2021 MEDSURG HESI V1 55 QUESTIONS ALL ANSWERED CORRECT
1. The nurse obtains a fingerstick blood glucose level utilizing bedside lancet/glucose meter
equipment from a client with a prescribed sliding scale insulin protocol. The meter indicated 56
mg/dl (3.12 mmol/l). At this time, which intervention should the nurse implement first?
A. Collect a blood specimen by venipuncture to send to the laboratory for serum glucose analysis
B. Prepare the prescribed dose of rapid acting insulin from the sliding scale instructions
C. Give the client six ounces of non-diet carbonated soda and instruct client to drink it entirely
D. Document the glucose reading in the electronic medical record as the only action needed
2. To achieve maximum mobility and independence for a client multiple sclerosis (MS), which
intervention is most important for the nurse to implement?
A. Provide a walker for ambulation
B. Frequently assist client to bathroom
C. Apply alternating patches over eyes
D. Teaching strengthening exercises
3. A client is admitted to the hospital with symptoms consistent with a right hemisphere stroke.
Which neurovascular assessment requires immediate intervention by the nurse?
A. Pupillary changes to ipsilateral dilation
B. Orientation to person and place only
C. Left-sided facial drooping and dysphagia
D. Unequal bilateral hand grip strengths
4. The nurse is teaching a client with glomerulonephritis about self care. Which dietary
recommendations should the nurse encourage the client to follow?
A. Limit oral fluid intake to 500 mL per day
B. Restrict protein intake by limiting meats and other high-protein foods
C. Increase intake of potassium-rich foods such as bananas or cantaloupe
D. Increase intake of high-fiber foods, such as bran cereal
, 5. The nurse id caring for a client with Herpes zoster who reports painful, red blisters that align
from the back along the chest’s curvature to the anterior chest. Which intervention is the
highest priority for the nurse?
A. Place the client on contact precautions
B. Administer antiviral medications
C. Place wet compresses to ruptured vesicles
D. Administer narcotic analgesics
6. A young adult who suffered a severe brain injury in an automobile collision has been
mechanically ventilated for the past three days and has no spontaneous respiratory effort. After
serial electroencephalograms (EEG) reveal no brain activity, the healthcare provider discusses
end-of-life options with the family who agree to discontinue life support. Which intervention
should the nurse implement?
A. Ask the family if they wish to remain at the bedside during withdrawal
B. Request a living will be placed in the client’s medical record
C. Discuss the withdrawal procedure with the family and offer support
D. Turn off the mechanical ventilator and note the time of death
7. Following a transurethral resection of the prostate (TURP), a client is discharged from the
hospital with an indwelling urinary catheter. Which instruction is most important for the nurse to
include in the discharge teaching plan?
A. Eliminate all spicy foods from your diet
B. Drink 3 liters of water each day
C. Clamp the catheter when taking a shower
D. Avoid driving a care for 2 weeks
8. On the first postoperative day, the nurse finds an older male client disoriented and trying to
climb over the bed railing. Previously, he was oriented to person, place, and time on admission.
Which intervention should the nurse implement first?
A. Apply wrist restraints
B. Determine the client’s blood pressure
C. Administer a mild sedative
D. Assess the client for pain
1. The nurse obtains a fingerstick blood glucose level utilizing bedside lancet/glucose meter
equipment from a client with a prescribed sliding scale insulin protocol. The meter indicated 56
mg/dl (3.12 mmol/l). At this time, which intervention should the nurse implement first?
A. Collect a blood specimen by venipuncture to send to the laboratory for serum glucose analysis
B. Prepare the prescribed dose of rapid acting insulin from the sliding scale instructions
C. Give the client six ounces of non-diet carbonated soda and instruct client to drink it entirely
D. Document the glucose reading in the electronic medical record as the only action needed
2. To achieve maximum mobility and independence for a client multiple sclerosis (MS), which
intervention is most important for the nurse to implement?
A. Provide a walker for ambulation
B. Frequently assist client to bathroom
C. Apply alternating patches over eyes
D. Teaching strengthening exercises
3. A client is admitted to the hospital with symptoms consistent with a right hemisphere stroke.
Which neurovascular assessment requires immediate intervention by the nurse?
A. Pupillary changes to ipsilateral dilation
B. Orientation to person and place only
C. Left-sided facial drooping and dysphagia
D. Unequal bilateral hand grip strengths
4. The nurse is teaching a client with glomerulonephritis about self care. Which dietary
recommendations should the nurse encourage the client to follow?
A. Limit oral fluid intake to 500 mL per day
B. Restrict protein intake by limiting meats and other high-protein foods
C. Increase intake of potassium-rich foods such as bananas or cantaloupe
D. Increase intake of high-fiber foods, such as bran cereal
, 5. The nurse id caring for a client with Herpes zoster who reports painful, red blisters that align
from the back along the chest’s curvature to the anterior chest. Which intervention is the
highest priority for the nurse?
A. Place the client on contact precautions
B. Administer antiviral medications
C. Place wet compresses to ruptured vesicles
D. Administer narcotic analgesics
6. A young adult who suffered a severe brain injury in an automobile collision has been
mechanically ventilated for the past three days and has no spontaneous respiratory effort. After
serial electroencephalograms (EEG) reveal no brain activity, the healthcare provider discusses
end-of-life options with the family who agree to discontinue life support. Which intervention
should the nurse implement?
A. Ask the family if they wish to remain at the bedside during withdrawal
B. Request a living will be placed in the client’s medical record
C. Discuss the withdrawal procedure with the family and offer support
D. Turn off the mechanical ventilator and note the time of death
7. Following a transurethral resection of the prostate (TURP), a client is discharged from the
hospital with an indwelling urinary catheter. Which instruction is most important for the nurse to
include in the discharge teaching plan?
A. Eliminate all spicy foods from your diet
B. Drink 3 liters of water each day
C. Clamp the catheter when taking a shower
D. Avoid driving a care for 2 weeks
8. On the first postoperative day, the nurse finds an older male client disoriented and trying to
climb over the bed railing. Previously, he was oriented to person, place, and time on admission.
Which intervention should the nurse implement first?
A. Apply wrist restraints
B. Determine the client’s blood pressure
C. Administer a mild sedative
D. Assess the client for pain
