**HESI Med Surg AUGUST 2025**
. A client with chronic kidney disease is started on hemodialysis. During the first dialysis
treatment, the clients blood pressure drops mmHg to 80/30 mmHg. Which action should
the nurse take first? - correct answerLower the head of the chair and elevate feet
. A client with pheochromocytoma reports the onset of a severe headache. The nurse
observes that the client is very diaphoretic. Which assessment data should the nurse
obtain next? - correct answerBlood pressure
. An adult who was recently diagnosed with glaucoma tells the nurse, "it feels like I am
driving through a tunnel." The client expresses great concern about going blind. Which
nursing instruction is most important for the nurse to provide this client? - correct
answerMaintain prescribed eye drop regimen.
. While assessing a client with degenerative joint disease, the nurse observes
Heberdens nodes, large prominences on the clients fingers that are reddened. The
client reports that the nodes are painful. Which action should the nurse take? - correct
answerDiscuss approaches to chronic pain control with the client
.A client receives a prescription for 1 liter of lacted ringers intravenously to be infused
over 6 hours. How many ml/hr should the nurse program the infusion pump to deliver? -
correct answer167 mL
A client is admitted to the medical unit during an exacerbation of systemic lupus
erythematosus (SLE). It is most important to report which assessment finding to the
health care provider? - correct answerHematuria
A client is hospitalized with heart failure (HF). Which intervention should the nurse
implement to improve ventilation and reduce venous return? - correct answerPlace the
client in high Fowler position
A client is recovering from a transurethral prostatectomy. Which activity should we
limited until the first postoperative visit with his health care provider? - correct
answerDriving in a car.
A client presents with the onset of a severe headache, fever, nuchal rigidity, and
petechial rash on arms and legs. The nurse recognizes the client is exhibiting symptoms
of which condition? - correct answer
A client reporting chest pain and shortness of breath receives an electrocardiogram
which shows ST elevation. The nurse notes the clients troponin level is 1.1 ng/mL.
Which complication should the nurse recognize the client is at risk for developing? -
correct answerPrerenal kidney injury
, A client tells the clinic nurse about experiencing burning on urination and assessment
reveals that the client had sexual intercourse four days ago with a person who has
casually met. Which action should the nurse implement? - correct answerObtain a
specimen of urethral drainage for culture
A client who had a C5 spinal cord injury 2 years ago is admitted to the emergency
department with the diagnosis of autonomic dysreflexia secondary to a full bladder.
Which assessment finding should the nurse expect this client to exhibit? - correct
answerProfuse diaphoresis and severe, pounding headache
A client who had colon surgery 3 days ago is anxious and requesting assistance to
reposition. While the nurse is turning the client, the wound dehiscence's and
eviscerates. The nurse moistens an available sterile dressing and places it over the
wound. Which intervention should the nurse implement next? - correct answerPrepare
the client to return to the operating room
A client who has a history of hypothyroidism was initially admitted with lethargy and
confusion. Which additional finding warrants the most immediate action by the nurse? -
correct answerFurther decline in level of consciousness
A client with a history of asthma and bronchitis arrives at the clinic with shortness of
breath, productive cough with thickened, tenacious mucous and the inability to walk up
a flight of stairs without experiencing breathlessness. Which action is most important for
the nurse to instruct the client about self care? - correct answerIncrease the daily intake
of oral fluids to liquefy secretions
A client with cholelithiasis is admitted with jaundice due to obstruction of the common
bile duct. Which finding is most important for the nurse to report to the healthcare
provider? - correct answerDistended, hard, and rigid abdomen
A client with Cushing's disease is admitted to the medical unit with uncontrolled
hypertension. Which intervention should the nurse implement for this client? (Select all
that apply) - correct answerMonitor serum glucose
Obtain daily weights
Promote verbalization of feelings
A client with draining skin lesions of the lower extremity is admitted with possible
Methicillin-resistant staphylococcus aureus (MRSA) which nursing intervention should
the nurse include in the plan of care? (Select all that apply) - correct answera. Monitor
the clients white blood cell count
b. Send wound drainage for culture and sensitivity
. A client with chronic kidney disease is started on hemodialysis. During the first dialysis
treatment, the clients blood pressure drops mmHg to 80/30 mmHg. Which action should
the nurse take first? - correct answerLower the head of the chair and elevate feet
. A client with pheochromocytoma reports the onset of a severe headache. The nurse
observes that the client is very diaphoretic. Which assessment data should the nurse
obtain next? - correct answerBlood pressure
. An adult who was recently diagnosed with glaucoma tells the nurse, "it feels like I am
driving through a tunnel." The client expresses great concern about going blind. Which
nursing instruction is most important for the nurse to provide this client? - correct
answerMaintain prescribed eye drop regimen.
. While assessing a client with degenerative joint disease, the nurse observes
Heberdens nodes, large prominences on the clients fingers that are reddened. The
client reports that the nodes are painful. Which action should the nurse take? - correct
answerDiscuss approaches to chronic pain control with the client
.A client receives a prescription for 1 liter of lacted ringers intravenously to be infused
over 6 hours. How many ml/hr should the nurse program the infusion pump to deliver? -
correct answer167 mL
A client is admitted to the medical unit during an exacerbation of systemic lupus
erythematosus (SLE). It is most important to report which assessment finding to the
health care provider? - correct answerHematuria
A client is hospitalized with heart failure (HF). Which intervention should the nurse
implement to improve ventilation and reduce venous return? - correct answerPlace the
client in high Fowler position
A client is recovering from a transurethral prostatectomy. Which activity should we
limited until the first postoperative visit with his health care provider? - correct
answerDriving in a car.
A client presents with the onset of a severe headache, fever, nuchal rigidity, and
petechial rash on arms and legs. The nurse recognizes the client is exhibiting symptoms
of which condition? - correct answer
A client reporting chest pain and shortness of breath receives an electrocardiogram
which shows ST elevation. The nurse notes the clients troponin level is 1.1 ng/mL.
Which complication should the nurse recognize the client is at risk for developing? -
correct answerPrerenal kidney injury
, A client tells the clinic nurse about experiencing burning on urination and assessment
reveals that the client had sexual intercourse four days ago with a person who has
casually met. Which action should the nurse implement? - correct answerObtain a
specimen of urethral drainage for culture
A client who had a C5 spinal cord injury 2 years ago is admitted to the emergency
department with the diagnosis of autonomic dysreflexia secondary to a full bladder.
Which assessment finding should the nurse expect this client to exhibit? - correct
answerProfuse diaphoresis and severe, pounding headache
A client who had colon surgery 3 days ago is anxious and requesting assistance to
reposition. While the nurse is turning the client, the wound dehiscence's and
eviscerates. The nurse moistens an available sterile dressing and places it over the
wound. Which intervention should the nurse implement next? - correct answerPrepare
the client to return to the operating room
A client who has a history of hypothyroidism was initially admitted with lethargy and
confusion. Which additional finding warrants the most immediate action by the nurse? -
correct answerFurther decline in level of consciousness
A client with a history of asthma and bronchitis arrives at the clinic with shortness of
breath, productive cough with thickened, tenacious mucous and the inability to walk up
a flight of stairs without experiencing breathlessness. Which action is most important for
the nurse to instruct the client about self care? - correct answerIncrease the daily intake
of oral fluids to liquefy secretions
A client with cholelithiasis is admitted with jaundice due to obstruction of the common
bile duct. Which finding is most important for the nurse to report to the healthcare
provider? - correct answerDistended, hard, and rigid abdomen
A client with Cushing's disease is admitted to the medical unit with uncontrolled
hypertension. Which intervention should the nurse implement for this client? (Select all
that apply) - correct answerMonitor serum glucose
Obtain daily weights
Promote verbalization of feelings
A client with draining skin lesions of the lower extremity is admitted with possible
Methicillin-resistant staphylococcus aureus (MRSA) which nursing intervention should
the nurse include in the plan of care? (Select all that apply) - correct answera. Monitor
the clients white blood cell count
b. Send wound drainage for culture and sensitivity
