HESI MED SURG Final Exam Review Questions and New Answers
[Latest Version]
What instruction should the nurse include in the discharge teaching plan of a client who had a cataract
extraction today? Correct Answer: Light housekeeping is permitted but avoid heavy lifting
A male adult comes to the urgent care clinic 5 days after being diagnose with influenza. He is short of
breath, febrile, and coughing green colored sputum. Which intervention should the nurse implement
first? Correct Answer: Obtain a sputum sample for culture
An elder male client tells the nurse that he is loosing sleep because he has to get up several times at
night to go to the bathroom that he has trouble starting his urinary stream and that he does not feel like
his bladder is ever completely empty. Which intervention should the nurse implement? Correct Answer:
palpate the bladder above the symphysis pubis
An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI)
Prescriptions for intravenous antibiotics and insulin infusion are initiated. Which serum laboratory value
warrants the most immediate intervention by the nurse? Correct Answer: potassium of 2.5 meq/l
A client with sickle cell anemia develops a fever during the last hour of administration of a unit of
packed red blood cell. When notifying the healthcare provider what information should the nurse
provide first using the SBAR communication process? Correct Answer: explain specific reason for urgent
notification
An adult male client is admitted for pneumocystis carinil pneumonia (PCP) secondary to aids. While
hospitalize he receives IV pentamidine isethionate therapy. In preparing this client for discharge what
important aspect regarding his medication therapy should the nurse explain? Correct Answer: It will be
necessary to continue prophylactic doses of IV or aerosol pentamine every month
A client subjective data includes dysuria, urgency, and urinary frequency. What action should the nurse
implement next? Correct Answer: collect a clean catch specimen
A client tells the nurse that her biopsy results indicate that the cancer cells are well differentiated How
should the nurse respond? Correct Answer: ask the client in the healthcare provider has giving her any
information about the classification of her cancer
A client with a chronic kidney disease is treated on hemodialysis. During the 1 treatment clients blood
pressure drops from 150/90 to 80/30 Which action should the nurse take first? Correct Answer: stop
dialysis treatment
A client with deep vain thrombosis (DVT) is receiving a continues infusion of heparin sodium 25,000 unit
in 5% dextrose injection 250ml. The prescription indicates the dosage should be increase 900 units/hr.
The nurse should program the infusion pump to deliver how many ml/hr? Correct Answer: 9
The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD).
Which subjective data reported by the client supports this diagnosis? Correct Answer: upper mid
abdominal gnawing and burning pain
, The nurse is providing preoperative education for a jewish client schedule to receive a xenograft graft to
promote burn healing. Which information should the nurse provide this client? Correct Answer: the
xenograft is taken from nonhuman sources
A client who took a camping vacation two weeks ago in a country with a tropical climate comes to the
clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for
the nurse to report? Correct Answer: jaundice sclera
During a home visit the nurse assesses the skin of a client with eczema who reports than an
exacerbation of symptoms has occurred during the last week. Which information is most useful in
determining the possible cause of the symptoms? Correct Answer: a grandson and his new dog recently
visited
When explaining dietary guidelines to a client with acute glomerulonephritis (AGN) which instruction
should the nurse include in the dietary teaching Correct Answer: restrict sodium intake
A male client who is 24hr post operative for an exploratory laparoctomy complains that he is starving
because he has had no real food since before surgery. Prior to advancing his diet which intervention
should the nurse implememt? Correct Answer: Auscultate bowel sound in all four quadrants
A client diagnose with stable angina secondary to ischemic heart disease has a prescription for
sublingual (SL) nitroglycerin (NTG). The nurse should tell the client to follow which instructions if chest
pain is not relieved after taking 3 NTG tables 5 min apart Correct Answer: call 911 pain is unrelieved and
chew a tablet of aspirin 325mg
After taking orlistat (Xenical) for one week a femela client tells the home health nurse that she is
experiencing increasingly frequent oily stools and flatus. What action should the nurse take? Correct
Answer: ask the client to describe her dietary intake history for the last several days
Two days after an abscess of the chin was drained the client returns to the clinic with fever chills and a
maculopapular rash with pruritis. The client has taken an oral antibiotic and cleansed the wound today
with provide iodine (Betadine) solution. Which intervention should the nurse implement first? Correct
Answer: assess airway patency and oxygen saturation
A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding
should the nurse report immediately to the health care provider? Correct Answer: low back pain and
hypotension
1.A young adult male who has had type 2 diabetes mellitus (DM) is admitted to the intensive care unit
with hyperglycemic nonketotic syndrome (HHNS). A sliding scale protocol for an isotonic IV solution with
regular insulin is prescribed based on the results of a continuous blood glucose monitoring device that is
attached to the client's central venous catheter. When the client's respirations become labored and his
lungs sound indicate crackles what action should the nurse take? Correct Answer: decrease infusion
rate to address fluid overload
When preparing to apply a fentanyl (Duragesic) transdermal patch the nurse notes that the previously
applied patch is intact on the client's upper back and the client denies pain. What action should the
nurse take? Correct Answer: Apply a new patch in a different location after removing the original patch
[Latest Version]
What instruction should the nurse include in the discharge teaching plan of a client who had a cataract
extraction today? Correct Answer: Light housekeeping is permitted but avoid heavy lifting
A male adult comes to the urgent care clinic 5 days after being diagnose with influenza. He is short of
breath, febrile, and coughing green colored sputum. Which intervention should the nurse implement
first? Correct Answer: Obtain a sputum sample for culture
An elder male client tells the nurse that he is loosing sleep because he has to get up several times at
night to go to the bathroom that he has trouble starting his urinary stream and that he does not feel like
his bladder is ever completely empty. Which intervention should the nurse implement? Correct Answer:
palpate the bladder above the symphysis pubis
An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI)
Prescriptions for intravenous antibiotics and insulin infusion are initiated. Which serum laboratory value
warrants the most immediate intervention by the nurse? Correct Answer: potassium of 2.5 meq/l
A client with sickle cell anemia develops a fever during the last hour of administration of a unit of
packed red blood cell. When notifying the healthcare provider what information should the nurse
provide first using the SBAR communication process? Correct Answer: explain specific reason for urgent
notification
An adult male client is admitted for pneumocystis carinil pneumonia (PCP) secondary to aids. While
hospitalize he receives IV pentamidine isethionate therapy. In preparing this client for discharge what
important aspect regarding his medication therapy should the nurse explain? Correct Answer: It will be
necessary to continue prophylactic doses of IV or aerosol pentamine every month
A client subjective data includes dysuria, urgency, and urinary frequency. What action should the nurse
implement next? Correct Answer: collect a clean catch specimen
A client tells the nurse that her biopsy results indicate that the cancer cells are well differentiated How
should the nurse respond? Correct Answer: ask the client in the healthcare provider has giving her any
information about the classification of her cancer
A client with a chronic kidney disease is treated on hemodialysis. During the 1 treatment clients blood
pressure drops from 150/90 to 80/30 Which action should the nurse take first? Correct Answer: stop
dialysis treatment
A client with deep vain thrombosis (DVT) is receiving a continues infusion of heparin sodium 25,000 unit
in 5% dextrose injection 250ml. The prescription indicates the dosage should be increase 900 units/hr.
The nurse should program the infusion pump to deliver how many ml/hr? Correct Answer: 9
The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD).
Which subjective data reported by the client supports this diagnosis? Correct Answer: upper mid
abdominal gnawing and burning pain
, The nurse is providing preoperative education for a jewish client schedule to receive a xenograft graft to
promote burn healing. Which information should the nurse provide this client? Correct Answer: the
xenograft is taken from nonhuman sources
A client who took a camping vacation two weeks ago in a country with a tropical climate comes to the
clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for
the nurse to report? Correct Answer: jaundice sclera
During a home visit the nurse assesses the skin of a client with eczema who reports than an
exacerbation of symptoms has occurred during the last week. Which information is most useful in
determining the possible cause of the symptoms? Correct Answer: a grandson and his new dog recently
visited
When explaining dietary guidelines to a client with acute glomerulonephritis (AGN) which instruction
should the nurse include in the dietary teaching Correct Answer: restrict sodium intake
A male client who is 24hr post operative for an exploratory laparoctomy complains that he is starving
because he has had no real food since before surgery. Prior to advancing his diet which intervention
should the nurse implememt? Correct Answer: Auscultate bowel sound in all four quadrants
A client diagnose with stable angina secondary to ischemic heart disease has a prescription for
sublingual (SL) nitroglycerin (NTG). The nurse should tell the client to follow which instructions if chest
pain is not relieved after taking 3 NTG tables 5 min apart Correct Answer: call 911 pain is unrelieved and
chew a tablet of aspirin 325mg
After taking orlistat (Xenical) for one week a femela client tells the home health nurse that she is
experiencing increasingly frequent oily stools and flatus. What action should the nurse take? Correct
Answer: ask the client to describe her dietary intake history for the last several days
Two days after an abscess of the chin was drained the client returns to the clinic with fever chills and a
maculopapular rash with pruritis. The client has taken an oral antibiotic and cleansed the wound today
with provide iodine (Betadine) solution. Which intervention should the nurse implement first? Correct
Answer: assess airway patency and oxygen saturation
A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding
should the nurse report immediately to the health care provider? Correct Answer: low back pain and
hypotension
1.A young adult male who has had type 2 diabetes mellitus (DM) is admitted to the intensive care unit
with hyperglycemic nonketotic syndrome (HHNS). A sliding scale protocol for an isotonic IV solution with
regular insulin is prescribed based on the results of a continuous blood glucose monitoring device that is
attached to the client's central venous catheter. When the client's respirations become labored and his
lungs sound indicate crackles what action should the nurse take? Correct Answer: decrease infusion
rate to address fluid overload
When preparing to apply a fentanyl (Duragesic) transdermal patch the nurse notes that the previously
applied patch is intact on the client's upper back and the client denies pain. What action should the
nurse take? Correct Answer: Apply a new patch in a different location after removing the original patch
