2022 HESI Med Surg Version 1 (v1) exit exam – Brand
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The nurse is preparing to assist a client with a cuffed tracheostomy tube to eat. What
intervention is the priority before the client is permitted to drink or eat? - ANSWER:
Inflate the cuff
Rationale: If a client with a tracheostomy is allowed to eat and the tracheostomy has
a cuff, the nurse should inflate the cuff to prevent aspiration of food or fluids. The
cuff would not be deflated because of the risk of aspiration.
The nurse has implemented a bowel maintenance program for an unconscious
client. The nurse would evaluate the plan as best meeting the needs of the client if
which method was successful in stimulating a bowel movement? - ANSWER: Glycerin
suppository
Rationale: The least amount of invasiveness needed to produce a bowel movement
is best. Use of glycerin suppositories is the least invasive method and usually
stimulates bowel evacuation within a half-hour.
A client is readmitted to the hospital with dehydration after surgery for creation of
an ileostomy. The nurse assesses that the client has lost 3 lb of weight, has poor skin
turgor, and has concentrated urine. The nurse interprets the client's clinical picture
as correlating most closely with recent intake of which medication, which is
contraindicated for the ileostomy client? - ANSWER: Biscodyl
Rationale: The client with an ileostomy is prone to dehydration because of the
location of the ostomy in the gastrointestinal tract and should not take laxatives
The client is complaining of skin irritation from the edges of a cast applied the
previous day. Which action should the nurse take? - ANSWER: The nurse petals the
edges of the cast with tape
Rationale: minimize skin irritation.
The nurse is taking a health history for a client with hyperparathyroidism. Which
question would elicit information about this client's condition? - ANSWER: "Are you
experiencing pain in your joints?"
Rationale: Hyperparathyroidism is associated with over secretion of parathyroid
hormone (PTH), which
causes excessive osteoblast growth and activity within the bones. When bone
reabsorption is increased,
, calcium is released from the bones into the blood, causing hypercalcemia. The bones
suffer demineralization as a result of calcium loss, leading to bone and joint pain
A client with type 2 diabetes mellitus has a blood glucose level greater than 600
mg/dL (34.3 mmol/L) and is complaining of polydipsia, polyuria, weight loss, and
weakness. The nurse reviews the health care provider's documentation and expects
to note which diagnosis? - ANSWER: Hyperosmolar hyperglycemic syndrome (HHS)
Rationale: HHS is seen primarily in clients with type 2 diabetes mellitus, who
experience a relative deficiency of insulin. The onset of signs and symptoms may be
gradual.
Manifestations may include polyuria, polydipsia, dehydration, mental status
alterations, weight loss, and weakness.
The nurse is developing a plan of care for a client who will be admitted to the
hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse
develops the plan, expecting that the health care provider (HCP) will most likely
prescribe which option? - ANSWER: Maintain activity level as prescribed.
Rationale: Standard management for the client with DVT includes maintaining the
activity level
as prescribed by the health care provider; limb elevation; relief of discomfort with
warm, moist
heat; and analgesics as needed. Recent research is showing that ambulation, as
previously thought, does not cause pulmonary embolism and does not cause the
existing DVT to worsen.
Therefore, the nurse should maintain the prescribed activity level, which could be
bed rest or ambulation.
A client has had surgery to repair a fractured left hip. When repositioning the client
from side to side in the bed, what should the nurse plan to use as the most
important item for this maneuver? - ANSWER: Abductor splint
Rationale: After surgery to repair a fractured hip, an abductor splint is used to
maintain the affected extremity in good alignment. A bed pillow and an overhead
trapeze also are used, but neither is the priority item to be used in repositioning the
client from side to side
The nurse is preparing to care for a client who had a supratentorial craniotomy. The
nurse should plan to place the client in which position ? - ANSWER: Semi Fowler's
Rationale: Supratentorial craniotomy means the exposure of any part of a cerebral
hemisphere over the basal line joining the nasion to the inion.
A client with an external arteriovenous shunt in place for hemodialysis is at risk for
bleeding. Which is the priority nursing intervention? - ANSWER: Ensure that small
clamps are attached to the arteriovenous shunt dressing.
New Q&As! Guaranteed Pass w/A+ Actual Screenshots
w/Questions & Answers Included!!!
The nurse is preparing to assist a client with a cuffed tracheostomy tube to eat. What
intervention is the priority before the client is permitted to drink or eat? - ANSWER:
Inflate the cuff
Rationale: If a client with a tracheostomy is allowed to eat and the tracheostomy has
a cuff, the nurse should inflate the cuff to prevent aspiration of food or fluids. The
cuff would not be deflated because of the risk of aspiration.
The nurse has implemented a bowel maintenance program for an unconscious
client. The nurse would evaluate the plan as best meeting the needs of the client if
which method was successful in stimulating a bowel movement? - ANSWER: Glycerin
suppository
Rationale: The least amount of invasiveness needed to produce a bowel movement
is best. Use of glycerin suppositories is the least invasive method and usually
stimulates bowel evacuation within a half-hour.
A client is readmitted to the hospital with dehydration after surgery for creation of
an ileostomy. The nurse assesses that the client has lost 3 lb of weight, has poor skin
turgor, and has concentrated urine. The nurse interprets the client's clinical picture
as correlating most closely with recent intake of which medication, which is
contraindicated for the ileostomy client? - ANSWER: Biscodyl
Rationale: The client with an ileostomy is prone to dehydration because of the
location of the ostomy in the gastrointestinal tract and should not take laxatives
The client is complaining of skin irritation from the edges of a cast applied the
previous day. Which action should the nurse take? - ANSWER: The nurse petals the
edges of the cast with tape
Rationale: minimize skin irritation.
The nurse is taking a health history for a client with hyperparathyroidism. Which
question would elicit information about this client's condition? - ANSWER: "Are you
experiencing pain in your joints?"
Rationale: Hyperparathyroidism is associated with over secretion of parathyroid
hormone (PTH), which
causes excessive osteoblast growth and activity within the bones. When bone
reabsorption is increased,
, calcium is released from the bones into the blood, causing hypercalcemia. The bones
suffer demineralization as a result of calcium loss, leading to bone and joint pain
A client with type 2 diabetes mellitus has a blood glucose level greater than 600
mg/dL (34.3 mmol/L) and is complaining of polydipsia, polyuria, weight loss, and
weakness. The nurse reviews the health care provider's documentation and expects
to note which diagnosis? - ANSWER: Hyperosmolar hyperglycemic syndrome (HHS)
Rationale: HHS is seen primarily in clients with type 2 diabetes mellitus, who
experience a relative deficiency of insulin. The onset of signs and symptoms may be
gradual.
Manifestations may include polyuria, polydipsia, dehydration, mental status
alterations, weight loss, and weakness.
The nurse is developing a plan of care for a client who will be admitted to the
hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse
develops the plan, expecting that the health care provider (HCP) will most likely
prescribe which option? - ANSWER: Maintain activity level as prescribed.
Rationale: Standard management for the client with DVT includes maintaining the
activity level
as prescribed by the health care provider; limb elevation; relief of discomfort with
warm, moist
heat; and analgesics as needed. Recent research is showing that ambulation, as
previously thought, does not cause pulmonary embolism and does not cause the
existing DVT to worsen.
Therefore, the nurse should maintain the prescribed activity level, which could be
bed rest or ambulation.
A client has had surgery to repair a fractured left hip. When repositioning the client
from side to side in the bed, what should the nurse plan to use as the most
important item for this maneuver? - ANSWER: Abductor splint
Rationale: After surgery to repair a fractured hip, an abductor splint is used to
maintain the affected extremity in good alignment. A bed pillow and an overhead
trapeze also are used, but neither is the priority item to be used in repositioning the
client from side to side
The nurse is preparing to care for a client who had a supratentorial craniotomy. The
nurse should plan to place the client in which position ? - ANSWER: Semi Fowler's
Rationale: Supratentorial craniotomy means the exposure of any part of a cerebral
hemisphere over the basal line joining the nasion to the inion.
A client with an external arteriovenous shunt in place for hemodialysis is at risk for
bleeding. Which is the priority nursing intervention? - ANSWER: Ensure that small
clamps are attached to the arteriovenous shunt dressing.
