FrmRN2u
HESI MEDSURGE VERSION 2 EXAM
A client arrives in the ED with slurred speech and right-sided weakness
Onset of symptoms
The community mental health nurse is planning to visit 4 clients with schizophrenia..see first
The father who took his children from school because aliens were after them
The nurse is assessing several clients at a homeless shelter. Which client should the nurse refer for
involuntary admission to a psych facility
A young adult who has lost his appetite because the communists are asking him to kill all conservative
Catholics
An adult male who has not eaten for 3 days and says he is Jesus Christ and that God loves all people
A middle-aged woman who sits for long periods of time and mumbles to herself about wanting to
die
A 7-year-old child is admitted to the hospital with acute glomerulonephritis (AGN). When obtaining the
nursing history, which finding should the nurse expect to obtain
A recent strep throat infection
Beginning with the vena cava, what is the normal sequence of blood circulation through the heart
(arrange from entry of the heart on top to exit of the heart on the bottom)
Right atrium, tricuspid valve, right ventricle, pulmonary semilunar valve, left atrium, mitral valve, left
ventricle, aortic semilunar valve
The nurse is assessing the emotional status of a client with Parkinson’s disease. Which client finding is
most helpful in planning goals to meet the client’s emotional needs
Cries frequently during the interview
What nursing intervention is particularly indicated for the second stage of labor
Assisting the client to push effectively so that expulsion of the fetus can be achieved
A newborn is apneic for 20 seconds. What action should the nurse implement
Stimulate by gently rubbing infant’s trunk
The nurse is completing a neurological assessment. Which observation indicates an abnormal pupil
response
When shining the light into the right eye, the left pupil does not constrict
The nurse manager is concerned about the number of falls that have occurred on the unit in the last
month. Which action is most likely to decrease the number of falls
Obtain the evidence based practice guidelines for falls prevention
The healthcare provider prescribes diltiazem (Cardizem ) for a child with hypertension who weighs 66
pounds. Based on the recommended dose of 3.5 mg/kg/day, how many mg should the child receive per
day
105
, FrmRN2u
One year after being diagnosed with Pneumocystic carinii pneumonia, a client is admitted with
respiratory failure. Respirations are shallow with periods of apnea. After the HCP delivers a grim
prognosis to the client’s family, which intervention should the nurse implement first
Clarify client’s end of life wishes
When preparing to start change-of-shift report, the charge nurse observes an unlicensed assistive
personnel (UAP) walking in the hallway with a urine specimen that is not covered. After telling the UAP
to cover the specimen, what intervention should the charge nurse implement
Review infection control guidelines with the UAP at the next opportunity
In monitoring a client’s respiratory status, which symptom is characteristic of early acute (adult)
respiratory distress syndrome (ARDS)
Increased respiratory rate
A client’s serum potassium test level is 6 mEq/L. The laboratory indicates, “Specimen is hemolyzed.”
What action should the nurse take
Draw a new blood specimen
Which action should the nurse implement to reduce a clients risk for nosocomial infection
Replace continuous tube feeding bag and tubing at least daily
During the admission interview, the nurse leader learns that a newly admitted adult client has a six
month history if recurring somatic pain. Which problem is most important for the nurse to further
explore with the client
Feelings of depression
An older male adult resident of an extended care facility receives a prescription for diphenhydramine
(Benadryl) 25 mg PO to treat generalized pruritis. Two hours after administration of the drug, he
continues to experience itching, is confused, and has an unsteady gait. Which actions should the nurse
implement first
Place the client on fall precautions
A female resident of a long-term care facility is being admitted to the medical department. The client
has a fractured humerous and methicillin-resistant staphylococcus aureus (MRSA). Which room should
the charge nurse assign this client
A semi-private room with another client who also has MRSA
The healthcare provider is working with a client who was recently diagnosed with asthma. Which
statement by the client indicates to the nurse that further teaching is needed
“I should always use my beclomethasone inhaler first, then follow it with my albuterol inhaler.”
The nurse is preparing to conduct discharge teaching for a client who had an anaphylactic reaction
following administration of ampicillin (Omnipen-N). What instruction is essential for the nurse to
provide this client prior to discharge
Instruct the client to wear a medic-alert bracelet so penicillin will not be given again
, FrmRN2u
What is the goal when planning nursing care for a client with edema and leg discoloration secondary to
chronic venous insufficiency
client’s skin integrity will remain intact
A client with a psychotic disorder is receiving haloperidol (Haldol) 3 mg IM q30 minutes x 3 hours for
agitation control. The medication is available in 5mg/ml. How many ml will the client receive over the
next 3 hours
3.6
The nurse plans to administer 1 teaspoon of a liquid to a toddler. What is the most accurate way to
administer the medication
measure the medication in an oral syringe
When assessing a client who had a supratentorial craniotomy, what action should the nurse implement
when determining the client’s Glasgow coma scale (GCS) rating
instruct the client to raise an arm
A client with a prescription for “do not resuscitate” (DNR) begins to manifest signs of impending death.
After notifying the family of the client’s status, what priority action should the nurse implement
the client’s need for pain medication should be determined
In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site,
and recognizes that hematoma formation at the bone fragment site has occurred. What action should
the nurse implement
document the extent of the bruising in the medical record
A client who is admitted to the hospital is suspected of having meningitis. The nurse should plan to
prepare the client for which diagnostic test
lumbar puncture
The school nurse is planning to begin an obesity screening program in a school system. It is best to begin
the screening program with which group
kindergarten
During a home visit, the nurse determines that a male client is experiencing symptoms that should be
controlled by his prescribed medication. The client states that he forgot when he was supposed to take
his medications. What is the priority nursing problem when the nurse develops the plan of care for this
client
ineffective health maintenance related to lack of knowledge
Immediately after an elective cardioversion for a rapid supraventricular tachycardia (SVT), a male client
who was premedicated with hydromorphone (Dilaudid) and midazolam (Versed) is difficult to arouse.
His vital signs are: oxygen saturation 94% while receiving oxygen at 2L/minute per nasal cannula, heart
rate 78 beats/minute, respirations 6 breaths/minute, and blood pressure 102/70. Which intervention
should the nurse implement
give IV naloxone (Narcan)
HESI MEDSURGE VERSION 2 EXAM
A client arrives in the ED with slurred speech and right-sided weakness
Onset of symptoms
The community mental health nurse is planning to visit 4 clients with schizophrenia..see first
The father who took his children from school because aliens were after them
The nurse is assessing several clients at a homeless shelter. Which client should the nurse refer for
involuntary admission to a psych facility
A young adult who has lost his appetite because the communists are asking him to kill all conservative
Catholics
An adult male who has not eaten for 3 days and says he is Jesus Christ and that God loves all people
A middle-aged woman who sits for long periods of time and mumbles to herself about wanting to
die
A 7-year-old child is admitted to the hospital with acute glomerulonephritis (AGN). When obtaining the
nursing history, which finding should the nurse expect to obtain
A recent strep throat infection
Beginning with the vena cava, what is the normal sequence of blood circulation through the heart
(arrange from entry of the heart on top to exit of the heart on the bottom)
Right atrium, tricuspid valve, right ventricle, pulmonary semilunar valve, left atrium, mitral valve, left
ventricle, aortic semilunar valve
The nurse is assessing the emotional status of a client with Parkinson’s disease. Which client finding is
most helpful in planning goals to meet the client’s emotional needs
Cries frequently during the interview
What nursing intervention is particularly indicated for the second stage of labor
Assisting the client to push effectively so that expulsion of the fetus can be achieved
A newborn is apneic for 20 seconds. What action should the nurse implement
Stimulate by gently rubbing infant’s trunk
The nurse is completing a neurological assessment. Which observation indicates an abnormal pupil
response
When shining the light into the right eye, the left pupil does not constrict
The nurse manager is concerned about the number of falls that have occurred on the unit in the last
month. Which action is most likely to decrease the number of falls
Obtain the evidence based practice guidelines for falls prevention
The healthcare provider prescribes diltiazem (Cardizem ) for a child with hypertension who weighs 66
pounds. Based on the recommended dose of 3.5 mg/kg/day, how many mg should the child receive per
day
105
, FrmRN2u
One year after being diagnosed with Pneumocystic carinii pneumonia, a client is admitted with
respiratory failure. Respirations are shallow with periods of apnea. After the HCP delivers a grim
prognosis to the client’s family, which intervention should the nurse implement first
Clarify client’s end of life wishes
When preparing to start change-of-shift report, the charge nurse observes an unlicensed assistive
personnel (UAP) walking in the hallway with a urine specimen that is not covered. After telling the UAP
to cover the specimen, what intervention should the charge nurse implement
Review infection control guidelines with the UAP at the next opportunity
In monitoring a client’s respiratory status, which symptom is characteristic of early acute (adult)
respiratory distress syndrome (ARDS)
Increased respiratory rate
A client’s serum potassium test level is 6 mEq/L. The laboratory indicates, “Specimen is hemolyzed.”
What action should the nurse take
Draw a new blood specimen
Which action should the nurse implement to reduce a clients risk for nosocomial infection
Replace continuous tube feeding bag and tubing at least daily
During the admission interview, the nurse leader learns that a newly admitted adult client has a six
month history if recurring somatic pain. Which problem is most important for the nurse to further
explore with the client
Feelings of depression
An older male adult resident of an extended care facility receives a prescription for diphenhydramine
(Benadryl) 25 mg PO to treat generalized pruritis. Two hours after administration of the drug, he
continues to experience itching, is confused, and has an unsteady gait. Which actions should the nurse
implement first
Place the client on fall precautions
A female resident of a long-term care facility is being admitted to the medical department. The client
has a fractured humerous and methicillin-resistant staphylococcus aureus (MRSA). Which room should
the charge nurse assign this client
A semi-private room with another client who also has MRSA
The healthcare provider is working with a client who was recently diagnosed with asthma. Which
statement by the client indicates to the nurse that further teaching is needed
“I should always use my beclomethasone inhaler first, then follow it with my albuterol inhaler.”
The nurse is preparing to conduct discharge teaching for a client who had an anaphylactic reaction
following administration of ampicillin (Omnipen-N). What instruction is essential for the nurse to
provide this client prior to discharge
Instruct the client to wear a medic-alert bracelet so penicillin will not be given again
, FrmRN2u
What is the goal when planning nursing care for a client with edema and leg discoloration secondary to
chronic venous insufficiency
client’s skin integrity will remain intact
A client with a psychotic disorder is receiving haloperidol (Haldol) 3 mg IM q30 minutes x 3 hours for
agitation control. The medication is available in 5mg/ml. How many ml will the client receive over the
next 3 hours
3.6
The nurse plans to administer 1 teaspoon of a liquid to a toddler. What is the most accurate way to
administer the medication
measure the medication in an oral syringe
When assessing a client who had a supratentorial craniotomy, what action should the nurse implement
when determining the client’s Glasgow coma scale (GCS) rating
instruct the client to raise an arm
A client with a prescription for “do not resuscitate” (DNR) begins to manifest signs of impending death.
After notifying the family of the client’s status, what priority action should the nurse implement
the client’s need for pain medication should be determined
In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site,
and recognizes that hematoma formation at the bone fragment site has occurred. What action should
the nurse implement
document the extent of the bruising in the medical record
A client who is admitted to the hospital is suspected of having meningitis. The nurse should plan to
prepare the client for which diagnostic test
lumbar puncture
The school nurse is planning to begin an obesity screening program in a school system. It is best to begin
the screening program with which group
kindergarten
During a home visit, the nurse determines that a male client is experiencing symptoms that should be
controlled by his prescribed medication. The client states that he forgot when he was supposed to take
his medications. What is the priority nursing problem when the nurse develops the plan of care for this
client
ineffective health maintenance related to lack of knowledge
Immediately after an elective cardioversion for a rapid supraventricular tachycardia (SVT), a male client
who was premedicated with hydromorphone (Dilaudid) and midazolam (Versed) is difficult to arouse.
His vital signs are: oxygen saturation 94% while receiving oxygen at 2L/minute per nasal cannula, heart
rate 78 beats/minute, respirations 6 breaths/minute, and blood pressure 102/70. Which intervention
should the nurse implement
give IV naloxone (Narcan)
