MED SURG HESI EXAM QUESTIONS WITH 100% CORRECT ANSWERS | LATEST UPDATE 2023/2024 (GRADED)

A client with a history of ear problems is going on vacation by aircraft. The nurse advises the client to include which activities to prevent barotrauma during ascent and descent - Yawning - Swallowing - Chewing gum - Sucking on a hard candy Rationale: Clients who are prone to barotrauma should perform any of a variety of mouth movements 4 / 20 MED SURG HESI 2022 of the airplane? Select all that apply: to equalize pressure between the ear and the atmosphere, particularly during ascent and descent of an aircraft. These can include yawning, swallowing, drinking, chewing, and sucking on hard candy. Valsalva maneuver also may be helpful. The client should avoid sitting with the mouth motionless during this time because the resulting lack of pressure change in the ear will contribute to pressure buildup behind the tympanic membrane. 15. The nurse is assessing a client with an abdominal aortic aneurysm. Which assessment finding by the nurse is unrelated to the aneurysm? A. Pulsatile abdominal mass B. Hyperactive bowel sounds in the area C. Systolic bruit over the area of the mass D. Subjective sensation of "heart beating" in the abdomen B. Hyperactive bowel sounds in the area Rationale: Hyperactive bowel sounds are not related specifically to an abdominal aortic aneurysm. Not all clients with abdominal aortic aneurysm exhibit symptoms. Those who do may describe a feeling of the "heart beating" in the abdomen when supine or being able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be auscultated over the mass. 16. The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective? A rise in blood pressure Rationale: Following pericardiocentesis, the client usually expresses immediate relief. Heart sounds are no longer muffled or distant and blood pressure increases. 17. The nurse is creating a plan of care for a client with a diagnosis - Monitor daily weight. - Maintain sodium restrictions. - Monitor intake and output (I&O). 5 / 20 MED SURG HESI 2022 of nephrotic syndrome whose glomerular filtration rate (GFR) is normal. Which interventions should the nurse include in the plan of care? Select all that apply. - Maintain bed rest when edema is severe Rationale:Controlling edema is a critical aspect of therapeutic management of nephrotic syndrome. If the GFR is normal, dietary intake of proteins is needed to restore normal plasma oncotic pressure and thereby decrease edema. Daily measurement of weight and abdominal girth, and careful monitoring of I&O will determine whether weight loss is caused by diuresis or protein loss. Dietary modifications may include salt restriction and fluid restriction and are based on the client's symptoms. Bed rest is prescribed to promote diuresis when edema is severe 18. The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal compartment. Which is the most appropriate action? Document the findings Rationale: Bubbling in the water seal compartment is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. Therefore, it is unnecessary to call the HCP or change the chest tube drainage system. Continuous bubbling during inspiration and expiration indicates an air leak. If this occurs, it must be corrected. 19. The nurse is preparing for removal of an endotracheal (ET) tube from a client. In assisting the health care provider with Suction the ET tube. Rationale: Once the client has been weaned successfully and has achieved an acceptable level of consciousness to sustain spontaneous respi6 / 20 MED SURG HESI 2022 this procedure, which is the initial nursing action? ration, an ET tube may be removed. The ET tube is suctioned first, and then the cuff is deflated and the tube is removed 20. The nurse determines that a client with a tracheostomy tube needs suctioning if which finding is noted? Rhonchi are auscultated. Rationale: When you auscultate that rhonchi, it is an indication that there are secretions in the large airways. The client requires suctioning if the client cannot expectorate them. A pulse oximetry reading of 96% is an acceptable reading. A pleural friction rub is indicative of inflamed pleural surfaces. Fine crackles are indicative of air moving into previously deflated alveoli. 21. The nursing student is assigned to care for a client with a diagnosis of acute kidney injury (AKI), diuretic phase. The nursing instructor asks the student about the primary goal of the treatment plan for this client. Which goal, if stated by the nursing student, indicates an adequate understanding of the treatment plan for this client ? Prevent loss of electrolytes. Rationale: In the diuretic phase , fluids and electrolytes are lost in the urine . As a result, the plan of care focuses on fluid and electrolyte replacement and monitoring. 22. The nurse has been caring for a client who required a Sengstaken-Blakemore tube because other treatment measures for esophageal varices were unsuccessful. The health care provider (HCP) arrives on the nursing unit and deHematemesis Rationale: A Sengstaken-Blakemore tube may be inserted in a client with a diagnosis of cirrhosis with bleeding esophageal varices. It has both an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The pressure of the esophageal balloon is 7 / 20 MED SURG HESI 2022 flates the esophageal balloon. Which assessment finding by the nurse is the most important and should be reported to the HCP immediately? released at intervals to decrease the risk of trauma to esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated, the client may begin to bleed again from the esophageal varices, manifested as vomiting of blood (hematemesis) 23. The nurse is planning discharge teaching for a client diagnosed and treated for compartment syndrome. Which information should the nurse include in the teaching? "Bleeding and swelling caused increased pressure in an area that couldn't expand." Rationale: Compartment syndrome is caused by bleeding and swelling within a tissue compartment that is lined by fascia, which does not expand. The bleeding and swelling put pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms. 24. The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply. - Head midline - Neck in neutral position - Head of bed elevated 30 to 45 degrees Rationale: Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure from elevating. The head of the client at risk for or with increased intracranial pressure should be positioned so that it is in a neutral, midline position. The head of the bed should be raised to 30 to 45 degrees. The nurse should avoid flexing or extending the client's neck or turning the client's head from side to side. 25. The nurse is caring for a postoperative pneumonectomy client. Which finding on assessment of the client is an adverse Lung crackles in the remaining lung Rationale: The client with pulmonary edema that developed after pneumonectomy demonstrates dyspnea, cough, frothy sputum, crackles, and 8 / 20 MED SURG HESI 2022 sign or symptom indicating pulmonary edema? possibly cyanosis. A pneumonectomy is a type of surgery to remove one of your lungs because of cancer, trauma, or some other condition. 26. A client is scheduled for surgical creation of an internal arteriovenous (AV) fistula on the following day. The client says to the nurse, "I'll be so happy when the fistula is made tomorrow. This means I can have that other hemodialysis catheter pulled right out." Which interpretation should the nurse make based on the client's statement? The client does not understand that the site needs to mature or develop for 1 to 2 weeks before use. Rationale: An AV fistula is the internal creation of an arterial-to-venous anastomosis. This causes engorgement of the vein, allowing both the artery and the vein to be easily cannulated for hemodialysis. Fistulas take 1 to 2 weeks to mature (engorgement) or develop before they can be used for dialysis, so the current method of access must remain in place to be used during that period 27. A client is admitted with suspected diabetic ketoacidosis (DKA). Which clinical manifestations best support a diagnosis of DKA? Blood glucose 350 mg/dL (19.4 mmol/L); arterial blood gases: pH 7.28, PaCo2 30, HCO3- 14. Rationale: DKA is caused by a profound deficiency of insulin and is characterized by hyperglycemia (blood glucose level greater than or equal to 250 mg/dL [13.9 mmol/L]), ketosis (ketones in urine or serum), metabolic acidosis, and dehydration. The correct option is 4, as it represents an elevated blood glucose and the arterial blood gases (ABGs) indicate metabolic acidosis. 28. A client with ulcerative colitis has a prescription to begin a salicylate compound medicaAfter meals Rationale: The medication needs to be taken after meals to reduce gastrointestinal irritation 9 / 20 MED SURG HESI 2022 tion to reduce inflammation. What instruction should the nurse give the client regarding when to take this medication? 29. A client with chronic kidney disease who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril. When should the nurse plan to administer this medication? On return from dialysis Rationale: Antihypertensive medications such as enalapril are given to the client following hemodialysis. This prevents the client from becoming hypotensive during dialysis and from having the medication removed from the bloodstream by dialysis. 30. The nurse is monitoring the function of a client's chest tube that is attached to a drainage system. The nurse notes that the fluid in the water seal chamber rises with inspiration and falls with expiration. The nurse determines that which is occurring? Tidaling is present. (expected) Rationale: When the chest tube is patent, the fluid in the water seal chamber rises with inspiration and falls with expiration. This is referred to as tidaling and indicates proper function of the system 31. A client with acute ulcerative colitis requests a snack. Which is the most appropriate snack for this client? A. Carrots and ranch dip B. Whole-grain cereal and milk C. A cup of popcorn and a cola drink D. Applesauce and a graham cracker D. Applesauce and a graham cracker Rationale: The diet for the client with ulcerative colitis should be low fiber (low residue). The nurse should avoid providing foods such as whole-wheat grains, nuts, and fresh fruits or vegetables. Typically, lactose-containing foods also are poorly tolerated. The client also should avoid caffeine, pepper, and alcohol 32. 10 / 20 MED SURG HESI 2022 The nurse is planning to teach a client with peripheral arterial disease about measures to limit disease progression. Which items should the nurse include on a list of suggestions for the client? Select all that apply. A. Soak the feet in hot water daily. B. Be careful not to injure the legs or feet. C. Use a heating pad on the legs to aid vasodilation. D. Walk each day to increase circulation to the legs. E. Cut down on the amount of fats consumed in the diet B. Be careful not to injure the legs or feet. D. Walk each day to increase circulation to the legs. E. Cut down on the amount of fats consumed in the diet. Rationale: Long-term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise), promote vasodilation (warmth), relieve pain, and maintain tissue integrity (foot care and nutrition). Soaking the feet in hot water and application of a heating pad to the extremity are contraindicated. The affected extremity may have decreased sensitivity and is at risk for burns. Also, the affected tissue does not obtain adequate circulation at rest. Direct application of heat raises oxygen and nutritional requirements of the tissue even further. 33. A client who has undergone gastric surgery has a nasogastric (NG) tube connected to low intermittent suction that is not draining properly. Which action should the nurse take initially? A. call the surgeon to report the problem. B. Reposition the NG tube to the proper location. C. Check the suction device to make sure it is working. C. Check the suction device to make sure it is working. Rationale: After gastric surgery, the client will have an NG tube in place until bowel function returns. It is important for the NG tube to drain properly to prevent abdominal distention and vomiting. The nurse must ensure that the NG tube is attached to suction at the level prescribed and that the suction device is working correctly. The tip of the NG tube may be placed near the suture line. Because of this possibility, 11 / 20 MED SURG HESI 2022 D. Irrigate the NG tube with saline to remove the obstruction. the nurse should never reposition the NG tube or irrigate it. If the NG tube needs to be repositioned, the nurse should call the surgeon, who would do this repositioning under fluoroscopy 34. The community health nurse is visiting a homeless shelter and is assessing the clients in the shelter for the presence of scabies. Which assessment finding should the nurse expect to note if scabies is present? A. Brown-red macules with scales B. Pustules on the trunk of the body C. White patches noted on the elbows and knees D. Multiple straight or wavy threadlike lines underneath the skin D. Multiple straight or wavy threadlike lines underneath the skin Rationale: Scabies can be identified by the multiple straight or wavy threadlike lines beneath the skin. The skin lesions are caused by the female, which burrows beneath the skin to lay its eggs. The eggs hatch in a few days, and the baby mites find their way to the skin surface, where they mate and complete the life cycle. Options 1, 2, and 3 are not characteristics of scabies 35. The registered nurse is precepting