Med-Surg II HESI Test Bank/ 100%
VERIFIED/ 2024 EDITION
A.BEST A nurse is reinforcing teaching with a client who has HIV and is being
discharged to home. Which of the following instructions should the nurse include in the
teaching?
A. Take temperature once a day.
B. Wash the armpits and genitals with a gentle cleanser daily.
C. Change the litter boxes while wearing gloves.
D. Wash dishes in warm water.//A.BEST A nurse is caring for a client who is
postoperative following a tracheostomy, and has copious and tenacious secretions.
Which of the following is an acceptable method for the nurse to use to thin this client's
secretions?
A. Provide humidified oxygen.
B. Perform chest physiotherapy prior to suctioning.
C. Prelubricate the suction catheter tip with sterile saline when suctioning the airway.
D. Hyperventilate the client with 100% oxygen before suctioning the airway..//B.BEST
Following admission, a client with a vascular occlusion of the right lower extremity calls
the nurse and reports difficulty sleeping because of cold feet. Which of the following
nursing actions should the nurse take to promote the client's comfort?
A. Rub the client's feet briskly for several minutes.
B. Obtain a pair of slipper socks for the client.
C. Increase the client's oral fluid intake.
D. Place a moist heating pad under the client's feet.//C.BEST A nurse is caring for a
client is who is 4 hr postoperative following a transurethral resection of the prostate
(TURP). Which of the following is the priority finding for the nurse report to the provider?
A. Emesis of 100 mL
B. Oral temperature of 37.5° C (99.5° F)
C. Thick, red-colored urine
D. Pain level of 4 on a 0 to 10 rating scale//A.BEST A nurse is caring for a client who
has a temperature of 39.7° C (103.5° F) and has a prescription for a hypothermia
blanket. The nurse should monitor the client for which of the following adverse effects of
the hypothermia blanket?
A. Shivering
B. Infection
C. Burns
D. Hypervolemia//D.BEST A nurse is reinforcing teaching about exercise with a client
who has type 1 diabetes mellitus. Which of the following statements by the client
indicates an understanding of the teaching?
A. "I will carry a complex carbohydrate snack with me when I exercise."
B. "I should exercise first thing in the morning before eating breakfast."
C. "I should avoid injecting insulin into my thigh if I am going to go running."
,D. "I will not exercise if my urine is positive for ketones."//A.BEST A nurse notes a small
section of bowel protruding from the abdominal incision of a client who
is postoperative. After calling for assistance, which of the following actions should the
nurse take first?
A. Cover the client's wound with a moist, sterile dressing.
B. Have the client lie supine with knees flexed.
C. Check the client's vital signs.
D. Inform the client about the need to return to surgery.//B.BEST A nurse is collecting
data from a client who has alcohol use disorder and is experiencing metabolic acidosis.
Which of the following manifestations should the nurse expect?
A. Cool, clammy skin.
B. Hyperventilation
C. Increased blood pressure
D. Bradycardia//A.BEST A nurse is reinforcing discharge teaching with a client following
a cataract extraction. Which of the following should the nurse include in the teaching?
A. Avoid bending at the waist.
B. Remove the eye shield at bedtime.
C. Limit the use of laxatives if constipated.
D. Seeing flashes of light is an expected finding following extraction.//CBEST A nurse is
caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The
client refuses breakfast and reports nausea. Which of the following actions should the
nurse take first?
1) Suggest that the client rests before eating the meal.
2) Request a dietary consult.
3) Check the client's vital signs.
4) Request an order for an antiemetic.//D.BEST A nurse is caring for a client who is 3
days postoperative following a cholecystectomy. The nurse suspects the client's wound
is infected because the drainage from the dressing is yellow and thick. Which of the
following findings should the nurse report as the type of drainage found?
1) Sanguineous
2) Serous
3) Serosanguineous
4) Purulent//A.BEST A nurse is reinforcing discharge teaching to a client following
arthroscopic surgery. To prevent postoperative complications which of the following
actions should be reinforced during the teaching?
1) Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises.
2) Place the client's affected leg into the CPM machine with the machine in the flexed
position.
3) Place the client into a high Fowler's position when initiating the CPM exercises.
4) Align the joints of the CPM machine with the knee gatch in the client's bed.//A, B, C,
DBEST A nurse is collecting data from a client who has emphysema. Which of the
following findings should the nurse expect? (Select all that apply.)
1) Dyspnea
2) Barrel chest
3) Clubbing of the fingers
4) Shallow respirations
, 5) Bradycardia//D.BEST A nurse is caring for a client who sustained a basal skull
fracture. When performing morning hygiene care, the nurse notices a thin stream of
clear drainage coming from out of the client's right nostril.
Which of the following actions should the nurse take first?
1) Take the client's temperature.
2) Place a dressing under the client's nose.
3) Notify the charge nurse.
4) Test the drainage for glucose.//C.BEST A nurse is caring for a client who has a spinal
cord injury at T-4. The nurse should recognize that the client is at risk for autonomic
dysreflexia. Which of the following interventions should the nurse take to prevent
autonomic dysreflexia?
1) Monitor for elevated blood pressure.
2) Provide analgesia for headaches.
3) Prevent bladder distention.
4) Elevate the client's head.//D.BEST A nurse is caring for a client who is being
evaluated for endometrial cancer. Which of the following findings should the nurse
expect the client to report?
1) Hot flashes
2) Recurrent urinary tract infections
3) Blood in the stool
4) Abnormal vaginal bleeding//A.BEST A nurse is caring for a client following an open
reduction and internal fixation of a fractured femur. Which of the following findings is the
nurse's priority?
1) Altered level of consciousness
2) Oral temperature of 37.7° C (100° C)
3) Muscle spasms
4) Headache//A.BEST A nurse is assisting in the care of a client who is 2 hours
postoperative following a wedge resection of the left lung and has a chest tube to
suction. Which of the following is the priority finding the nurse should report to the
provider?
1) Abdomen is distended
2) Chest tube drainage of 70 mL in the last hour
3) Subcutaneous emphysema is noted to the left chest wall
4) Pain level of 6 on a 0 to 10 scale//A.BEST A nurse is reinforcing discharge teaching
with a client about how to care for a newly created ileal conduit. Which of the following
instructions should the nurse include in the teaching?
1) Change the ostomy pouch daily.
2) Empty the ostomy pouch when it is 2/3 full.
3) Trim the opening of the ostomy seal to be 1/2 in. wider than the stoma.
4) Apply lotion to the peristomal skin when changing the ostomy pouch.//B.BEST A
nurse is assisting in the plan of care for a client who had a removal of the pituitary
gland. Which of the following actions should the nurse include in the plan?
1) Position the client supine while in bed.
2) Change the nasal drip pad as needed.
3) Encourage frequent brushing of teeth.
VERIFIED/ 2024 EDITION
A.BEST A nurse is reinforcing teaching with a client who has HIV and is being
discharged to home. Which of the following instructions should the nurse include in the
teaching?
A. Take temperature once a day.
B. Wash the armpits and genitals with a gentle cleanser daily.
C. Change the litter boxes while wearing gloves.
D. Wash dishes in warm water.//A.BEST A nurse is caring for a client who is
postoperative following a tracheostomy, and has copious and tenacious secretions.
Which of the following is an acceptable method for the nurse to use to thin this client's
secretions?
A. Provide humidified oxygen.
B. Perform chest physiotherapy prior to suctioning.
C. Prelubricate the suction catheter tip with sterile saline when suctioning the airway.
D. Hyperventilate the client with 100% oxygen before suctioning the airway..//B.BEST
Following admission, a client with a vascular occlusion of the right lower extremity calls
the nurse and reports difficulty sleeping because of cold feet. Which of the following
nursing actions should the nurse take to promote the client's comfort?
A. Rub the client's feet briskly for several minutes.
B. Obtain a pair of slipper socks for the client.
C. Increase the client's oral fluid intake.
D. Place a moist heating pad under the client's feet.//C.BEST A nurse is caring for a
client is who is 4 hr postoperative following a transurethral resection of the prostate
(TURP). Which of the following is the priority finding for the nurse report to the provider?
A. Emesis of 100 mL
B. Oral temperature of 37.5° C (99.5° F)
C. Thick, red-colored urine
D. Pain level of 4 on a 0 to 10 rating scale//A.BEST A nurse is caring for a client who
has a temperature of 39.7° C (103.5° F) and has a prescription for a hypothermia
blanket. The nurse should monitor the client for which of the following adverse effects of
the hypothermia blanket?
A. Shivering
B. Infection
C. Burns
D. Hypervolemia//D.BEST A nurse is reinforcing teaching about exercise with a client
who has type 1 diabetes mellitus. Which of the following statements by the client
indicates an understanding of the teaching?
A. "I will carry a complex carbohydrate snack with me when I exercise."
B. "I should exercise first thing in the morning before eating breakfast."
C. "I should avoid injecting insulin into my thigh if I am going to go running."
,D. "I will not exercise if my urine is positive for ketones."//A.BEST A nurse notes a small
section of bowel protruding from the abdominal incision of a client who
is postoperative. After calling for assistance, which of the following actions should the
nurse take first?
A. Cover the client's wound with a moist, sterile dressing.
B. Have the client lie supine with knees flexed.
C. Check the client's vital signs.
D. Inform the client about the need to return to surgery.//B.BEST A nurse is collecting
data from a client who has alcohol use disorder and is experiencing metabolic acidosis.
Which of the following manifestations should the nurse expect?
A. Cool, clammy skin.
B. Hyperventilation
C. Increased blood pressure
D. Bradycardia//A.BEST A nurse is reinforcing discharge teaching with a client following
a cataract extraction. Which of the following should the nurse include in the teaching?
A. Avoid bending at the waist.
B. Remove the eye shield at bedtime.
C. Limit the use of laxatives if constipated.
D. Seeing flashes of light is an expected finding following extraction.//CBEST A nurse is
caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The
client refuses breakfast and reports nausea. Which of the following actions should the
nurse take first?
1) Suggest that the client rests before eating the meal.
2) Request a dietary consult.
3) Check the client's vital signs.
4) Request an order for an antiemetic.//D.BEST A nurse is caring for a client who is 3
days postoperative following a cholecystectomy. The nurse suspects the client's wound
is infected because the drainage from the dressing is yellow and thick. Which of the
following findings should the nurse report as the type of drainage found?
1) Sanguineous
2) Serous
3) Serosanguineous
4) Purulent//A.BEST A nurse is reinforcing discharge teaching to a client following
arthroscopic surgery. To prevent postoperative complications which of the following
actions should be reinforced during the teaching?
1) Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises.
2) Place the client's affected leg into the CPM machine with the machine in the flexed
position.
3) Place the client into a high Fowler's position when initiating the CPM exercises.
4) Align the joints of the CPM machine with the knee gatch in the client's bed.//A, B, C,
DBEST A nurse is collecting data from a client who has emphysema. Which of the
following findings should the nurse expect? (Select all that apply.)
1) Dyspnea
2) Barrel chest
3) Clubbing of the fingers
4) Shallow respirations
, 5) Bradycardia//D.BEST A nurse is caring for a client who sustained a basal skull
fracture. When performing morning hygiene care, the nurse notices a thin stream of
clear drainage coming from out of the client's right nostril.
Which of the following actions should the nurse take first?
1) Take the client's temperature.
2) Place a dressing under the client's nose.
3) Notify the charge nurse.
4) Test the drainage for glucose.//C.BEST A nurse is caring for a client who has a spinal
cord injury at T-4. The nurse should recognize that the client is at risk for autonomic
dysreflexia. Which of the following interventions should the nurse take to prevent
autonomic dysreflexia?
1) Monitor for elevated blood pressure.
2) Provide analgesia for headaches.
3) Prevent bladder distention.
4) Elevate the client's head.//D.BEST A nurse is caring for a client who is being
evaluated for endometrial cancer. Which of the following findings should the nurse
expect the client to report?
1) Hot flashes
2) Recurrent urinary tract infections
3) Blood in the stool
4) Abnormal vaginal bleeding//A.BEST A nurse is caring for a client following an open
reduction and internal fixation of a fractured femur. Which of the following findings is the
nurse's priority?
1) Altered level of consciousness
2) Oral temperature of 37.7° C (100° C)
3) Muscle spasms
4) Headache//A.BEST A nurse is assisting in the care of a client who is 2 hours
postoperative following a wedge resection of the left lung and has a chest tube to
suction. Which of the following is the priority finding the nurse should report to the
provider?
1) Abdomen is distended
2) Chest tube drainage of 70 mL in the last hour
3) Subcutaneous emphysema is noted to the left chest wall
4) Pain level of 6 on a 0 to 10 scale//A.BEST A nurse is reinforcing discharge teaching
with a client about how to care for a newly created ileal conduit. Which of the following
instructions should the nurse include in the teaching?
1) Change the ostomy pouch daily.
2) Empty the ostomy pouch when it is 2/3 full.
3) Trim the opening of the ostomy seal to be 1/2 in. wider than the stoma.
4) Apply lotion to the peristomal skin when changing the ostomy pouch.//B.BEST A
nurse is assisting in the plan of care for a client who had a removal of the pituitary
gland. Which of the following actions should the nurse include in the plan?
1) Position the client supine while in bed.
2) Change the nasal drip pad as needed.
3) Encourage frequent brushing of teeth.
