MED-SURG II HESI TEST BANK
1. A.: A nurse is reinforcing teaching with a client who has HIV and is
being discharged to home. Which of the following instructions should
the nurse include in the teaching?
A. Take temperature once a day.
B. Wash the armpits and genitals with a gentle cleanser daily.
C. Change the litter boxes while wearing gloves.
D.Wash dishes in warm water.
2. A.: A nurse is caring for a client who is postoperative following a
tracheostomy, and has copious and tenacious secretions. Which of the
following is an acceptable method for the nurse to use to thin this
client's secretions?
A. Provide humidified oxygen.
B. Perform chest physiotherapy prior to suctioning.
C. Prelubricate the suction catheter tip with sterile saline when
suctioning the airway.
D.Hyperventilate the client with 100% oxygen before suctioning the
airway..
3. B.: Following admission, a client with a vascular occlusion of the
right lower extremity calls the nurse and reports difficulty sleeping
because of cold feet. Which of the following nursing actions should the
nurse take to promote the client's comfort?
A. Rub the client's feet briskly for several minutes.
B. Obtain a pair of slipper socks for the client.
,C. Increase the client's oral fluid intake.
D.Place a moist heating pad under the client's feet.
4. C.: A nurse is caring for a client is who is 4 hr postoperative following
a transurethral resection of the prostate (TURP). Which of the following
is the priority finding for the nurse report to the provider?
A. Emesis of 100 mL
B. Oral temperature of 37.5° C (99.5° F)
C. Thick, red-colored urine
D.Pain level of 4 on a 0 to 10 rating scale
5. A.: A nurse is caring for a client who has a temperature of 39.7° C
(103.5° F) and has a prescription for a hypothermia blanket. The
nurse should monitor the client for which of the following adverse
effects of the hypothermia blanket?
A. Shivering
B. Infection
C. Burns
D.Hypervolemia
,6. D.: A nurse is reinforcing teaching about exercise with a client who
has type 1 diabetes mellitus. Which of the following statements by
the client indicates an understanding of the teaching?
A. "I will carry a complex carbohydrate snack with me when I exercise."
B. "I should exercise first thing in the morning before eating breakfast."
C. "I should avoid injecting insulin into my thigh if I am going to go
running."
D."I will not exercise if my urine is positive for ketones."
7. A.: A nurse notes a small section of bowel protruding from the
abdominal incision of a client who
is postoperative. After calling for assistance, which of the following
actions should the nurse take first?
A. Cover the client's wound with a moist, sterile dressing.
B. Have the client lie supine with knees flexed.
C. Check the client's vital signs.
D.Inform the client about the need to return to surgery.
8. B.: A nurse is collecting data from a client who has alcohol use
disorder and is experiencing metabolic acidosis. Which of the following
manifestations should the nurse expect?
A. Cool, clammy skin.
B. Hyperventilation
C. Increased blood pressure
D.Bradycardia
9. A.: A nurse is reinforcing discharge teaching with a client following
, a cataract extraction. Which of the following should the nurse include
in the teaching?
A. Avoid bending at the waist.
B. Remove the eye shield at bedtime.
C. Limit the use of laxatives if constipated.
D.Seeing flashes of light is an expected finding following extraction.
10.C: A nurse is caring for a client who has heart failure and has been
taking digoxin 0.25 mg daily. The client refuses breakfast and reports
nausea. Which of the following actions should the nurse take first?
1) Suggest that the client rests before eating the meal.
2) Request a dietary consult.
3) Check the client's vital signs.
4) Request an order for an antiemetic.
11.D.: A nurse is caring for a client who is 3 days postoperative
following a cholecystectomy. The nurse suspects the client's wound is
infected because the drainage from the dressing is yellow and thick.
Which of the following findings
1. A.: A nurse is reinforcing teaching with a client who has HIV and is
being discharged to home. Which of the following instructions should
the nurse include in the teaching?
A. Take temperature once a day.
B. Wash the armpits and genitals with a gentle cleanser daily.
C. Change the litter boxes while wearing gloves.
D.Wash dishes in warm water.
2. A.: A nurse is caring for a client who is postoperative following a
tracheostomy, and has copious and tenacious secretions. Which of the
following is an acceptable method for the nurse to use to thin this
client's secretions?
A. Provide humidified oxygen.
B. Perform chest physiotherapy prior to suctioning.
C. Prelubricate the suction catheter tip with sterile saline when
suctioning the airway.
D.Hyperventilate the client with 100% oxygen before suctioning the
airway..
3. B.: Following admission, a client with a vascular occlusion of the
right lower extremity calls the nurse and reports difficulty sleeping
because of cold feet. Which of the following nursing actions should the
nurse take to promote the client's comfort?
A. Rub the client's feet briskly for several minutes.
B. Obtain a pair of slipper socks for the client.
,C. Increase the client's oral fluid intake.
D.Place a moist heating pad under the client's feet.
4. C.: A nurse is caring for a client is who is 4 hr postoperative following
a transurethral resection of the prostate (TURP). Which of the following
is the priority finding for the nurse report to the provider?
A. Emesis of 100 mL
B. Oral temperature of 37.5° C (99.5° F)
C. Thick, red-colored urine
D.Pain level of 4 on a 0 to 10 rating scale
5. A.: A nurse is caring for a client who has a temperature of 39.7° C
(103.5° F) and has a prescription for a hypothermia blanket. The
nurse should monitor the client for which of the following adverse
effects of the hypothermia blanket?
A. Shivering
B. Infection
C. Burns
D.Hypervolemia
,6. D.: A nurse is reinforcing teaching about exercise with a client who
has type 1 diabetes mellitus. Which of the following statements by
the client indicates an understanding of the teaching?
A. "I will carry a complex carbohydrate snack with me when I exercise."
B. "I should exercise first thing in the morning before eating breakfast."
C. "I should avoid injecting insulin into my thigh if I am going to go
running."
D."I will not exercise if my urine is positive for ketones."
7. A.: A nurse notes a small section of bowel protruding from the
abdominal incision of a client who
is postoperative. After calling for assistance, which of the following
actions should the nurse take first?
A. Cover the client's wound with a moist, sterile dressing.
B. Have the client lie supine with knees flexed.
C. Check the client's vital signs.
D.Inform the client about the need to return to surgery.
8. B.: A nurse is collecting data from a client who has alcohol use
disorder and is experiencing metabolic acidosis. Which of the following
manifestations should the nurse expect?
A. Cool, clammy skin.
B. Hyperventilation
C. Increased blood pressure
D.Bradycardia
9. A.: A nurse is reinforcing discharge teaching with a client following
, a cataract extraction. Which of the following should the nurse include
in the teaching?
A. Avoid bending at the waist.
B. Remove the eye shield at bedtime.
C. Limit the use of laxatives if constipated.
D.Seeing flashes of light is an expected finding following extraction.
10.C: A nurse is caring for a client who has heart failure and has been
taking digoxin 0.25 mg daily. The client refuses breakfast and reports
nausea. Which of the following actions should the nurse take first?
1) Suggest that the client rests before eating the meal.
2) Request a dietary consult.
3) Check the client's vital signs.
4) Request an order for an antiemetic.
11.D.: A nurse is caring for a client who is 3 days postoperative
following a cholecystectomy. The nurse suspects the client's wound is
infected because the drainage from the dressing is yellow and thick.
Which of the following findings
