HESI Med Surg Exit Exam V1 -with latest
solutions-2023-2024|| Complete
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TEST 1
Multiple Choice
Identify the letter of the choice that best completes the statement or answers the question.
1. While assessing a client with diabetes mellitus, the nurse observes an
absence of hair growthon the client's legs. What additional assessment
provides further data to support this finding?
• Palpate for the presence of femoral pulses bilaterally.
• Assess for the presence of a positive Homan's sign.
• Observe the appearance of the skin on the client's legs.
• Watch the client's posture and balance during ambulation.
2. The healthcare provider prescribes 15 mg/kg of Streptomycin for an infant
weighing 4 pounds.
The drug is diluted in 25 ml of D5W to run over 8 hours. How much
Streptomycin will theinfant receive?
• 9 mg.
• 18 mg.
• 27 mg.
• 36 mg.
3. In assessing a client with preeclampsia who is receiving magnesium
sulfate, the nurse determines that her deep tendon reflexes are 1+;
respiratory rate is 12 breaths/minute; urinary output is 90 ml in 4
hours; magnesium sulfate level is 9 mg/dl. Based on these findings,
what intervention should the nurse implement?
• Continue the magnesium sulfate infusion as prescribed.
• Decrease the magnesium sulfate infusion by one-half.
• Stop the magnesium sulfate infusion immediately.
• Administer calcium gluconate immediately.
4. A client is on a mechanical ventilator. Which client response indicates that
the neuromuscularblocker tubocurarine chloride (Tubarine) is effective?
• The client’s expremities are paralyzed.
• The peripheral nerve stimulator causes twitching.
• The client clinches fist upon command.
• The client’s Glagow Coma Scale score is 14.
,5. An elderly female client comes to the clinic for a regular check-up. The client
tells the nurse that she has increased her daily doses of acetaminophen
(Tylenol) for the past month to control joint pain. Based on this client's
comment, what previous lab values should the nursecompare with today's
lab report?
• Look at last quarter's hemoglobin and hematocrit, expecting an
increase today dueto dehydration.
• Look for an increase in today's LDH compared to the
previous one to assess for possible liver damage.
1
• Expect to find an increase in today's APTT as compared
to last quarter's dueto bleeding.
• Determine if there is a decrease in serum potassium due to renal compromise.
6. Aspirin is prescribed for a 9-year-old child with rheumatic fever to control
the inflammatoryprocess, promote comfort, and reduce fever. What
intervention is most important for the nurse to implement?
• Instruct the parents to hold the aspirin until the child has first
had a tepid spongebath.
• Administer the aspirin with at least two ounces of water or juice.
• Notify the healthcare provider if the child complains of ringing in the ears.
• Advise the parents to question the child about seeing yellow halos around
objects.
7. Which signs or symptoms are characteristic of an adult client
diagnosed with Cushing'ssyndrome?
• Husky voice and complaints of hoarseness.
• Warm, soft, moist, salmon-colored skin.
• Visible swelling of the neck, with no pain.
• Central-type obesity, with thin extremities.
8. A charge nurse agrees to cover another nurse’s assignment during a lunch
break. Based on thestatus report provided by the nurse who is leaving for
lunch, which client should be checked first by the charge nurse? The client
• admitted yesterday with diabetec ketoacidosis whose
blood glucose levelis now 195 mg/dl.
• with an ileal conduit created two days ago with a scant
amount of blood inthe drainage pouch.
• post-triple coronary bypass four days ago who has
serosanguinous drainagein the chest tube.
, • with a pneumothorax secondary to a gunshot wound
with a current pulseoximeter reading of 90%.
9. An outcome for treatment of peripheral vascular disease is, "The client will
have decreased venous congestion." What client behavior would indicate
to the nurse that this outcome hasbeen met?
• Avoids prolonged sitting or standing.
• Avoids trauma and irritation to skin.
• Wears protective shoes.
• Quits smoking.
10. The healthcare provider performs a paracentesis on a client with ascites and
3 liters of fluid are removed. Which assessment parameter is most critical
for the nurse to monitor followingthe procedure?
• Pedal pulses.
• Breath sounds.
• Gag reflex.
• Vital signs.
11. The nurse is administering sevelamer (RenaGel) during lunch to a client
with end stage renaldisease (ESRD). The client asks the nurse to bring the
medication later. The nurse should describe which action of RenaGel as an
explanation for taking it with meals?
• Prevents indigestion associated with ingestion of spicy foods.
• Binds with phosphorus in foods and prevents absorption.
• Promotes stomach emptying and prevents gastric reflux.
• Buffers hydrochloric acid and prevents gastric erosion.
12. The nurse formulates a nursing diagnosis of, "High risk for ineffective
airway clearance" fora client with myasthenia gravis. What is the most
likely etiology for this nursing diagnosis?
• Pain when coughing.
• Diminished cough effort.
• Thick dry secretions.
• Excessive inflammation.
13. Following a CVA, the nurse assess that a client developed dysphagia,
hypoactive bowel soundsand firm, distended abdomen. Which prescription
for the client should the nurse question?
• Continous tube feeding at 65 ml/hr via gastrostomy.
• Total parenteral nutrition to be infused at 125 ml/hour.
• Nasogastric tube connected to low intermittent suction.
• Metoclopramide (Reglan) intermittent piggyback.
14. A client's telemetry monitor indicates the sudden onset of ventricular
fibrillation. Which assessment finding should the nurse anticipate?
• Bounding erratic pulse.
, • Regularly irregular pulse.
• Thready irregular pulse.
• No palpable pulse.
15. In assessing a 70-year-old female client with Alzheimer's disease, the nurse
notes that she has deep inflamed cracks at the corners of her mouth. What
intervention should the nurse includein this client's plan of care?
• Scrub the lesions with warm soapy water.
• Encourage the client to drink orange juice for added vitamin C.
• Notify the healthcare provider of the need for oral antibiotics.
• Ensure that the client gets adequate B vitamins in foods or supplements.
16. A young adult female client is seen in the emergency department for a minor
injury followinga motor vehicle collision. She states she is very angry at the
person who hit her car. What is the best nursing response?
• "You are lucky to be alive. Be grateful no one was killed."
• "I understand your car was not seriously damaged."
• "You are upset that this incident has brought you here."
• "Have you ever been in the emergency department before?"
17. An 85-year-old male resident of an extended care facility reaches for the
hand of the unlicensed assistive personnel (UAP) and tries to kiss her hand
several times during his morning care. The UAP reports the incident to the
charge nurse. What is the best assessment of the situation?
• This is sexual harassment and needs to
be reported to theadministration
immediately.
• The UAP needs to be reassigned to another group of residents,
preferably femalesonly.
• The client may be suffering from touch deprivation
and needs to knowappropriate ways to express his
need.
• The resident needs to know the rules concerning unwanted
touching of the staffand the consequences.
18. The parents of a newborn infant with hypospadias are concerned about
when the surgicalcorrection should occur. What information should the
nurse provide?
• Repair should be done by one month to prevent bladder infections.
• Repairs typically should be done before the child is potty-trained.
• Delaying the repair until school age reduces castration fears.
• To form a proper urethra repair, it should be done after sexual maturity.
solutions-2023-2024|| Complete
qns&answrs||Rated A+.Latest!!
TEST 1
Multiple Choice
Identify the letter of the choice that best completes the statement or answers the question.
1. While assessing a client with diabetes mellitus, the nurse observes an
absence of hair growthon the client's legs. What additional assessment
provides further data to support this finding?
• Palpate for the presence of femoral pulses bilaterally.
• Assess for the presence of a positive Homan's sign.
• Observe the appearance of the skin on the client's legs.
• Watch the client's posture and balance during ambulation.
2. The healthcare provider prescribes 15 mg/kg of Streptomycin for an infant
weighing 4 pounds.
The drug is diluted in 25 ml of D5W to run over 8 hours. How much
Streptomycin will theinfant receive?
• 9 mg.
• 18 mg.
• 27 mg.
• 36 mg.
3. In assessing a client with preeclampsia who is receiving magnesium
sulfate, the nurse determines that her deep tendon reflexes are 1+;
respiratory rate is 12 breaths/minute; urinary output is 90 ml in 4
hours; magnesium sulfate level is 9 mg/dl. Based on these findings,
what intervention should the nurse implement?
• Continue the magnesium sulfate infusion as prescribed.
• Decrease the magnesium sulfate infusion by one-half.
• Stop the magnesium sulfate infusion immediately.
• Administer calcium gluconate immediately.
4. A client is on a mechanical ventilator. Which client response indicates that
the neuromuscularblocker tubocurarine chloride (Tubarine) is effective?
• The client’s expremities are paralyzed.
• The peripheral nerve stimulator causes twitching.
• The client clinches fist upon command.
• The client’s Glagow Coma Scale score is 14.
,5. An elderly female client comes to the clinic for a regular check-up. The client
tells the nurse that she has increased her daily doses of acetaminophen
(Tylenol) for the past month to control joint pain. Based on this client's
comment, what previous lab values should the nursecompare with today's
lab report?
• Look at last quarter's hemoglobin and hematocrit, expecting an
increase today dueto dehydration.
• Look for an increase in today's LDH compared to the
previous one to assess for possible liver damage.
1
• Expect to find an increase in today's APTT as compared
to last quarter's dueto bleeding.
• Determine if there is a decrease in serum potassium due to renal compromise.
6. Aspirin is prescribed for a 9-year-old child with rheumatic fever to control
the inflammatoryprocess, promote comfort, and reduce fever. What
intervention is most important for the nurse to implement?
• Instruct the parents to hold the aspirin until the child has first
had a tepid spongebath.
• Administer the aspirin with at least two ounces of water or juice.
• Notify the healthcare provider if the child complains of ringing in the ears.
• Advise the parents to question the child about seeing yellow halos around
objects.
7. Which signs or symptoms are characteristic of an adult client
diagnosed with Cushing'ssyndrome?
• Husky voice and complaints of hoarseness.
• Warm, soft, moist, salmon-colored skin.
• Visible swelling of the neck, with no pain.
• Central-type obesity, with thin extremities.
8. A charge nurse agrees to cover another nurse’s assignment during a lunch
break. Based on thestatus report provided by the nurse who is leaving for
lunch, which client should be checked first by the charge nurse? The client
• admitted yesterday with diabetec ketoacidosis whose
blood glucose levelis now 195 mg/dl.
• with an ileal conduit created two days ago with a scant
amount of blood inthe drainage pouch.
• post-triple coronary bypass four days ago who has
serosanguinous drainagein the chest tube.
, • with a pneumothorax secondary to a gunshot wound
with a current pulseoximeter reading of 90%.
9. An outcome for treatment of peripheral vascular disease is, "The client will
have decreased venous congestion." What client behavior would indicate
to the nurse that this outcome hasbeen met?
• Avoids prolonged sitting or standing.
• Avoids trauma and irritation to skin.
• Wears protective shoes.
• Quits smoking.
10. The healthcare provider performs a paracentesis on a client with ascites and
3 liters of fluid are removed. Which assessment parameter is most critical
for the nurse to monitor followingthe procedure?
• Pedal pulses.
• Breath sounds.
• Gag reflex.
• Vital signs.
11. The nurse is administering sevelamer (RenaGel) during lunch to a client
with end stage renaldisease (ESRD). The client asks the nurse to bring the
medication later. The nurse should describe which action of RenaGel as an
explanation for taking it with meals?
• Prevents indigestion associated with ingestion of spicy foods.
• Binds with phosphorus in foods and prevents absorption.
• Promotes stomach emptying and prevents gastric reflux.
• Buffers hydrochloric acid and prevents gastric erosion.
12. The nurse formulates a nursing diagnosis of, "High risk for ineffective
airway clearance" fora client with myasthenia gravis. What is the most
likely etiology for this nursing diagnosis?
• Pain when coughing.
• Diminished cough effort.
• Thick dry secretions.
• Excessive inflammation.
13. Following a CVA, the nurse assess that a client developed dysphagia,
hypoactive bowel soundsand firm, distended abdomen. Which prescription
for the client should the nurse question?
• Continous tube feeding at 65 ml/hr via gastrostomy.
• Total parenteral nutrition to be infused at 125 ml/hour.
• Nasogastric tube connected to low intermittent suction.
• Metoclopramide (Reglan) intermittent piggyback.
14. A client's telemetry monitor indicates the sudden onset of ventricular
fibrillation. Which assessment finding should the nurse anticipate?
• Bounding erratic pulse.
, • Regularly irregular pulse.
• Thready irregular pulse.
• No palpable pulse.
15. In assessing a 70-year-old female client with Alzheimer's disease, the nurse
notes that she has deep inflamed cracks at the corners of her mouth. What
intervention should the nurse includein this client's plan of care?
• Scrub the lesions with warm soapy water.
• Encourage the client to drink orange juice for added vitamin C.
• Notify the healthcare provider of the need for oral antibiotics.
• Ensure that the client gets adequate B vitamins in foods or supplements.
16. A young adult female client is seen in the emergency department for a minor
injury followinga motor vehicle collision. She states she is very angry at the
person who hit her car. What is the best nursing response?
• "You are lucky to be alive. Be grateful no one was killed."
• "I understand your car was not seriously damaged."
• "You are upset that this incident has brought you here."
• "Have you ever been in the emergency department before?"
17. An 85-year-old male resident of an extended care facility reaches for the
hand of the unlicensed assistive personnel (UAP) and tries to kiss her hand
several times during his morning care. The UAP reports the incident to the
charge nurse. What is the best assessment of the situation?
• This is sexual harassment and needs to
be reported to theadministration
immediately.
• The UAP needs to be reassigned to another group of residents,
preferably femalesonly.
• The client may be suffering from touch deprivation
and needs to knowappropriate ways to express his
need.
• The resident needs to know the rules concerning unwanted
touching of the staffand the consequences.
18. The parents of a newborn infant with hypospadias are concerned about
when the surgicalcorrection should occur. What information should the
nurse provide?
• Repair should be done by one month to prevent bladder infections.
• Repairs typically should be done before the child is potty-trained.
• Delaying the repair until school age reduces castration fears.
• To form a proper urethra repair, it should be done after sexual maturity.
