HESI MEDICAL SURG FINAL EXAM
2024 WITH 200 QUESTIONS AND
CORRECT ANSWERS ALREADY
GRADED A+ | HESI MEDICAL SURG
LATEST 2024-2025 |BRAND NEW!!
A client with hypertension has been receiving ramipril, 5 mg PO, daily for 2 weeks
and is scheduled to receive a dose at 0900. At 0830, the client's blood pressure is
120/70 mm Hg. Which action should the nurse take?
A. Administer the prescribed dose at the scheduled time.
B. Hold the dose and contact the health care provider.
C. Hold the dose and recheck the blood pressure in 1 hour.
D. Check the health care provider's prescription to clarify the dose. - ANSWER- A.
Administer the prescribed dose at the scheduled time.
Rationale:
The client's blood pressure is within normal limits, indicating that the
ramipril, an antihypertensive, is having the desired effect and should be
administered. Options B and C would be appropriate if the client's blood pressure
was excessively low (<100 mm Hg systolic) or if the client were exhibiting signs
,of hypotension such as dizziness. This prescribed dose is within the normal dosage
range, as defined by the manufacturer; therefore, option D is not necessary
The nurse is concerned about infection for a client after an esophagogastrostomy
for esophageal cancer. Which actions should the nurse include in the client's plan
of care? (Select all that apply.)
A. Frequent oral care every 2 hours while awake.
B. Use an incentive spirometer every 2 hours.
C. Empty contents from the NG tube every 8 hours.
D. Ambulate within 1 hour of return from the PACU.E. Limit visitors until
postoperative day 2. - ANSWER- A. Frequent oral care every 2 hours while
awake.
B. Use an incentive spirometer every 2 hours.
C. Empty contents from the NG tube every 8 hours.
Rationale:
One hour post op is too soon to ambulate for this client. Visitors help
support the patient and are encouraged to visit. Oral care is necessary as the client
will be NPO. To decrease the risk of infection post operatively, implement routine
pulmonary exercises. The client will have an NG tube in place, likely to
intermittent suction, to decompress the stomach post surgery.
The client is returned demonstrating wrapping of the left limb amputated above the
knee. The nurse evaluates whether the client is starting the wrapping method
correctly when the client places the end of the bandage at which point.
A. Around the waist
,B. The inner aspect of the left stump
C. The outer aspect of the left stump
D. At the left groin area - ANSWER- A. Around the waist
Rationale:
The waist is the anchor point for the bandage for an above the knee
amputation.
A nurse is assisting an 82-year-old client with ambulation and is concerned that the
client may fall. Which area contains the older person's center of gravity?
A. Head and neck
B. Upper torso
C. Bilateral arms
D. Feet and legs - ANSWER- B. Upper torso
Rationale:
Stooped posture results in the upper torso becoming the center of gravity
for older persons. The center of gravity for adults is the hips. However, as a person
grows older, a stooped posture is common because of changes caused by
osteoporosis and normal bone degeneration. Furthermore, the knees, hips, and
elbows flex. The head and neck and feet and legs are not the center of gravity in
the older adult. Although the arms comprise a part of the upper torso, they do not
reflect the best and most complete answer.
The nurse is providing care for a client diagnosed with trigeminal neuralgia (tic
douloureux). Which symptoms will the nurse be looking for in the focused
assessment related to this condition? (Select all that apply.)
, A. Facial muscle spasms
B. Sudden facial pain
C. Unilateral facial weakness
D. Difficulty in chewing
E. Tinnitus
F. Hearing difficulties - ANSWER- A. Facial muscle spasms
B. Sudden facial pain
Rationale:
Trigeminal neuralgia is characterized by paroxysms of pain, similar to an
electric shock, in the area innervated by one or more branches of the trigeminal
nerve (cranial V). The remaining symptoms are not related to trigeminal neuralgia.
In caring for a client with acute diverticulitis, which assessment data warrants
immediate nursing action?
A. The client has a rigid hard abdomen and elevated WBC.
B. The client has left lower quadrant pain and an elevated temperature.
C. The client is refusing to eat any of the meals and is complaining of nausea.
D. The client has not had a bowel movement in 2 days and has a soft abdomen. -
ANSWER- A. The client has a rigid hard abdomen and elevated WBC.
Rationale:
A hard rigid abdomen and elevated WBC is indicative of peritonitis,
which is a medical emergency and should be reported to the health care provider
immediately. Options B and C are expected clinical manifestations of diverticulitis.
Option D does not warrant immediate intervention.
2024 WITH 200 QUESTIONS AND
CORRECT ANSWERS ALREADY
GRADED A+ | HESI MEDICAL SURG
LATEST 2024-2025 |BRAND NEW!!
A client with hypertension has been receiving ramipril, 5 mg PO, daily for 2 weeks
and is scheduled to receive a dose at 0900. At 0830, the client's blood pressure is
120/70 mm Hg. Which action should the nurse take?
A. Administer the prescribed dose at the scheduled time.
B. Hold the dose and contact the health care provider.
C. Hold the dose and recheck the blood pressure in 1 hour.
D. Check the health care provider's prescription to clarify the dose. - ANSWER- A.
Administer the prescribed dose at the scheduled time.
Rationale:
The client's blood pressure is within normal limits, indicating that the
ramipril, an antihypertensive, is having the desired effect and should be
administered. Options B and C would be appropriate if the client's blood pressure
was excessively low (<100 mm Hg systolic) or if the client were exhibiting signs
,of hypotension such as dizziness. This prescribed dose is within the normal dosage
range, as defined by the manufacturer; therefore, option D is not necessary
The nurse is concerned about infection for a client after an esophagogastrostomy
for esophageal cancer. Which actions should the nurse include in the client's plan
of care? (Select all that apply.)
A. Frequent oral care every 2 hours while awake.
B. Use an incentive spirometer every 2 hours.
C. Empty contents from the NG tube every 8 hours.
D. Ambulate within 1 hour of return from the PACU.E. Limit visitors until
postoperative day 2. - ANSWER- A. Frequent oral care every 2 hours while
awake.
B. Use an incentive spirometer every 2 hours.
C. Empty contents from the NG tube every 8 hours.
Rationale:
One hour post op is too soon to ambulate for this client. Visitors help
support the patient and are encouraged to visit. Oral care is necessary as the client
will be NPO. To decrease the risk of infection post operatively, implement routine
pulmonary exercises. The client will have an NG tube in place, likely to
intermittent suction, to decompress the stomach post surgery.
The client is returned demonstrating wrapping of the left limb amputated above the
knee. The nurse evaluates whether the client is starting the wrapping method
correctly when the client places the end of the bandage at which point.
A. Around the waist
,B. The inner aspect of the left stump
C. The outer aspect of the left stump
D. At the left groin area - ANSWER- A. Around the waist
Rationale:
The waist is the anchor point for the bandage for an above the knee
amputation.
A nurse is assisting an 82-year-old client with ambulation and is concerned that the
client may fall. Which area contains the older person's center of gravity?
A. Head and neck
B. Upper torso
C. Bilateral arms
D. Feet and legs - ANSWER- B. Upper torso
Rationale:
Stooped posture results in the upper torso becoming the center of gravity
for older persons. The center of gravity for adults is the hips. However, as a person
grows older, a stooped posture is common because of changes caused by
osteoporosis and normal bone degeneration. Furthermore, the knees, hips, and
elbows flex. The head and neck and feet and legs are not the center of gravity in
the older adult. Although the arms comprise a part of the upper torso, they do not
reflect the best and most complete answer.
The nurse is providing care for a client diagnosed with trigeminal neuralgia (tic
douloureux). Which symptoms will the nurse be looking for in the focused
assessment related to this condition? (Select all that apply.)
, A. Facial muscle spasms
B. Sudden facial pain
C. Unilateral facial weakness
D. Difficulty in chewing
E. Tinnitus
F. Hearing difficulties - ANSWER- A. Facial muscle spasms
B. Sudden facial pain
Rationale:
Trigeminal neuralgia is characterized by paroxysms of pain, similar to an
electric shock, in the area innervated by one or more branches of the trigeminal
nerve (cranial V). The remaining symptoms are not related to trigeminal neuralgia.
In caring for a client with acute diverticulitis, which assessment data warrants
immediate nursing action?
A. The client has a rigid hard abdomen and elevated WBC.
B. The client has left lower quadrant pain and an elevated temperature.
C. The client is refusing to eat any of the meals and is complaining of nausea.
D. The client has not had a bowel movement in 2 days and has a soft abdomen. -
ANSWER- A. The client has a rigid hard abdomen and elevated WBC.
Rationale:
A hard rigid abdomen and elevated WBC is indicative of peritonitis,
which is a medical emergency and should be reported to the health care provider
immediately. Options B and C are expected clinical manifestations of diverticulitis.
Option D does not warrant immediate intervention.
