Chamberlain College of Nursing HESI- med surg
Question and Answers 2022
-A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the
best initial nursing action?
{{{Answer}}} (Observe the color, consistency, and amount of sputum)
-A client is brought to the ED 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?
{{{Answer}}} (Breath sounds over bilateral lung field)
-After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a client develops
pontine myselinolysis. Which intervention should the nurse implement first?
{{{Answer}}} (Reorient client to his room)
-A male client with heart failure (HF) calls the clinic andreports that he cannot put his shoes on because
they aretoo tight. Which additional information should the nurseobtain?
{{{Answer}}} (Has his weight changed in the last several days?)
-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?
{{{Answer}}} (Assist her to an upright position)
-A 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?
{{{Answer}}} (Increase the daily intake of oral fluids to liquefy secretions)
-A cardiac catherterization 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?
{{{Answer}}} (Three main arteries have major blockages, with only 1 to5% of blood flow getting
through to the heart muscle.)
-What information should the nurse include in the teaching plan of a client diagnosed with
gastroesophageal reflux disease (GERD)?
{{{Answer}}} (Minimize symptoms by wearing loose, comfortable clothing)
-The nurse is caring for a client with a lower left lobe pulmonary abscess. Which position should the
nurse instruct the client to maintain?
{{{Answer}}} (left lateral)
,-A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink
without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare
provider.
{{{Answer}}} (Yellow sclera)
-While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological
assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?
{{{Answer}}} (Weakened cough effort)
-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?
{{{Answer}}} (The xenograft is taken from nonhuman sources)
-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?
{{{Answer}}} (Prepare the client to return to the operating room)
-A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117
mEq/L. Which nursing problem should the nurse include in this client's plan of care?
{{{Answer}}} (Fluid volume excess)
-A female client enters the clinic and insists on being seen. She is weak, nervous, and reports a racing
heart beat 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?
{{{Answer}}} (Space the client's care to provide periods of rest)
-The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendations
should the nurse encourage the client to follow?
{{{Answer}}} (Restrict protein intake by limiting meats and other high-protein foods)
-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.)
{{{Answer}}} (Check his fingerstick glucose level
Assess his skin temperature and moisture
Measure his pulse and blood pressure)
-A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which
assessment finding warrants immediate intervention by the nurse?
{{{Answer}}} (Irregular apical pulse)
-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?
{{{Answer}}} (Continue to monitor the fingers until color returns to normal)
-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, respirations28 breaths/minute, and blood
pressure 122/82. Which intervention is most important for the nurse to implement first
{{{Answer}}} (Administer PRN oral antipyretic)
-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?
{{{Answer}}} (The client's blood pressure reading is 184/88 mm Hg)
-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
{{{Answer}}} (Further decline in level of consciousness)
-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?
{{{Answer}}} (Keep the drainage bag lower than the level of the bladder)
-Which client has the highest risk for developing skin cancer?
{{{Answer}}} (A 65 year-old fair-skinned male who is a construction worker)
-When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to
obtain?
{{{Answer}}} (Daily weight)
-A female client who was involved in a motor vehicle collision is admitted with a fractured left femur
which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation
(ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions
should the nurse implement?(Select all that apply.
{{{Answer}}} (Verify pedal pulses using a doppler pulse device Monitor left leg for pain, pallor,
paresthesia, paralysis,pressure
Evaluate the application of the splint to the left leg)
-A male client with Herpes zoster (shingles) on his thorax tells the nurse that he is having difficulty
sleeping. What is the probable etiology of this problem?
{{{Answer}}} (pain)
-When planning care for a client newly diagnosed with open angle glaucoma, the nurse identifies a
priority nursing diagnosis of, "visual sensory/perceptual alterations." This diagnosis is based on which
etiology?
{{{Answer}}} (decreased peripheral vision)
-A client who is newly diagnosed with emphysema is being prepared for discharge. Which instruction is
best for the nurse to provide the client to assist them with dyspnea self-management?
{{{Answer}}} (Practice inhaling through the nose and exhaling slowly)
-A client with cancer is receiving chemotherapy with a known vesicant. The client's IV has been in place
for 72hours. The nurse determines that a new IV site cannot be obtained, and leaves the present IV in
place. What is the greatest clinical risk related to this situation?
{{{Answer}}} (Impaired skin integrity)
Question and Answers 2022
-A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the
best initial nursing action?
{{{Answer}}} (Observe the color, consistency, and amount of sputum)
-A client is brought to the ED 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?
{{{Answer}}} (Breath sounds over bilateral lung field)
-After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a client develops
pontine myselinolysis. Which intervention should the nurse implement first?
{{{Answer}}} (Reorient client to his room)
-A male client with heart failure (HF) calls the clinic andreports that he cannot put his shoes on because
they aretoo tight. Which additional information should the nurseobtain?
{{{Answer}}} (Has his weight changed in the last several days?)
-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?
{{{Answer}}} (Assist her to an upright position)
-A 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?
{{{Answer}}} (Increase the daily intake of oral fluids to liquefy secretions)
-A cardiac catherterization 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?
{{{Answer}}} (Three main arteries have major blockages, with only 1 to5% of blood flow getting
through to the heart muscle.)
-What information should the nurse include in the teaching plan of a client diagnosed with
gastroesophageal reflux disease (GERD)?
{{{Answer}}} (Minimize symptoms by wearing loose, comfortable clothing)
-The nurse is caring for a client with a lower left lobe pulmonary abscess. Which position should the
nurse instruct the client to maintain?
{{{Answer}}} (left lateral)
,-A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink
without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare
provider.
{{{Answer}}} (Yellow sclera)
-While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological
assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?
{{{Answer}}} (Weakened cough effort)
-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?
{{{Answer}}} (The xenograft is taken from nonhuman sources)
-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?
{{{Answer}}} (Prepare the client to return to the operating room)
-A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117
mEq/L. Which nursing problem should the nurse include in this client's plan of care?
{{{Answer}}} (Fluid volume excess)
-A female client enters the clinic and insists on being seen. She is weak, nervous, and reports a racing
heart beat 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?
{{{Answer}}} (Space the client's care to provide periods of rest)
-The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendations
should the nurse encourage the client to follow?
{{{Answer}}} (Restrict protein intake by limiting meats and other high-protein foods)
-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.)
{{{Answer}}} (Check his fingerstick glucose level
Assess his skin temperature and moisture
Measure his pulse and blood pressure)
-A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which
assessment finding warrants immediate intervention by the nurse?
{{{Answer}}} (Irregular apical pulse)
-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?
{{{Answer}}} (Continue to monitor the fingers until color returns to normal)
-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, respirations28 breaths/minute, and blood
pressure 122/82. Which intervention is most important for the nurse to implement first
{{{Answer}}} (Administer PRN oral antipyretic)
-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?
{{{Answer}}} (The client's blood pressure reading is 184/88 mm Hg)
-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
{{{Answer}}} (Further decline in level of consciousness)
-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?
{{{Answer}}} (Keep the drainage bag lower than the level of the bladder)
-Which client has the highest risk for developing skin cancer?
{{{Answer}}} (A 65 year-old fair-skinned male who is a construction worker)
-When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to
obtain?
{{{Answer}}} (Daily weight)
-A female client who was involved in a motor vehicle collision is admitted with a fractured left femur
which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation
(ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions
should the nurse implement?(Select all that apply.
{{{Answer}}} (Verify pedal pulses using a doppler pulse device Monitor left leg for pain, pallor,
paresthesia, paralysis,pressure
Evaluate the application of the splint to the left leg)
-A male client with Herpes zoster (shingles) on his thorax tells the nurse that he is having difficulty
sleeping. What is the probable etiology of this problem?
{{{Answer}}} (pain)
-When planning care for a client newly diagnosed with open angle glaucoma, the nurse identifies a
priority nursing diagnosis of, "visual sensory/perceptual alterations." This diagnosis is based on which
etiology?
{{{Answer}}} (decreased peripheral vision)
-A client who is newly diagnosed with emphysema is being prepared for discharge. Which instruction is
best for the nurse to provide the client to assist them with dyspnea self-management?
{{{Answer}}} (Practice inhaling through the nose and exhaling slowly)
-A client with cancer is receiving chemotherapy with a known vesicant. The client's IV has been in place
for 72hours. The nurse determines that a new IV site cannot be obtained, and leaves the present IV in
place. What is the greatest clinical risk related to this situation?
{{{Answer}}} (Impaired skin integrity)
