Med Surg 1 HESI Final Exam 2 Questions with
Correct Solutions
1.1. A nurse is visiting a client who is receiving home health care, focusing
on medication and dietary instructions and management of heart failure.
The nurse should reinforce which instruction?
A.) If you feel tired and short of breath, lie down flat and prop up your feet.
B.) Eating liver several times a week will help build up your strength.
C.) Your daily dose of furosemide should be taken first thing in the morning.
D.) The dose of enalapril will help prevent vasodilation from occurring.:
An- swer: C
2.2. A nurse planning care for a client who has undergone transurethral
resection of the prostate (TURP) remembers that the most common cause
of postoperative pain is which factor?
A.) Bladder spasms
B.) Bleeding within the bladder
C.) The location of the incision
D.) Tension on the Foley catheter: Answer: A
3.3. A nurse assessing the skin of a client who is immobile notes this
change in appearance of the skin in the sacral area:
The nurse documents this finding in which way?
A.) Stage I pressure ulcer
B.) Stage II pressure ulcer
C.) Stage III pressure ulcer
D.) Stage IV pressure ulcer: Answer: A
4.4. A nurse reinforces teaching given to a client with gastroesophageal
reflux disease (GERD) about measures to manage the disease. What does
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,the nurse encourage the client to do to obtain relief of the symptoms?
A.) Limit intake of coffee and tea.
B.) Eat three large, well-balanced meals per day.
C.) Rest in a supine position for 30 minutes after each meal.
D.) Elevate the head of the bed at least 6 to 8 inches for sleep.: Answer: D
5.5. A nurse provides instructions to a client who is taking allopurinol for
the treatment of gout. Which statements by the client indicate an
understanding of the medication?
A.) "I need to take the medication 1 hour before I eat."
B.) "I need to drink at least 8 glasses of fluid every day."
C. "I'll start taking a vitamin C supplement each morning."
D.) "I can use an antihistamine lotion if I get an itchy rash.": Answer: B
6.6. A client with phantom limb pain has decided to use transcutaneous
electrical nerve stimulation (TENS) as prescribed by the health care
provider. The nurse reinforces instructions regarding the use of the TENS
unit. Which statements by the client indicate a need for further instruction
regarding this pain-relief measure?
A.) "I'm so glad this will help relieve the pain."
B.) "Now I won't need to take so many pain medications."
C.) "I need to put the electrodes on the areas that you marked."
D.) "I'm not sure I'm going to like having those electrodes attached to
my skin.": Answer: C
7.7. A hospitalized client has just been found to have acute renal failure
(ARF). The laboratory calls the nursing unit and reports that the client has a
serum potassium level of 6.4 mEq/L. On the basis of this laboratory finding,
the nurse should first take which action?
A.) Call the health care provider
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, B.) Check the client's sodium level
C.) Encourage the client to increase fluid intake
D.) Have the client decrease intake of potassium-rich foods: Answer: A
8.8. A nurse is caring for a client who has just had a plaster leg cast
applied. Which measure does the nurse implement to prevent the
development of compartment syndrome?
A.) Elevating the limb and applying ice to the affected leg
B.) Elevating the limb and covering the limb with bath blankets
C.) Keeping the leg horizontal and applying ice to the affected leg
D.) Placing the leg in a slightly dependent position and applying ice to
the affected leg: Answer: A
9.9. On the first day after undergoing total knee arthroplasty, the client tells
the nurse that he is experiencing pain when he extends his leg. The nurse
should take which action?
A.) Notify the health care provider immediately
B.) Administer an analgesic and evaluate the response
C.) Immobilize the knee temporarily and contact the health care provider
to report pain
D.) Put the client's knee through full passive range of motion to
assess tolerance: Answer: B
10.10. A nurse in the emergency department is assisting with data
collection from a client who sustained an open leg fracture in a fall from a
ladder. Which question is most important for the nurse to ask the client?
A.) "When was your last tetanus vaccine?"
B.) "Have you ever had a tuberculin test?"
C.) "Have you had a chest x-ray recently?"
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Correct Solutions
1.1. A nurse is visiting a client who is receiving home health care, focusing
on medication and dietary instructions and management of heart failure.
The nurse should reinforce which instruction?
A.) If you feel tired and short of breath, lie down flat and prop up your feet.
B.) Eating liver several times a week will help build up your strength.
C.) Your daily dose of furosemide should be taken first thing in the morning.
D.) The dose of enalapril will help prevent vasodilation from occurring.:
An- swer: C
2.2. A nurse planning care for a client who has undergone transurethral
resection of the prostate (TURP) remembers that the most common cause
of postoperative pain is which factor?
A.) Bladder spasms
B.) Bleeding within the bladder
C.) The location of the incision
D.) Tension on the Foley catheter: Answer: A
3.3. A nurse assessing the skin of a client who is immobile notes this
change in appearance of the skin in the sacral area:
The nurse documents this finding in which way?
A.) Stage I pressure ulcer
B.) Stage II pressure ulcer
C.) Stage III pressure ulcer
D.) Stage IV pressure ulcer: Answer: A
4.4. A nurse reinforces teaching given to a client with gastroesophageal
reflux disease (GERD) about measures to manage the disease. What does
1/
19
,the nurse encourage the client to do to obtain relief of the symptoms?
A.) Limit intake of coffee and tea.
B.) Eat three large, well-balanced meals per day.
C.) Rest in a supine position for 30 minutes after each meal.
D.) Elevate the head of the bed at least 6 to 8 inches for sleep.: Answer: D
5.5. A nurse provides instructions to a client who is taking allopurinol for
the treatment of gout. Which statements by the client indicate an
understanding of the medication?
A.) "I need to take the medication 1 hour before I eat."
B.) "I need to drink at least 8 glasses of fluid every day."
C. "I'll start taking a vitamin C supplement each morning."
D.) "I can use an antihistamine lotion if I get an itchy rash.": Answer: B
6.6. A client with phantom limb pain has decided to use transcutaneous
electrical nerve stimulation (TENS) as prescribed by the health care
provider. The nurse reinforces instructions regarding the use of the TENS
unit. Which statements by the client indicate a need for further instruction
regarding this pain-relief measure?
A.) "I'm so glad this will help relieve the pain."
B.) "Now I won't need to take so many pain medications."
C.) "I need to put the electrodes on the areas that you marked."
D.) "I'm not sure I'm going to like having those electrodes attached to
my skin.": Answer: C
7.7. A hospitalized client has just been found to have acute renal failure
(ARF). The laboratory calls the nursing unit and reports that the client has a
serum potassium level of 6.4 mEq/L. On the basis of this laboratory finding,
the nurse should first take which action?
A.) Call the health care provider
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, B.) Check the client's sodium level
C.) Encourage the client to increase fluid intake
D.) Have the client decrease intake of potassium-rich foods: Answer: A
8.8. A nurse is caring for a client who has just had a plaster leg cast
applied. Which measure does the nurse implement to prevent the
development of compartment syndrome?
A.) Elevating the limb and applying ice to the affected leg
B.) Elevating the limb and covering the limb with bath blankets
C.) Keeping the leg horizontal and applying ice to the affected leg
D.) Placing the leg in a slightly dependent position and applying ice to
the affected leg: Answer: A
9.9. On the first day after undergoing total knee arthroplasty, the client tells
the nurse that he is experiencing pain when he extends his leg. The nurse
should take which action?
A.) Notify the health care provider immediately
B.) Administer an analgesic and evaluate the response
C.) Immobilize the knee temporarily and contact the health care provider
to report pain
D.) Put the client's knee through full passive range of motion to
assess tolerance: Answer: B
10.10. A nurse in the emergency department is assisting with data
collection from a client who sustained an open leg fracture in a fall from a
ladder. Which question is most important for the nurse to ask the client?
A.) "When was your last tetanus vaccine?"
B.) "Have you ever had a tuberculin test?"
C.) "Have you had a chest x-ray recently?"
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