Med Surg Hesi 2025
a 26 year old client is admitted to the hospital for treatment of simple goiter, and
levothyroxine is prescribed. Which symptom indicates to the nurse that the prescribed
dosage is too high for this client
1. palpitations and shortness of breath
2. bradycardia and constipation
3. lethargy and lack of appetite
4. muscle cramps and dry, flushed skin - correct answer1. palpitations and shortness of
breath
a client admitted yesterday with an MI and is having increased PVC's. Which
pathological change increases the frequency of disturbances following an MI?
1. cellular ischemia increases automaticity of myocardial cells
2. myocardial cells switch to anaerobic metabolism causing metabolic acidosis
3. infarction prolongs the refactory period in the cardiac cycle
4. potassium and ion movement across cell membrane is interupted - correct answer1
A client has an ANC of 500 after completing chemo. Which intervention is most
important for the nurse to implement?
1. Place in protective isolation
2. Implement bleeding precautions
3. Assess vs q4
4. Review the need for pneumococcal vaccine - correct answer1. Place in protective
isolation
A client has been taking finasteride for BPH to shrink the prostate gland gets admitted
to the hospital for continuing BPH symptoms. When planning care, which nursing
problem should the RN address first
1. urinary retention
2. disturbed sleep pattern
3. risk for infection
4. Chronic Pain - correct answer1. urinary retention
a client is admitted with acute diabetes insipidus and related hyperatremia. In planning
care, which clien data is most important for the nurse to obtain during the hourly nursing
assessment
1. bowel sounds
2. capillary glucose
3. pain level
4. mental status - correct answer4. mental status
A client is admitted with DKA and is having kussmaul's breathing, a severe headache
and nausea. Her ABG's are pH: 7.50, PaCO2 30, HCO3 24. Which assessment below
requires immediate nursing interventions
, 1. Mental stupor
2. muscle stiffness
3. fruity, breath
4. abdominal pain - correct answer1. mental stupor
A client is admitted with rapid atrial flutter is receiving amiodarone 1mg/min via a
peripheral line. The UAP reports to the nurse that the client's HR is 90 BPM, and BP is
110/50. Which intervention should the nurse implement?
1. tell the uap to turn off the amiodarone
2. restart the IV infusion in another site
3. Determine the regularity of the peripheral pulses
4. Evaluate the rhythm of the heart rate - correct answer$. Evaluate the rhythm of the
heart rate
A client is being treated for AKI. On exam the client has generalized edema and
changes in mental status. Which intervention should the nurse include in the client's
plan of care
1. measure the ankle circumference e
2. auscultate for irregular HR
3. Review ABG results
4. Measure and document urine output - correct answer4. measure and document urine
output
a client is being treated for SIADH. On examination the client has a weight gain of
4.4lbs. In 24 hours, and an elevated HR. Which intervention should the nurse implement
first?
1. Record usual eating patterns
2. Measure ankle circumference
3. Review ABG's
4. Enurse the client takes a diuretic every morning - correct answer4. Ensure the client
takes a diuretic every morning
a client is diagnosed with digoxin toxicity. Which action should the nurse expect to
implement?
1. check acid base and electrolyte values
2. give digoxin by another route
3. administer potassium to stabilize HR
4. Begin cardioversion to stabilize heart rhythm - correct answer1. check acid base and
electrolyte values
A client is in the ED after a motor vehicle accident with the following assessment
findings: altered mental status, SOB, lethargy, abg's pH 7.32, PaCO2 62, HCO3 36.
Which further assessment findings indicates the client is in a life threatening situation?
1. 10 seconds periods of apenic breathing
2. large amounts of gross hematuria
3. Peripheral cap refill greater 5 secs
a 26 year old client is admitted to the hospital for treatment of simple goiter, and
levothyroxine is prescribed. Which symptom indicates to the nurse that the prescribed
dosage is too high for this client
1. palpitations and shortness of breath
2. bradycardia and constipation
3. lethargy and lack of appetite
4. muscle cramps and dry, flushed skin - correct answer1. palpitations and shortness of
breath
a client admitted yesterday with an MI and is having increased PVC's. Which
pathological change increases the frequency of disturbances following an MI?
1. cellular ischemia increases automaticity of myocardial cells
2. myocardial cells switch to anaerobic metabolism causing metabolic acidosis
3. infarction prolongs the refactory period in the cardiac cycle
4. potassium and ion movement across cell membrane is interupted - correct answer1
A client has an ANC of 500 after completing chemo. Which intervention is most
important for the nurse to implement?
1. Place in protective isolation
2. Implement bleeding precautions
3. Assess vs q4
4. Review the need for pneumococcal vaccine - correct answer1. Place in protective
isolation
A client has been taking finasteride for BPH to shrink the prostate gland gets admitted
to the hospital for continuing BPH symptoms. When planning care, which nursing
problem should the RN address first
1. urinary retention
2. disturbed sleep pattern
3. risk for infection
4. Chronic Pain - correct answer1. urinary retention
a client is admitted with acute diabetes insipidus and related hyperatremia. In planning
care, which clien data is most important for the nurse to obtain during the hourly nursing
assessment
1. bowel sounds
2. capillary glucose
3. pain level
4. mental status - correct answer4. mental status
A client is admitted with DKA and is having kussmaul's breathing, a severe headache
and nausea. Her ABG's are pH: 7.50, PaCO2 30, HCO3 24. Which assessment below
requires immediate nursing interventions
, 1. Mental stupor
2. muscle stiffness
3. fruity, breath
4. abdominal pain - correct answer1. mental stupor
A client is admitted with rapid atrial flutter is receiving amiodarone 1mg/min via a
peripheral line. The UAP reports to the nurse that the client's HR is 90 BPM, and BP is
110/50. Which intervention should the nurse implement?
1. tell the uap to turn off the amiodarone
2. restart the IV infusion in another site
3. Determine the regularity of the peripheral pulses
4. Evaluate the rhythm of the heart rate - correct answer$. Evaluate the rhythm of the
heart rate
A client is being treated for AKI. On exam the client has generalized edema and
changes in mental status. Which intervention should the nurse include in the client's
plan of care
1. measure the ankle circumference e
2. auscultate for irregular HR
3. Review ABG results
4. Measure and document urine output - correct answer4. measure and document urine
output
a client is being treated for SIADH. On examination the client has a weight gain of
4.4lbs. In 24 hours, and an elevated HR. Which intervention should the nurse implement
first?
1. Record usual eating patterns
2. Measure ankle circumference
3. Review ABG's
4. Enurse the client takes a diuretic every morning - correct answer4. Ensure the client
takes a diuretic every morning
a client is diagnosed with digoxin toxicity. Which action should the nurse expect to
implement?
1. check acid base and electrolyte values
2. give digoxin by another route
3. administer potassium to stabilize HR
4. Begin cardioversion to stabilize heart rhythm - correct answer1. check acid base and
electrolyte values
A client is in the ED after a motor vehicle accident with the following assessment
findings: altered mental status, SOB, lethargy, abg's pH 7.32, PaCO2 62, HCO3 36.
Which further assessment findings indicates the client is in a life threatening situation?
1. 10 seconds periods of apenic breathing
2. large amounts of gross hematuria
3. Peripheral cap refill greater 5 secs
