HESI 101- MED SURGE HESI RN 2 LATEST
VERSIONS 2024-2025 WITH QUESTIONS AND
CORRECT ANSWERS|A GRADE
An older male client comes to the outpatient clinic complaining of pain in
his left calf. The nurse notices a reddened area on the calf of his right leg
that is warm to the touch, and the nurse suspects that the client may have
thrombophlebitis. Which additional assessment is most important for the
nurse to perform?
A. Measure the client's calf circumference
B. Auscultate the client's breath sounds
C. Observe for ecchymosis and petechiae
D. Obtain the client's blood pressure
B. Auscultate the client's breath sounds
All these techniques provide useful assessment data. The most important is to
auscultate the client's breath sounds because the client may have a pulmonary
embolus secondary to the thrombophlebitis. Option A may provide data that support
the nurse's suspicion of thrombophlebitis. Option C is the least helpful assessment
because bruising is not a typical finding associated with thrombophlebitis. Option D
is always useful in evaluating the client's response to a problem but is of less
immediate priority than breath sound auscultation.
The nurse is assessing a client who presents with jaundice. Which
assessment finding is most important for the nurse to follow up?
A. Urine specific gravity of 1.03
B. Frothy, tea-colored urine
C. Clay-colored stools
D. Elevated serum amylase and lipase levels
D. Elevated serum amylase and lipase levels
Obstructive cholelithiasis and alcoholism are the two major causes of pancreatitis,
and elevated serum amylase and lipase levels indicate pancreatic injury. Option A is
a normal finding. Options B and C are expected findings related to jaundice.
The nurse is assessing a male client with acute pancreatitis. Which finding
requires the most immediate intervention by the nurse?
A. The client's amylase level is three times higher than the normal level
B. While the nurse is taking the client's blood pressure, he has a carpal
spasm
C. On a 1 to 10 scale, the client tells the nurse that his epigastric pain is at
7
D. The client states that he will continue to drink alcohol after going home
VERSIONS 2024-2025 WITH QUESTIONS AND
CORRECT ANSWERS|A GRADE
An older male client comes to the outpatient clinic complaining of pain in
his left calf. The nurse notices a reddened area on the calf of his right leg
that is warm to the touch, and the nurse suspects that the client may have
thrombophlebitis. Which additional assessment is most important for the
nurse to perform?
A. Measure the client's calf circumference
B. Auscultate the client's breath sounds
C. Observe for ecchymosis and petechiae
D. Obtain the client's blood pressure
B. Auscultate the client's breath sounds
All these techniques provide useful assessment data. The most important is to
auscultate the client's breath sounds because the client may have a pulmonary
embolus secondary to the thrombophlebitis. Option A may provide data that support
the nurse's suspicion of thrombophlebitis. Option C is the least helpful assessment
because bruising is not a typical finding associated with thrombophlebitis. Option D
is always useful in evaluating the client's response to a problem but is of less
immediate priority than breath sound auscultation.
The nurse is assessing a client who presents with jaundice. Which
assessment finding is most important for the nurse to follow up?
A. Urine specific gravity of 1.03
B. Frothy, tea-colored urine
C. Clay-colored stools
D. Elevated serum amylase and lipase levels
D. Elevated serum amylase and lipase levels
Obstructive cholelithiasis and alcoholism are the two major causes of pancreatitis,
and elevated serum amylase and lipase levels indicate pancreatic injury. Option A is
a normal finding. Options B and C are expected findings related to jaundice.
The nurse is assessing a male client with acute pancreatitis. Which finding
requires the most immediate intervention by the nurse?
A. The client's amylase level is three times higher than the normal level
B. While the nurse is taking the client's blood pressure, he has a carpal
spasm
C. On a 1 to 10 scale, the client tells the nurse that his epigastric pain is at
7
D. The client states that he will continue to drink alcohol after going home
