Med Surg Hesi and study guide
Med Surg Hesi and 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
1
,Med Surg Hesi and study guide
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.
2
,Med Surg Hesi and study guide
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?
3
, Med Surg Hesi and study guide
Weakened cough effort.
4
Med Surg Hesi and 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
1
,Med Surg Hesi and study guide
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.
2
,Med Surg Hesi and study guide
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?
3
, Med Surg Hesi and study guide
Weakened cough effort.
4
