Med Surg RN HESI Questins And
Answers Solved Update 2023
A male client tells the clinic nurse that he is experiencing burning on urination, and
assessment reveals that he had sexual intercourse four days ago with a woman he
casually met. Which action should the nurse implement? - Obtain a specimen of
urethraldrainage for culture
A client with Addison's disease started taking hydrocortisone in a divided daily dose last
week. It is most important for the nurse to monitor which serum laboratory value? -
Glucose
A client with acquired immunodeficiency syndrome (AIDS) has impaired gas exchange
from a respiratory infection. Which assessment finding warrants immediate intervention
by the nurse? - Pain when swallowing
An older male client tells the nurse that he is losing sleep because he has to get up
several times at night to go to the bathroom, that he has trouble starting his urinary
stream, and that he does not feel like his bladder is ever completely empty. Which
intervention should the nurse implement? - Palpate the bladder above the symphysis
pubis
Fluids are restricted to 1,500 ml daily for a male client with acute kidney injury (AKI). He
is frustrated and complaining of constant thirst, and the nurse discovers that the family
is providing the client with additional fluids. Which intervention should the nurse
implement? - Provide the client with oral swabs to moisten his mouth
During a paracentesis, two liters of fluid are removed from the abdomen of a client with
ascites. A drainage bag is placed, and 50 ml of clear, straw-colored fluid drains within
the first hour. What action should the nurse implement? - Continue to monitor the fluid
output
While assessing a client with degenerative joint disease, the nurse observes
Heberden's nodes, large prominences on the client's fingers that are reddened. The
client reports that the nodes are painful. Which action should the nurse take? - Discuss
approaches to the chronic pain control with the client
A client who took a camping vacation two weeks ago in a county with a tropical climate
comes to the clinic describing vague symptoms and diarrhea for the past week. Which
finding is most important for the nurse report to the healthcare provider? - Jaundiced
sclera
,Ten hours following thrombolysis for an ST elevation myocardial infarction (STEMI), a
client is receiving a lidocaine infusion for isolated runs of ventricular tachycardia (VT).
Which finding should the nurse document in the electronic medical record as a
therapeutic response to the lidocaine infusion? - Decreased frequency of episodes of
ventricular tachycardia (VT)
After a computer tomography (CT) scan with intravenous contrast medium, a client
returns to the room complaining of shortness of breath and itching. Which intervention
should the nurse implement? - Prepare a dose of epinephrine aka Adrenalin
The nurse reports that a client is at risk for a brain attack (stroke) based on which
assessment finding? - Carotid bruit
The nurse is preparing to administer enoxaparin (Lovenox) 135 mg subcutaneously.
The medication is available in a cartridge labeled 150 mg/ml. How many ml should the
nurse administer? (enter numeric value only. If rounding is required, round to the
nearest tenth.) - 0.9 ml
The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's
finger, the nurse observes that the distal tip of the finger appears reddened and
engorged. What action should the nurse take? - Collect the blood sample
A client admitted to a surgical unit is being evaluated for an intestinal obstruction. The
healthcare provider prescribes a nasogastric tube (NGT) to be inserted and placed to
intermittent low wall suction. Which intervention should the nurse implement to facilitate
proper tube placement? - Elevate head of bed 60 to 90 degrees
A young female client with seven children is having frequent morning headaches,
dizziness, and blurred vision. Her blood pressure (BP) is 168/104 mmHg. The client
reports that her husband recently lost his job and she is not sleeping well. After
administering a STAT dose of an antihypertensive IV medication, which intervention is
most important for the nurse to implement? - Use an automated Blood Pressure
machine to monitor for hypotension
The wife of a client with Parkinson's disease expresses concern because her husband
has lost so much weight. Which teaching is best for the nurse to provide? - Invite friends
over regularly to share in meal times
A client who was discharged 8 months ago with cirrhosis and ascites is admitted with
anorexia and recent hemoptysis. The client is drowsy but responds to verbal stimuli.
The nurse programs a blood pressure monitor to take readings every 15 minutes,.
Which assessment should the nurse implement first? - Palpate the abdomen for
tenderness and rigidity
, A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention
should the nurse include in the client's postoperative discharge instructions? - Monitor
urinary stream for decrease in output
A fair-skinned female client who is an avid runner is diagnosed with malignant
melanoma, which is located on the lateral surface of the lower leg. After wide margin
resection, the nurse provides discharge teaching. I t is most important for the nurse to
emphasize the need to observe for changes in which characteristic? - Appearance of
any moles
A healthcare worker with no known exposure to tuberculosis has received a Mantoux
tuberculosis skin test. The nurse's assessment of the test after 62 hours indicates 5 mm
of erythema without induration. What is the best initial nursing action? - Document
negative results in the client's medical record
The nurse is teaching the importance of an exercise regime that includes walking daily
for a group of clients with asthma, chronic bronchitis, and emphysema at a pulmonary
rehabilitation clinic. Which rationale should the nurse include when motivating the
clients? - Daily exercise and walking enhances cardiovascular fitness
The nurse reviews the laboratory results of a client during an annual physical
examination and identifies a positive guaiac test of stool. Which additional serum
laboratory test result should the nurse review? - Platelet count
A client with hypothyroidism reports difficulty falling asleep because of feelings of
depression. Which action should the nurse implement? - Review most recent thyroid
function test results
An older client arrives at the outpatient eye surgery clinic for a right cataract extraction
and lens implant. During the immediate postoperative period, which intervention should
the nurse implement? - Provide an eye shield to be worn while sleeping
A client with Guillain-Barre syndrome has paralysis of all extremities and requires
mechanical ventilation. The nurse observes that the client is not blinking. Which action
should the nurse
implement? - Protect cornea with lubricant and eye shields
An older adult man recently diagnosed with chronic obstructive pulmonary disease
(COPD) is admitted with shortness of breath. The nurse observes the client sitting
upright and leaning over the bedside table, using accessory muscles to assist in
breathing. What action should the nurse take? - Instruct the client in pursed lip breathing
techniques
A client with multiple sclerosis has urinary retention related to sensorimotor deficits.
Which action should the nurse include in the client's plan of care? - Teach the client
techniques for performing intermittent catheterization
Answers Solved Update 2023
A male client tells the clinic nurse that he is experiencing burning on urination, and
assessment reveals that he had sexual intercourse four days ago with a woman he
casually met. Which action should the nurse implement? - Obtain a specimen of
urethraldrainage for culture
A client with Addison's disease started taking hydrocortisone in a divided daily dose last
week. It is most important for the nurse to monitor which serum laboratory value? -
Glucose
A client with acquired immunodeficiency syndrome (AIDS) has impaired gas exchange
from a respiratory infection. Which assessment finding warrants immediate intervention
by the nurse? - Pain when swallowing
An older male client tells the nurse that he is losing sleep because he has to get up
several times at night to go to the bathroom, that he has trouble starting his urinary
stream, and that he does not feel like his bladder is ever completely empty. Which
intervention should the nurse implement? - Palpate the bladder above the symphysis
pubis
Fluids are restricted to 1,500 ml daily for a male client with acute kidney injury (AKI). He
is frustrated and complaining of constant thirst, and the nurse discovers that the family
is providing the client with additional fluids. Which intervention should the nurse
implement? - Provide the client with oral swabs to moisten his mouth
During a paracentesis, two liters of fluid are removed from the abdomen of a client with
ascites. A drainage bag is placed, and 50 ml of clear, straw-colored fluid drains within
the first hour. What action should the nurse implement? - Continue to monitor the fluid
output
While assessing a client with degenerative joint disease, the nurse observes
Heberden's nodes, large prominences on the client's fingers that are reddened. The
client reports that the nodes are painful. Which action should the nurse take? - Discuss
approaches to the chronic pain control with the client
A client who took a camping vacation two weeks ago in a county with a tropical climate
comes to the clinic describing vague symptoms and diarrhea for the past week. Which
finding is most important for the nurse report to the healthcare provider? - Jaundiced
sclera
,Ten hours following thrombolysis for an ST elevation myocardial infarction (STEMI), a
client is receiving a lidocaine infusion for isolated runs of ventricular tachycardia (VT).
Which finding should the nurse document in the electronic medical record as a
therapeutic response to the lidocaine infusion? - Decreased frequency of episodes of
ventricular tachycardia (VT)
After a computer tomography (CT) scan with intravenous contrast medium, a client
returns to the room complaining of shortness of breath and itching. Which intervention
should the nurse implement? - Prepare a dose of epinephrine aka Adrenalin
The nurse reports that a client is at risk for a brain attack (stroke) based on which
assessment finding? - Carotid bruit
The nurse is preparing to administer enoxaparin (Lovenox) 135 mg subcutaneously.
The medication is available in a cartridge labeled 150 mg/ml. How many ml should the
nurse administer? (enter numeric value only. If rounding is required, round to the
nearest tenth.) - 0.9 ml
The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's
finger, the nurse observes that the distal tip of the finger appears reddened and
engorged. What action should the nurse take? - Collect the blood sample
A client admitted to a surgical unit is being evaluated for an intestinal obstruction. The
healthcare provider prescribes a nasogastric tube (NGT) to be inserted and placed to
intermittent low wall suction. Which intervention should the nurse implement to facilitate
proper tube placement? - Elevate head of bed 60 to 90 degrees
A young female client with seven children is having frequent morning headaches,
dizziness, and blurred vision. Her blood pressure (BP) is 168/104 mmHg. The client
reports that her husband recently lost his job and she is not sleeping well. After
administering a STAT dose of an antihypertensive IV medication, which intervention is
most important for the nurse to implement? - Use an automated Blood Pressure
machine to monitor for hypotension
The wife of a client with Parkinson's disease expresses concern because her husband
has lost so much weight. Which teaching is best for the nurse to provide? - Invite friends
over regularly to share in meal times
A client who was discharged 8 months ago with cirrhosis and ascites is admitted with
anorexia and recent hemoptysis. The client is drowsy but responds to verbal stimuli.
The nurse programs a blood pressure monitor to take readings every 15 minutes,.
Which assessment should the nurse implement first? - Palpate the abdomen for
tenderness and rigidity
, A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention
should the nurse include in the client's postoperative discharge instructions? - Monitor
urinary stream for decrease in output
A fair-skinned female client who is an avid runner is diagnosed with malignant
melanoma, which is located on the lateral surface of the lower leg. After wide margin
resection, the nurse provides discharge teaching. I t is most important for the nurse to
emphasize the need to observe for changes in which characteristic? - Appearance of
any moles
A healthcare worker with no known exposure to tuberculosis has received a Mantoux
tuberculosis skin test. The nurse's assessment of the test after 62 hours indicates 5 mm
of erythema without induration. What is the best initial nursing action? - Document
negative results in the client's medical record
The nurse is teaching the importance of an exercise regime that includes walking daily
for a group of clients with asthma, chronic bronchitis, and emphysema at a pulmonary
rehabilitation clinic. Which rationale should the nurse include when motivating the
clients? - Daily exercise and walking enhances cardiovascular fitness
The nurse reviews the laboratory results of a client during an annual physical
examination and identifies a positive guaiac test of stool. Which additional serum
laboratory test result should the nurse review? - Platelet count
A client with hypothyroidism reports difficulty falling asleep because of feelings of
depression. Which action should the nurse implement? - Review most recent thyroid
function test results
An older client arrives at the outpatient eye surgery clinic for a right cataract extraction
and lens implant. During the immediate postoperative period, which intervention should
the nurse implement? - Provide an eye shield to be worn while sleeping
A client with Guillain-Barre syndrome has paralysis of all extremities and requires
mechanical ventilation. The nurse observes that the client is not blinking. Which action
should the nurse
implement? - Protect cornea with lubricant and eye shields
An older adult man recently diagnosed with chronic obstructive pulmonary disease
(COPD) is admitted with shortness of breath. The nurse observes the client sitting
upright and leaning over the bedside table, using accessory muscles to assist in
breathing. What action should the nurse take? - Instruct the client in pursed lip breathing
techniques
A client with multiple sclerosis has urinary retention related to sensorimotor deficits.
Which action should the nurse include in the client's plan of care? - Teach the client
techniques for performing intermittent catheterization
