Med-Surg II HESI Test Bank 2023, Complete
solution With Answers
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.
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..
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.
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
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
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."
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.
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
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.
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.
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 should the nurse report as
the type of drainage found?
1) Sanguineous
2) Serous
3) Serosanguineous
4) Purulent
A.
, A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To
prevent postoperative complications which of the following actions should be reinforced
during the teaching?
1) Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises.
2) Place the client's affected leg into the CPM machine with the machine in the flexed
position.
3) Place the client into a high Fowler's position when initiating the CPM exercises.
4) Align the joints of the CPM machine with the knee gatch in the client's bed.
A, B, C, D
A nurse is collecting data from a client who has emphysema. Which of the following
findings should the nurse expect? (Select all that apply.)
1) Dyspnea
2) Barrel chest
3) Clubbing of the fingers
4) Shallow respirations
5) Bradycardia
D.
A nurse is caring for a client who sustained a basal skull fracture. When performing
morning hygiene care, the nurse notices a thin stream of clear drainage coming from
out of the client's right nostril.
Which of the following actions should the nurse take first?
1) Take the client's temperature.
2) Place a dressing under the client's nose.
3) Notify the charge nurse.
4) Test the drainage for glucose.
C.
A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should
recognize that the client is at risk for autonomic dysreflexia. Which of the following
interventions should the nurse take to prevent autonomic dysreflexia?
1) Monitor for elevated blood pressure.
2) Provide analgesia for headaches.
3) Prevent bladder distention.
4) Elevate the client's head.
D.
A nurse is caring for a client who is being evaluated for endometrial cancer. Which of
the following findings should the nurse expect the client to report?
1) Hot flashes
2) Recurrent urinary tract infections
3) Blood in the stool
4) Abnormal vaginal bleeding
A.
A nurse is caring for a client following an open reduction and internal fixation of a
fractured femur. Which of the following findings is the nurse's priority?
1) Altered level of consciousness
2) Oral temperature of 37.7° C (100° C)
solution With Answers
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.
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..
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.
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
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
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."
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.
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
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.
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.
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 should the nurse report as
the type of drainage found?
1) Sanguineous
2) Serous
3) Serosanguineous
4) Purulent
A.
, A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To
prevent postoperative complications which of the following actions should be reinforced
during the teaching?
1) Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises.
2) Place the client's affected leg into the CPM machine with the machine in the flexed
position.
3) Place the client into a high Fowler's position when initiating the CPM exercises.
4) Align the joints of the CPM machine with the knee gatch in the client's bed.
A, B, C, D
A nurse is collecting data from a client who has emphysema. Which of the following
findings should the nurse expect? (Select all that apply.)
1) Dyspnea
2) Barrel chest
3) Clubbing of the fingers
4) Shallow respirations
5) Bradycardia
D.
A nurse is caring for a client who sustained a basal skull fracture. When performing
morning hygiene care, the nurse notices a thin stream of clear drainage coming from
out of the client's right nostril.
Which of the following actions should the nurse take first?
1) Take the client's temperature.
2) Place a dressing under the client's nose.
3) Notify the charge nurse.
4) Test the drainage for glucose.
C.
A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should
recognize that the client is at risk for autonomic dysreflexia. Which of the following
interventions should the nurse take to prevent autonomic dysreflexia?
1) Monitor for elevated blood pressure.
2) Provide analgesia for headaches.
3) Prevent bladder distention.
4) Elevate the client's head.
D.
A nurse is caring for a client who is being evaluated for endometrial cancer. Which of
the following findings should the nurse expect the client to report?
1) Hot flashes
2) Recurrent urinary tract infections
3) Blood in the stool
4) Abnormal vaginal bleeding
A.
A nurse is caring for a client following an open reduction and internal fixation of a
fractured femur. Which of the following findings is the nurse's priority?
1) Altered level of consciousness
2) Oral temperature of 37.7° C (100° C)
