Med-Surg Hesi Exit Exam with 100%Correct Answers (UPDATED) April 2023.

Med-Surg Hesi Exit Exam with 100%Correct Answers (UPDATED) April 2023. April 2023 1-While caring for a client who is being mechanically ventilated, the nurse responds to a high-pressure alarm on the ventilator. Which assessment finding warrants immediate intervention by the nurse? Endotracheal cuff pressure greater than 25 cm H20. Decreased lung compliance during ventilation. Bilateral crackles with increased secretions. Restless client who is biting the endotracheal tube. 2-While making rounds, the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bed-side table. The client is currently receiving oxygen at 2 liters/minute via nasal cannula. The client is wheezing and is using pursed-lip breathing. Which intervention should the nurse implement? Administer a nebulizer treatment. Increase oxygen to 6 liters/minute. Assist the client to lie back in bed. Call for an Ambu resuscitating bag. 3-After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the Xray findings that indicate the CVC tip is in the client's superior vena cava. Which action should the nurse implement? Remove the catheter and apply direct pressure for 5 minutes. Initiate intravenous fluids as prescribed. Secure the catheter using aseptic technique. Notify the healthcare provider of the need to reposition the catheter. 4-While caring for a client's postoperative dressing, the nurse observes purulent wound drainage. Previously, the wound was inflamed and tender but without drainage. Which is the most important action for the nurse to take? Determine if the drainage has an unpleasant odor. Monitor the client's white blood cell count (WBC). Request a culture and sensitivity of the wound. Cleanse the wound with a sterile saline solution. 5-A client who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). The nurse observes that the suction control chamber is bubbling at the -10 cm H20 mark, with fluctuation in the water seal, and over the past hour 75 mL of bright red blood is measured in the collection chamber. Which intervention should the nurse implement? Increase wall suction to eliminate fluctuation in water seal. Give blood from the collection chamber as autotransfusion. Add sterile water to the suction control chamber. Manipulate blood in tubing to drain into chamber. 6-A client admitted to the hospital with advanced liver failure related to chronic alcoholism is exhibiting ascites and edema. Which pathophysiological mechanisms should the nurse identify as responsible for the third spacing symptoms? (Select all that apply.) Portal hypertension. Sodium and water retention. Decreased serum albumin. Abnormal protein metabolism Portosystemic shunting. 7-The nurse is providing care for a client with a draining postoperative wound infected with methicillinresistant Staphylococcus aureus (MRSA). Which is the most important action for the nurse to take? Encourage increased oral fluids. Provide high-protein snacks. Change the wound dressing. Administer prescribed antibiotics. Med-Surg Hesi Exit Exam 8-A client with hemorrhoids asks for information about a high fiber diet. Which breakfast menu items should the nurse suggest? (Select all that apply.) Raisin bran muffins. Bowl of oatmeal. Cup of raspberries. Scrambled eggs. Bacon slices. 9-When teaching a group of school-aged children how to reduce the risk for Lyme disease, which instruction should the camp nurse include? Wash hands frequently. Avoid drinking lake water. Do not share personal products. Wear long sleeves and pants. 10-Which client will benefit most from the application of pneumatic compression devices to the lower extremities? The client who is immobile on prescribed bedrest. has pressure ulcers on several toes. has diminished pedal pulse volume. is confused and tries to climb out of bed 11-A 4-year-old with acute lymphocytic leukemia (ALL) is receiving chemotherapy protocol that includes methotrexate, an antimetabolite. Which information should the nurse provide the parents about caring for their child? Use sunblock or protective clothing when outdoors Include the child on regular outings with the family Obtain any childhood vaccination that is not up-to-date Use diluted commercial mouthwash with mouth care 12-After placing a client at 26-weeks gestation in the lithotomy position, the client complains of dizziness and becomes pale and diaphoretic. What action should the nurse implement? Instruct the client to take deep breaths. Place a wedge under the client's hip. Place the client in the Trendelenburg position. Remove the client's legs from the stirrups. 13-A grand multiparous client had a precipitous delivery in the emergency room 6 hours ago. The client was given oxytocin intramuscularly after birth. The nurse examines the client and observes the pad under her buttocks is full of blood. Which action should the nurse take first? Place a new pad and weigh the pad removed to determine blood loss. Massage the fundus and express clots. Start an IV and begin an oxytocin infusion. Clean the perineal area and encourage her to breastfeed. 14-A 9-year-old is receiving vancomycin 400 mg IV every 6 hours for a methicillin-resistant (Betalactam-resistant) Staphylococci aureus (MRSA) infection. The medication is diluted in a 100 mL bag of saline with instructions to infuse over one and a half hours. How many mL/hour should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.) Ans: __67__ 15-A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing interventions should the nurse include in the plan of care? (Select all that apply.) Explain the purpose of a low bacteria diet. Institute contact precautions for staff and visitors. Use standard precautions and wear a mask Monitor the client's white blood cell count. Send wound drainage for culture and sensitivity. 16-Which laboratory values are critical for the nurse to monitor for a client who is experiencing a thyrotoxic crisis? Glucose and calcium levels. Blood and urine cultures. Electrolytes and hemoglobin. Renal and liver function tests. 17-An unconscious client is admitted to the intensive care unit and is placed on a ventilator. The ventilator alarms continuously and the client's oxygen saturation level is 62%. Which action should the nurse take first? Silence the alarm and call the technician. Monitor oxygen saturation levels every 5 minutes. Begin manual ventilation immediately. Call respiratory therapy. 18-A 5-year-old child with a history of a waddling gait and frequent falls is brought into the hospital for diagnostic testing. When explaining the diagnostic testing to the parents, the nurse should provide information based on which understanding of the underlying disease pathology? Systemic autoimmune vasculopathy. Muscle fiber degeneration. Impaired neuron function. Autonomic neuropathy. 19-An older client is referred to a rehabilitation facility following a cerebrovascular accident (CVA). The client is aphasic with left-side paresis and is having difficulty swallowing. Which intervention is most important for the nurse to include in the client's plan of care? Multiple-Choice Single-Answer Select your answer from the options on Initiate passive range of motion exercises. Use pictures and gestures to communicate. Facilitate a consultation for speech therapy. Arrange for daily home care assistance. 20-The nurse-manager is involved in agency restructuring. During this re-engineering process, it is most important for the nurse to address which employee concern? Employees' job security. Changes in job descriptions. Potential changes in employee benefits. New management's expectations.