HESI MED SURG EXIT EXAM 2 NEWEST
VERSION-with 100% verified answers-
2023 160 QUESTIONS AND ANSWERS
Answers are on the last pages
A client who has Type 1 diabetes and is at 10-weeks gestation comes to the prenatal
clinic complaining of a headache, nausea, sweating, feeling shaky, and being tired all the
time. What action should the nurse take first?
a. Check the blood glucose level.
b. Draw blood for a Hemoglobin A1C.
c. Assess urine for ketone levels.
d. Provide the client with a protein snack.
.A client in labor states, "I think my water just broke!" The nurse notes that theumbilical
cord is on the perineum. What action should the nurse perform first?
a. Administer oxygen via face mask.
c. Notify the operating room team.
b. Place the client in Trendelenburg.
c. Administer a fluid bolus of 500 ml.
The nurse is planning care for a non-potty-trained child with nephrotic syndrome.Which
intervention provides the best means of determining fluid retention?
a. Weigh the child daily.
b. Observe the lower extremities for pitting edema.
c. Measure the child's abdominal girth weekly.
d. Weigh the child's wet diapers.
The mother of a 9-month-old who was diagnosed with respiratory syncytial virus (RSV)
yesterday calls the clinic to inquire if it will be all right to take her infant to the first
birthday party of a friend's child the following day. What response should the nurseprovide
this mother?
a. The child can be around other children but should wear a mask at all times.
b. The child will no longer be contagious, no need to take any further precautions.
c. Make sure there are no children under the age of 6 months around the infected child.
d. Do not expose other children. RSV is very contagious even without direct oral contact.
.A client from a nursing home is admitted with urinary sepsis and has a single-lumen,
peripherally-inserted central catheter (PICC). Four medications are prescribed for 9:00
a.m. and the nurse is running behind schedule. Which medication should the nurse
administer first?
a. Piperacillin/tazobactam (Zosyn) in 100 ml D5W, IV over 30 minutes q8 hours.
b. Vancomycin (Vancocin) 1 gm in 250 ml D5W, IV over 90 minutes q12 hours.
c. Pantoprazole (Protonix) 40 mg PO daily
d. Enoxaparin (Lovenox) 40 mg subq q24 hours.
,Which action should the nurse implement to reduce the risk of vesicant extravasationin
the client who is receiving intravenous chemotherapy?
, a. Administer an antiemetic before starting the chemotherapy.
b. Instruct the client to drink plenty of fluids during the treatment.
c. Keep the head of the bed elevated until the treatment is completed.
d. Monitor the client's intravenous site hourly during the treatment.
Name: ID: A 7
An elderly male client reports to the clinic nurse that he is experiencing increasing
nocturia with difficulty initiating his urine stream. He reports a weak urine flow and
frequent dribbling after voiding. Which nursing action should be implemented?
a. Obtain a urine specimen for culture and sensitivity.
b. Encourage the client to schedule a digital rectal exam.
c. Advise the client to maintain a voiding diary for one week.
d. Instruct the client in effective techniques to cleanse the glans penis.
The nurse is performing an admission physical assessment of a newborn who is smallfor
gestational age (SGA). Which finding should the nurse report immediately to the pediatric
healthcare provider?
a. Heel stick glucose of 65 mg/dl.
b. Head circumference of 35 cm (14 inches).
c. Widened, tense, bulging fontanel.
d. High-pitched shrill cry.
Which client's laboratory value requires immediate intervention by a nurse?
a. A client with GI bleeding who is receiving a blood transfusion and has a hemoglobin of 7
grams.
b. A client with pancreatitis who has a fasting glucose of 190 mg/dl today and had 160 mg/dl
yesterday.
c. A client with hepatitis who is jaundiced and has a bilirubin level that is 4 times the normal
value.
d. A client with cancer who has an absolute count of neutrophils < 500 today and had 2,000
yesterday.
In planning the turning schedule for a bedfast client, it is most important for thenurse
to consider what assessment finding?
a. 4+ pitting edema of both lower extremities.
b. A Braden risk assessment scale rating score of ten.
c. Warm, dry skin with a fever of 100° F.
d. Hypoactive bowel sounds with infrequent bowel movements.
The healthcare provider prescribes naproxen (Naprosyn) 500 mg PO twice a day for aclient
with osteoarthritis. During a follow-up visit one month later, the client tells the nurse,
"The pills don't seem to be working. They are not helping the pain at all." Which factor
should influence the nurse's response?
a. Noncompliance is probably affecting optimum medication effectiveness.
b. Drug dosage is inadequate and needs to be increased to four times a day.
c. The drug needs 4 to 6 weeks to reach therapeutic levels in the bloodstream.
d. NSAID response is variable and another NSAID may be more effective.
, A nurse is interested in studying the incidence of infant death in a particular city and wants
to compare that city's rate to the state's rate. What state resource is most likely to provide
this information?
a. Disease registry.
b. Department of Health.
c. Bureau of Vital Statistics.
d. Census data.
Name: ID: A 8
A 60-year-old male client is admitted to the hospital with the complaint of right kneepain
for the past week. His right knee and calf are warm and edematous. He has a historyof
diabetes and arthritis. Which neurological assessment action should the nurse perform for
this client?
a. Glasgow coma scale.
b. Pulses, paresthesia, paralysis distal to the right knee.
c. Pulses, paresthesia, paralysis proximal to the right knee.
d. Optic nerve using an ophthalmoscope.
A highly successful businessman presents to the community mental health center
complaining of sleeplessness and anxiety over his financial status. What action should the
nurse take to assist this client in diminishing his anxiety?
a. Encourage him to initiate daily rituals.
b. Reinforce the reality of his financial situation.
c. Direct him to drink a glass of red wine at bedtime.
d. Teach him to limit sugar and caffeine intake.
What physical assessment data should the nurse consider a normal finding for a
primigravida client who is 12 hours postpartum?
a. Soft, spongy fundus.
b. Saturating two perineal pads per hour.
c. Pulse rate of 56 BPM.
d. Unilateral lower leg pain.
The nurse plans to educate a client about the purpose for taking the prescribed
antipsychotic medication clozapine (Clozaril). Which statement should the nurse
provide?
a. "It will help you function better in the community."
b. "The medication will help you think more clearly."
c. "You will be able to cope with your symptoms."
d. "It will improve your grooming and hygiene."
A male client is admitted to the neurological unit. He has just sustained a C-5 spinal cord
injury. Which assessment finding of this client warrants immediate intervention by the
nurse?
a. Is unable to feel sensation in the arms and hands.
b. Has flaccid upper and lower extremities.
c. Blood pressure is 110/70 and the apical pulse is 68.
d. Respirations are shallow, labored, and 14 breaths/minute.
VERSION-with 100% verified answers-
2023 160 QUESTIONS AND ANSWERS
Answers are on the last pages
A client who has Type 1 diabetes and is at 10-weeks gestation comes to the prenatal
clinic complaining of a headache, nausea, sweating, feeling shaky, and being tired all the
time. What action should the nurse take first?
a. Check the blood glucose level.
b. Draw blood for a Hemoglobin A1C.
c. Assess urine for ketone levels.
d. Provide the client with a protein snack.
.A client in labor states, "I think my water just broke!" The nurse notes that theumbilical
cord is on the perineum. What action should the nurse perform first?
a. Administer oxygen via face mask.
c. Notify the operating room team.
b. Place the client in Trendelenburg.
c. Administer a fluid bolus of 500 ml.
The nurse is planning care for a non-potty-trained child with nephrotic syndrome.Which
intervention provides the best means of determining fluid retention?
a. Weigh the child daily.
b. Observe the lower extremities for pitting edema.
c. Measure the child's abdominal girth weekly.
d. Weigh the child's wet diapers.
The mother of a 9-month-old who was diagnosed with respiratory syncytial virus (RSV)
yesterday calls the clinic to inquire if it will be all right to take her infant to the first
birthday party of a friend's child the following day. What response should the nurseprovide
this mother?
a. The child can be around other children but should wear a mask at all times.
b. The child will no longer be contagious, no need to take any further precautions.
c. Make sure there are no children under the age of 6 months around the infected child.
d. Do not expose other children. RSV is very contagious even without direct oral contact.
.A client from a nursing home is admitted with urinary sepsis and has a single-lumen,
peripherally-inserted central catheter (PICC). Four medications are prescribed for 9:00
a.m. and the nurse is running behind schedule. Which medication should the nurse
administer first?
a. Piperacillin/tazobactam (Zosyn) in 100 ml D5W, IV over 30 minutes q8 hours.
b. Vancomycin (Vancocin) 1 gm in 250 ml D5W, IV over 90 minutes q12 hours.
c. Pantoprazole (Protonix) 40 mg PO daily
d. Enoxaparin (Lovenox) 40 mg subq q24 hours.
,Which action should the nurse implement to reduce the risk of vesicant extravasationin
the client who is receiving intravenous chemotherapy?
, a. Administer an antiemetic before starting the chemotherapy.
b. Instruct the client to drink plenty of fluids during the treatment.
c. Keep the head of the bed elevated until the treatment is completed.
d. Monitor the client's intravenous site hourly during the treatment.
Name: ID: A 7
An elderly male client reports to the clinic nurse that he is experiencing increasing
nocturia with difficulty initiating his urine stream. He reports a weak urine flow and
frequent dribbling after voiding. Which nursing action should be implemented?
a. Obtain a urine specimen for culture and sensitivity.
b. Encourage the client to schedule a digital rectal exam.
c. Advise the client to maintain a voiding diary for one week.
d. Instruct the client in effective techniques to cleanse the glans penis.
The nurse is performing an admission physical assessment of a newborn who is smallfor
gestational age (SGA). Which finding should the nurse report immediately to the pediatric
healthcare provider?
a. Heel stick glucose of 65 mg/dl.
b. Head circumference of 35 cm (14 inches).
c. Widened, tense, bulging fontanel.
d. High-pitched shrill cry.
Which client's laboratory value requires immediate intervention by a nurse?
a. A client with GI bleeding who is receiving a blood transfusion and has a hemoglobin of 7
grams.
b. A client with pancreatitis who has a fasting glucose of 190 mg/dl today and had 160 mg/dl
yesterday.
c. A client with hepatitis who is jaundiced and has a bilirubin level that is 4 times the normal
value.
d. A client with cancer who has an absolute count of neutrophils < 500 today and had 2,000
yesterday.
In planning the turning schedule for a bedfast client, it is most important for thenurse
to consider what assessment finding?
a. 4+ pitting edema of both lower extremities.
b. A Braden risk assessment scale rating score of ten.
c. Warm, dry skin with a fever of 100° F.
d. Hypoactive bowel sounds with infrequent bowel movements.
The healthcare provider prescribes naproxen (Naprosyn) 500 mg PO twice a day for aclient
with osteoarthritis. During a follow-up visit one month later, the client tells the nurse,
"The pills don't seem to be working. They are not helping the pain at all." Which factor
should influence the nurse's response?
a. Noncompliance is probably affecting optimum medication effectiveness.
b. Drug dosage is inadequate and needs to be increased to four times a day.
c. The drug needs 4 to 6 weeks to reach therapeutic levels in the bloodstream.
d. NSAID response is variable and another NSAID may be more effective.
, A nurse is interested in studying the incidence of infant death in a particular city and wants
to compare that city's rate to the state's rate. What state resource is most likely to provide
this information?
a. Disease registry.
b. Department of Health.
c. Bureau of Vital Statistics.
d. Census data.
Name: ID: A 8
A 60-year-old male client is admitted to the hospital with the complaint of right kneepain
for the past week. His right knee and calf are warm and edematous. He has a historyof
diabetes and arthritis. Which neurological assessment action should the nurse perform for
this client?
a. Glasgow coma scale.
b. Pulses, paresthesia, paralysis distal to the right knee.
c. Pulses, paresthesia, paralysis proximal to the right knee.
d. Optic nerve using an ophthalmoscope.
A highly successful businessman presents to the community mental health center
complaining of sleeplessness and anxiety over his financial status. What action should the
nurse take to assist this client in diminishing his anxiety?
a. Encourage him to initiate daily rituals.
b. Reinforce the reality of his financial situation.
c. Direct him to drink a glass of red wine at bedtime.
d. Teach him to limit sugar and caffeine intake.
What physical assessment data should the nurse consider a normal finding for a
primigravida client who is 12 hours postpartum?
a. Soft, spongy fundus.
b. Saturating two perineal pads per hour.
c. Pulse rate of 56 BPM.
d. Unilateral lower leg pain.
The nurse plans to educate a client about the purpose for taking the prescribed
antipsychotic medication clozapine (Clozaril). Which statement should the nurse
provide?
a. "It will help you function better in the community."
b. "The medication will help you think more clearly."
c. "You will be able to cope with your symptoms."
d. "It will improve your grooming and hygiene."
A male client is admitted to the neurological unit. He has just sustained a C-5 spinal cord
injury. Which assessment finding of this client warrants immediate intervention by the
nurse?
a. Is unable to feel sensation in the arms and hands.
b. Has flaccid upper and lower extremities.
c. Blood pressure is 110/70 and the apical pulse is 68.
d. Respirations are shallow, labored, and 14 breaths/minute.
