HESI MEDSURG 1 EXAM REVIEW
1. Nurse in ED caring for a client who is having an acute asthma attack. How can she tell the
client in in respiratory distress (Select all)
A. 95% O2
B. Wheezing
C. Retraction of sternal muscles
D. Pink mucous membranes
E. Premature ventricular complexes (PVCs)
2. Morning
3. Newly admitted patient w/diagnosis of ascites. What order would the nurse question?
(select all)
a. High sodium
b. Spironolactone
c. Paracentesis
d. Administration of salt-poor albumin
e. Assisted ambulation
4. A client is administered to the emergency department with several large kidney stones.
What is the nursing priority of this patient?
a. Administer a Foley catheter
b. Have the patient transferred to the ER to have the stones surgically removed
c. Administer hydrochlorothiazide
d. Administer acetaminophen
5. A student nurse is completing a pain assessment. The patient states that the pain is
located in his abdomen, and relieved by defecation. After reviewing his chart she noticed
the consistency of his stools also changed. What would the student suspect his diagnosis
to be?
a. Appendicitis
b. Irritable bowel syndrome
c. Irregular diet
d. Abdominal hernia
6. The nurse obtains a diet history from a pregnant 16 yr old girl. The girl tells the nurse her
typical daily diet includes cereal and milk for breakfast, pizza and soda for lunch, and a
cheeseburger, milkshake, fries and a salad for dinner. Which of the following is the MOST
accurate nursing diagnosis based on the data?
a. Altered nutrition: more than body requirements related to high-fat diet
https://www.coursehero.com/file/54147092/Level-3-Medsurg-HESIpdf/
, b. Knowledge deficit: nutrition in pregnancy
c. Altered nutrition: less that body requirements related to increased nutritional
demands of pregnancy
d. Risk for injury: fetal malnutrition related to poor maternal diet
7. A boy was riding his bike to school when he hit the curb. He fell and hurt his leg. The
school nurse was called and found him alert and conscious, but in severe pain with a
possible fracture to the right femur. Which of the following is the FIRST action the nurse
should take
a. check the pedal pulse and blanching sign in both legs
b. immobilize the affected limb with a splint and ask him not to move
c. make a thorough assessment of the circumstances surrounding the accident
d. put him in semi-fowler’s position for comfort
8. A 65 year old patient with pneumonia is receiving gentamicin. It would be most important
for a nurse to monitor which of the following lab values in this patient
a. Hemoglobin and Hematocrit
b. BUN and creatinine: cleared by kidneys, gentamicin is nephrotoxic
c. Platelet count and clotting time
d. Sodium and potassium
9. To enhance the percutaneous absorption of nitroglycerin ointment, it would be MOST
important for the nurse to select a site that is
a. Muscular, non-hairy, near the heart. Nitro placement on anterior chest wall; want
to keep up with it, need it to attach and be seen. Non-hairy is the most important
so that it can be seen
10. The nurse care for a client diagnosed with a right-sided cerebrovascular accident (CVA)
with dysphagia. Which of the following actions by the nurse reflects appropriate care for
the client (SELECT ALL THAT APPLY).
a. The nurse assesses the client’s ability to swallow
b. the nurse offers the client scrambled eggs (make sure they are more whole)
c. the nurse positions the client at a 45 degree angle-should be 90 degrees
d. the nurse instructs the client to place food on the left side of the mouth-stroke
affects the left side of the mouth, can’t chew on this side
e. the nurse turns off the tv
11. You are teaching a patient with a sigmoid colostomy about colostomy care. Which
statement made by the patient shows the patient has an understanding?
a. I should clean my stoma with hydrogen peroxide
b. I will have watery stools now-ileostomy
c. I should make sure my stoma is dry
d. My stools will be formed-location
https://www.coursehero.com/file/54147092/Level-3-Medsurg-HESIpdf/
1. Nurse in ED caring for a client who is having an acute asthma attack. How can she tell the
client in in respiratory distress (Select all)
A. 95% O2
B. Wheezing
C. Retraction of sternal muscles
D. Pink mucous membranes
E. Premature ventricular complexes (PVCs)
2. Morning
3. Newly admitted patient w/diagnosis of ascites. What order would the nurse question?
(select all)
a. High sodium
b. Spironolactone
c. Paracentesis
d. Administration of salt-poor albumin
e. Assisted ambulation
4. A client is administered to the emergency department with several large kidney stones.
What is the nursing priority of this patient?
a. Administer a Foley catheter
b. Have the patient transferred to the ER to have the stones surgically removed
c. Administer hydrochlorothiazide
d. Administer acetaminophen
5. A student nurse is completing a pain assessment. The patient states that the pain is
located in his abdomen, and relieved by defecation. After reviewing his chart she noticed
the consistency of his stools also changed. What would the student suspect his diagnosis
to be?
a. Appendicitis
b. Irritable bowel syndrome
c. Irregular diet
d. Abdominal hernia
6. The nurse obtains a diet history from a pregnant 16 yr old girl. The girl tells the nurse her
typical daily diet includes cereal and milk for breakfast, pizza and soda for lunch, and a
cheeseburger, milkshake, fries and a salad for dinner. Which of the following is the MOST
accurate nursing diagnosis based on the data?
a. Altered nutrition: more than body requirements related to high-fat diet
https://www.coursehero.com/file/54147092/Level-3-Medsurg-HESIpdf/
, b. Knowledge deficit: nutrition in pregnancy
c. Altered nutrition: less that body requirements related to increased nutritional
demands of pregnancy
d. Risk for injury: fetal malnutrition related to poor maternal diet
7. A boy was riding his bike to school when he hit the curb. He fell and hurt his leg. The
school nurse was called and found him alert and conscious, but in severe pain with a
possible fracture to the right femur. Which of the following is the FIRST action the nurse
should take
a. check the pedal pulse and blanching sign in both legs
b. immobilize the affected limb with a splint and ask him not to move
c. make a thorough assessment of the circumstances surrounding the accident
d. put him in semi-fowler’s position for comfort
8. A 65 year old patient with pneumonia is receiving gentamicin. It would be most important
for a nurse to monitor which of the following lab values in this patient
a. Hemoglobin and Hematocrit
b. BUN and creatinine: cleared by kidneys, gentamicin is nephrotoxic
c. Platelet count and clotting time
d. Sodium and potassium
9. To enhance the percutaneous absorption of nitroglycerin ointment, it would be MOST
important for the nurse to select a site that is
a. Muscular, non-hairy, near the heart. Nitro placement on anterior chest wall; want
to keep up with it, need it to attach and be seen. Non-hairy is the most important
so that it can be seen
10. The nurse care for a client diagnosed with a right-sided cerebrovascular accident (CVA)
with dysphagia. Which of the following actions by the nurse reflects appropriate care for
the client (SELECT ALL THAT APPLY).
a. The nurse assesses the client’s ability to swallow
b. the nurse offers the client scrambled eggs (make sure they are more whole)
c. the nurse positions the client at a 45 degree angle-should be 90 degrees
d. the nurse instructs the client to place food on the left side of the mouth-stroke
affects the left side of the mouth, can’t chew on this side
e. the nurse turns off the tv
11. You are teaching a patient with a sigmoid colostomy about colostomy care. Which
statement made by the patient shows the patient has an understanding?
a. I should clean my stoma with hydrogen peroxide
b. I will have watery stools now-ileostomy
c. I should make sure my stoma is dry
d. My stools will be formed-location
https://www.coursehero.com/file/54147092/Level-3-Medsurg-HESIpdf/
