nurse is turning him,
the wound dehiscences and eviscerates. The nurse moistens an
available sterile dressing and places it over the wound. What
intervention should the nurse implement next?
Prepare the client to return to the operating room.
17. A client with carcinoma of the lung is complaining of weakness and
has a serum sodium level 117 mEq/L. Which nursing problem should
the nurse include in this client's plan of care?
Fluid volume excess.
18. A female client enters the clinic and insists on being seen. She
is weak, nervous, and reports a racing heartbeat and recent weight
loss of 15 pounds. After ruling out substance withdrawal, the
healthcare provider suspects hyperthyroidism and admits her for
further testing. Which action should the nurse implement?
Space the client's care to provide periods of rest.
19. The nurse is teaching a client with glomerulonephritis about
self-care. Which dietary recommendations should the nurse
encourage the client to follow?
Restrict protein intake by limiting meats and other high-protein foods.
20. An overweight, young adult made who was recently diagnosed
with type 2 diabetes mellitus is admitted for a hernia repair. He tells
the nurse that he is feeling very weak and jittery. Which actions
should the nurse implement? (Select all that apply.)
Check his fingerstick glucose level
Assess his skin temperature and
moisture Measure his pulse and
blood pressure
21. A client with Cushing's syndrome is recovering from an
elective laparoscopic procedure. Which assessment finding
warrants immediate intervention by the nurse?
Irregular apical pulse.
, 22. An adult woman with primary Raynaud phenomenon develops
pallor and then cyanosis of her fingers. After warming her hands,
the fingers turn red and the client reports a burning sensation.
What action should the nurse take?
Continue to monitor the fingers until color returns to normal.
23. A male client with muscular dystrophy fell in his home and is
admitted with a right hip fracture. His right foot is cool, with
palpable pedal pulses. Lungs are coarse with diminished bibasilar
breath sounds. Vital signs are temperature 101F, heart rate 128
beats/minute, respirations 28 breaths/minute, and blood pressure
122/82. Which intervention is most important for the nurse to
implement first?
Assess lower extremity circulation.
24. The nurse is completing the preoperative assessment of a client
who is scheduled for a laparoscopic cholecystectomy under general
anesthesia. Which finding warrants notification of the healthcare
provider prior to proceeding with the scheduled procedure?
The client's blood pressure reading is 184/88 mm Hg.
25. A client who has a history of hypothyroidism was initially
admitted with lethargy and confusion. Which additional finding
warrants the most immediate action by the nurse?
Further decline in level of consciousness.
26. Following surgical repair of the bladder, a female client is being
discharged from the hospital to home with an indwelling urinary
catheter. Which instruction is most important for the nurse to provide
to this client?
Keep the drainage bag lower than the level of the bladder.
27. Which client has the highest risk for developing skin cancer?
A 65-year-old fair-skinned male who is a construction worker.
28. When caring for a client with nephrotic syndrome, which
assessment is most important for the nurse to obtain?
Daily weight.
