NCLEX (HESI Med Surg Exam: Questions & Answers
Which method elicits the most accurate information during a physical assessment of an older client? -
ANSWER:Use reliable assessment tools for older adults
A client who has just tested positive for HIV does not appear to hear what the nurse is saying during
post-test counseling. Which information should the nurse offer to facilitate the client's adjustment to HIV
infection? - ANSWER:Discuss retesting to verify the results, which will ensure continuing contact and give
the patient support and hope, as well as time to cope
The nurse is caring for a client with HIV who develops Mycobacterium avium complex. What is the most
significant desired outcome for this patient? - ANSWER:Return to pre-illness weight
MAC is an opportunistic infection that presents like TB
MAC is a major contributing factor to development of wasting syndrome so adequate nutrition and
return to pre-illness weight is priority
A client who had abdominal surgery two days ago has prescriptions for IV morphine sulfate 4 mg every 2
hours and clear liquid diet. Client complains of feeling distended and has sharp, cramping gas pains.
What nursing intervention should be implemented? - ANSWER:Assist the client to ambulate in the hall
A client with Meniere's disease is incapacitated by vertigo and is lying in bed grasping the side rails and
staring at the television. Which nursing intervention should the nurse implement? - ANSWER:Turn off the
television and darken the room.
Any visual stimuli or rotational movement should be minimized
A client who has chronic cough with blood-tinged sputum returns to the unit after a bronchoscopy. What
nursing interventions should be implemented in the immediate post-procedural period? - ANSWER:NPO
until gag reflex returns
Prior to bronchoscopy the nasal pharynx and pharynx are anesthetized and bronchoscope is coated with
lidocaine to inhibit gag reflex during insertion.
The nurse is assessing a client with a cuffed tracheostomy tube in place who is breathing spontaneously.
To evaluate if the client can tolerate cuff deflation to promote speaking and swallowing, what action
should the nurse implement? - ANSWER:Observe the client for coughing colored sputum after drinking a
small amount of colored water
What assessment finding should the nurse identify that indicates a client with an acute asthma
exacerbation is beginning to improve after treatment? - ANSWER:Wheezing becomes louder as airways
(that were initially so restricted wheezing was absent) successfully respond to bronchodilators
A client with sickle cell anemia is admitted with severe abdominal pain and the diagnosis is sickle cell
crisis. What is the most important nursing action to implement? - ANSWER:Evaluate the effectiveness of
narcotic analgesics because pain management is priority for patient during sickle cell crisis
,The nurse is caring for a client with non-Hodgkin's lymphoma who is receiving chemotherapy. Lab results
reveal platelet count of 10,000/mL. What action should the nurse implement? - ANSWER:Check stools
for occult blood because platelets less than 100,000/mL are indicative of thrombocytopenia (a common
side effect of chemotherapy)
A client is admitted for complaints of chest pain and aching for the past 4 days. The results for serum
creatinine kinase-MB (CK-MB) and troponin levels are obtained. What rationale should the nurse use to
evaluate lab findings? - ANSWER:Myocardial damage that occurred several days early is best validated by
serum troponin levels.
**CK-MB and troponin are 2 most important cardiac markers for MI
A male client with chronic atrial fibrillation and a slow ventricular response is scheduled for surgical
placement of a permanent pacemaker. The client asks the nurse how this device will help him. How
should the nurse explain the action of a synchronous pacemaker? - ANSWER:An electrical stimulus is
discharged when no ventricular response is sensed.
Synchronous - impulse generated on demand or as needed according to patient intrinsic rhythm
A man who smokes two packs of cigarettes a day wants to know if smoking is contributing to the
difficulty that he and his wife are having getting pregnant. What information is best for the nurse to
provide? - ANSWER:Smoking can decrease quantity and quality of sperm
The first semen analysis should be repeated to confirm sperm counts
Cessation of smoking improves general health and fertility
The nurse is providing postoperative instructions for a female client after a mastectomy. Which
information should the nurse include in the teaching plan? - ANSWER:Report inflammation of the
incision site or affected arm
Avoid lifting more than 4.5 kg (10lb) or reaching above head
A client in the preoperative holding area receives a prescription for midazolam (Versed) IV. The nurse
determines that the surgical consent form needs to be signed by the client. Which action should the
nurse implement? - ANSWER:Withhold the drug until the client validates understanding of the surgical
procedure and signs the consent form.
The HCP should explain procedure to client before arriving to the preoperative area
A client with acute osteomyelitis has undergone surgical debridement of the diseased bone and asks the
nurse how long will antibiotics have to be administered. Which information should the nurse
communicate? - ANSWER:Parenteral antibiotics for 4-8 weeks then oral antibiotics for 4-8 weeks.
The nurse is preparing an adult client for an upper GI series. Which information should the nurse include
in the teaching plan? - ANSWER:Nothing by mouth is allowed for 6-8 hours before the study
The nurse is caring for a client scheduled to undergo insertion of a percutaneous endoscopic
gastrostomy (PEG) tube. The client asked the nurse to explain how a PEG tube differs from a gastrostomy
tube (GT). Which explanation best describes how they are different? - ANSWER:Method of insertion.
, GT - incision in the wall of the abdomen and suturing the tube to the gastric wall.
PEG - inserted with endoscopic visualization through the esophagus into the stomach and then pulled
through a stab wound in the abdominal wall.
The HCP prescribes high-protein, high-fat, low-carbohydrate diet with limited fluids during meals for a
client recovering from gastric surgery. The client asks the nurse what the purpose is for this type of diet.
Which rationale should be included in the nurse's explanation to this client? - ANSWER:This type of diet
is slowly digested and is slow to leave the stomach
The nurse is caring for a client with a small bowel obstruction. The client is vomiting foul smelling fecal-
like material. What action should the nurse implement? - ANSWER:Give IV fluids with electrolytes
What instruction should the nurse include in the discharge teaching for a client who needs to perform
self-catheterization technique at home? - ANSWER:Catheterize every 3-4 hours.
Sterile technique used at hospital but clean technique used at home
A client's prostate-specific antigen (PSA) exam result showed a PSA density of 0.13 ng/ml. Which
conclusion regarding this lab data is accurate? - ANSWER:Low risk for prostate cancer
PSA density <0.15 ng/mL = low risk
The nurse is caring for a client after transurethral resection of the prostate and determines the client's
urinary catheter is not draining. What should the nurse implement? - ANSWER:Irrigate the catheter
because blood clots after TURPs commonly cause obstruction of urinary flow
A male client with a prostatic stent is preparing for discharge. What should the nurse ensure the client
understands? - ANSWER:The client should not be catheterized through the stent for at least 3 months
When teaching a client with breast cancer about the prescribed radiation therapy for treatment, what
information is important to include? - ANSWER:Dry, itchy skin changes may occur
Side effects from breast cancer radiation most often include temporary skin changes: dryness,
tenderness, redness, swelling, pruritis
The nurse is caring for a client receiving tamoxifen (Nolvadex) for treatment of breast cancer. Which
action should the nurse include in the client's plan of care? - ANSWER:Assist client in coping with hot
flashes because tamoxifen (estrogen receptor blocking agent) can cause hot flashes
The nurse is assessing a middle-aged male client for risk factors related to chronic illness. Which finding
should the nurse assess further? - ANSWER:Increase in abdominal fat deposits because this may be
indicative of metabolic syndrome which places client at risk for cardiac disease
What is the priority nursing action while caring for a client on a ventilator when an electrical fire occurs
in the intensive care unit? - ANSWER:Use a bag-valve-mask resuscitator while removing the client from
the area
Unplugging the patient and moving them away from oxygen sources during a fire promotes client safety
Which method elicits the most accurate information during a physical assessment of an older client? -
ANSWER:Use reliable assessment tools for older adults
A client who has just tested positive for HIV does not appear to hear what the nurse is saying during
post-test counseling. Which information should the nurse offer to facilitate the client's adjustment to HIV
infection? - ANSWER:Discuss retesting to verify the results, which will ensure continuing contact and give
the patient support and hope, as well as time to cope
The nurse is caring for a client with HIV who develops Mycobacterium avium complex. What is the most
significant desired outcome for this patient? - ANSWER:Return to pre-illness weight
MAC is an opportunistic infection that presents like TB
MAC is a major contributing factor to development of wasting syndrome so adequate nutrition and
return to pre-illness weight is priority
A client who had abdominal surgery two days ago has prescriptions for IV morphine sulfate 4 mg every 2
hours and clear liquid diet. Client complains of feeling distended and has sharp, cramping gas pains.
What nursing intervention should be implemented? - ANSWER:Assist the client to ambulate in the hall
A client with Meniere's disease is incapacitated by vertigo and is lying in bed grasping the side rails and
staring at the television. Which nursing intervention should the nurse implement? - ANSWER:Turn off the
television and darken the room.
Any visual stimuli or rotational movement should be minimized
A client who has chronic cough with blood-tinged sputum returns to the unit after a bronchoscopy. What
nursing interventions should be implemented in the immediate post-procedural period? - ANSWER:NPO
until gag reflex returns
Prior to bronchoscopy the nasal pharynx and pharynx are anesthetized and bronchoscope is coated with
lidocaine to inhibit gag reflex during insertion.
The nurse is assessing a client with a cuffed tracheostomy tube in place who is breathing spontaneously.
To evaluate if the client can tolerate cuff deflation to promote speaking and swallowing, what action
should the nurse implement? - ANSWER:Observe the client for coughing colored sputum after drinking a
small amount of colored water
What assessment finding should the nurse identify that indicates a client with an acute asthma
exacerbation is beginning to improve after treatment? - ANSWER:Wheezing becomes louder as airways
(that were initially so restricted wheezing was absent) successfully respond to bronchodilators
A client with sickle cell anemia is admitted with severe abdominal pain and the diagnosis is sickle cell
crisis. What is the most important nursing action to implement? - ANSWER:Evaluate the effectiveness of
narcotic analgesics because pain management is priority for patient during sickle cell crisis
,The nurse is caring for a client with non-Hodgkin's lymphoma who is receiving chemotherapy. Lab results
reveal platelet count of 10,000/mL. What action should the nurse implement? - ANSWER:Check stools
for occult blood because platelets less than 100,000/mL are indicative of thrombocytopenia (a common
side effect of chemotherapy)
A client is admitted for complaints of chest pain and aching for the past 4 days. The results for serum
creatinine kinase-MB (CK-MB) and troponin levels are obtained. What rationale should the nurse use to
evaluate lab findings? - ANSWER:Myocardial damage that occurred several days early is best validated by
serum troponin levels.
**CK-MB and troponin are 2 most important cardiac markers for MI
A male client with chronic atrial fibrillation and a slow ventricular response is scheduled for surgical
placement of a permanent pacemaker. The client asks the nurse how this device will help him. How
should the nurse explain the action of a synchronous pacemaker? - ANSWER:An electrical stimulus is
discharged when no ventricular response is sensed.
Synchronous - impulse generated on demand or as needed according to patient intrinsic rhythm
A man who smokes two packs of cigarettes a day wants to know if smoking is contributing to the
difficulty that he and his wife are having getting pregnant. What information is best for the nurse to
provide? - ANSWER:Smoking can decrease quantity and quality of sperm
The first semen analysis should be repeated to confirm sperm counts
Cessation of smoking improves general health and fertility
The nurse is providing postoperative instructions for a female client after a mastectomy. Which
information should the nurse include in the teaching plan? - ANSWER:Report inflammation of the
incision site or affected arm
Avoid lifting more than 4.5 kg (10lb) or reaching above head
A client in the preoperative holding area receives a prescription for midazolam (Versed) IV. The nurse
determines that the surgical consent form needs to be signed by the client. Which action should the
nurse implement? - ANSWER:Withhold the drug until the client validates understanding of the surgical
procedure and signs the consent form.
The HCP should explain procedure to client before arriving to the preoperative area
A client with acute osteomyelitis has undergone surgical debridement of the diseased bone and asks the
nurse how long will antibiotics have to be administered. Which information should the nurse
communicate? - ANSWER:Parenteral antibiotics for 4-8 weeks then oral antibiotics for 4-8 weeks.
The nurse is preparing an adult client for an upper GI series. Which information should the nurse include
in the teaching plan? - ANSWER:Nothing by mouth is allowed for 6-8 hours before the study
The nurse is caring for a client scheduled to undergo insertion of a percutaneous endoscopic
gastrostomy (PEG) tube. The client asked the nurse to explain how a PEG tube differs from a gastrostomy
tube (GT). Which explanation best describes how they are different? - ANSWER:Method of insertion.
, GT - incision in the wall of the abdomen and suturing the tube to the gastric wall.
PEG - inserted with endoscopic visualization through the esophagus into the stomach and then pulled
through a stab wound in the abdominal wall.
The HCP prescribes high-protein, high-fat, low-carbohydrate diet with limited fluids during meals for a
client recovering from gastric surgery. The client asks the nurse what the purpose is for this type of diet.
Which rationale should be included in the nurse's explanation to this client? - ANSWER:This type of diet
is slowly digested and is slow to leave the stomach
The nurse is caring for a client with a small bowel obstruction. The client is vomiting foul smelling fecal-
like material. What action should the nurse implement? - ANSWER:Give IV fluids with electrolytes
What instruction should the nurse include in the discharge teaching for a client who needs to perform
self-catheterization technique at home? - ANSWER:Catheterize every 3-4 hours.
Sterile technique used at hospital but clean technique used at home
A client's prostate-specific antigen (PSA) exam result showed a PSA density of 0.13 ng/ml. Which
conclusion regarding this lab data is accurate? - ANSWER:Low risk for prostate cancer
PSA density <0.15 ng/mL = low risk
The nurse is caring for a client after transurethral resection of the prostate and determines the client's
urinary catheter is not draining. What should the nurse implement? - ANSWER:Irrigate the catheter
because blood clots after TURPs commonly cause obstruction of urinary flow
A male client with a prostatic stent is preparing for discharge. What should the nurse ensure the client
understands? - ANSWER:The client should not be catheterized through the stent for at least 3 months
When teaching a client with breast cancer about the prescribed radiation therapy for treatment, what
information is important to include? - ANSWER:Dry, itchy skin changes may occur
Side effects from breast cancer radiation most often include temporary skin changes: dryness,
tenderness, redness, swelling, pruritis
The nurse is caring for a client receiving tamoxifen (Nolvadex) for treatment of breast cancer. Which
action should the nurse include in the client's plan of care? - ANSWER:Assist client in coping with hot
flashes because tamoxifen (estrogen receptor blocking agent) can cause hot flashes
The nurse is assessing a middle-aged male client for risk factors related to chronic illness. Which finding
should the nurse assess further? - ANSWER:Increase in abdominal fat deposits because this may be
indicative of metabolic syndrome which places client at risk for cardiac disease
What is the priority nursing action while caring for a client on a ventilator when an electrical fire occurs
in the intensive care unit? - ANSWER:Use a bag-valve-mask resuscitator while removing the client from
the area
Unplugging the patient and moving them away from oxygen sources during a fire promotes client safety
