MED SURG HESI BSN LATEST
266
A client with Type I diabetes mellitus (DM) is admitted for an
emergency cholecystectomy. To prevent diabetic ketoacidosis
(DKA), which intervention is most important for the nurse to
implement?
Supplement insulin needs using a sliding scale
A client with metastatic cancer who was taking hydromorphone
(Dilaudid) PO at home is not receiving the medication IV while in
the hospital. To evaluate if the client is receiving an equianalgesic
dose of the Dilaudid, what assessment should the nurse complete?
pain scale
The nurse observes a newly-employed unlicensed assistive personnel
(UAP) taking an elderly client’s blood pressure. The nurse says,
“You need to start over. The blood pressure reading you obtained
was falsely high for that client.” What is the most likely explanation
for the erroneous reading?
The size of the cuff used was too small for this adult client’s arm
Which activity is best for the nurse to initiate with a depressed
client?
Make cut-out cookies
A postoperative client returns to the nursing unit following a
ureterolithotomy via a flank incision. Which potential nursing
END OF
PAGE
1
, MED SURG HESI BSN LATEST
266
problem has the highest priority when planning nursing care for
this client?
Ineffective airway clearance
When the nurse enters the room to change the dressing of a male
client with cancer, he asks, “have you ever been with someone when
they died?” Best response?
“Yes I have. Do you have questions about dying?”
The nurse is assessing a client on the first postoperative day
following thyroid surgery. Which laboratory value is most
important for the nurse to monitor?
calcium
Several clients on a telemetry unit are scheduled for discharge in the
morning, but a telemetry-monitored bed is needed immediately. The
charge nurse should make arrangements to transfer which client to
another medical unit?
Learning to self-administer insulin injections after being diagnosed
with diabetes mellitus
The nurse preceptor is orienting a new graduate nurse to the critical
care unit. The preceptor asks the new graduate to state symptoms
that most likely indicate the beginning of a shock state in a critically
ill client. What findings should the new graduate nurse identify?
Tachycardia, mental status change, and low urine output
END OF
PAGE
2
, MED SURG HESI BSN LATEST
266
A client is diagnosed with a frontal lobe glioma, which is a benign
brain tumor. When teaching the client about the tumor, which
information should the nurse consider?
Personality changes or expressive aphasia are likely.
A client who has suffered 3rd degree burns over 60% of the body is
admitted to the emergency department. The healthcare provider
writes a prescription for “IV Lactated Ringer’s 350 ml/hr”. Which
intervention should the nurse implement?
Obtain an intravenous infusion pump prior to administering the IV.
A client just returned to the nursing unit after surgery, and initial
assessment findings include a pulse rate of 120 beats/minute,
restlessness, cyanosis, and gurgling sounds on inspiration and
expiration. What action should the nurse take first?
Perform oropharyngeal suctioning.
A female client comes to the clinic complaining of fatigue and
inability to sleep because she is the full-time caretaker for a 22-year-
old son who was paralyzed by a motor vehicle collision. She adds
that her husband left her because he says he can’t take her behavior
anymore since all she does is care for their son. What intervention
should the nurse implement?
Acknowledge the client’s stress and suggest that she consider respite
care.
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PAGE
3
, MED SURG HESI BSN LATEST
266
The nurse plans to administer a scheduled dose of metoprolol
(Toprol SR) at 0900 to a client with hypertension. At 0800, the nurse
notes that the client’s telemetry pattern shows a second-degree heart
block with a ventricular rate of 50. What action should the nurse
take?
Hold the scheduled dose of Toprol and notify the healthcare
provider of the telemetry pattern.
In shift report the charge nurse is told of several problems. Which
problem should the nurse address first?
A bucket of water was spilled in the hallway.
After receiving report on an inpatient acute care unit, which client
should the nurse asses first?
with a bowel obstruction due to a volvulus who is experiencing
abdominal rigidity.
A male client diagnosed with gastroesophageal reflux (GERD) often
wakes up at night experiencing heartburn. He tells the nurse that he
sleeps with the head of the bed on blocks, and always drinks a glass
of milk at bedtime to help him fall asleep. How should the nurse
respond?
“Drinking milk before bedtime can increase your symptoms at
night.”
END OF
PAGE
4
266
A client with Type I diabetes mellitus (DM) is admitted for an
emergency cholecystectomy. To prevent diabetic ketoacidosis
(DKA), which intervention is most important for the nurse to
implement?
Supplement insulin needs using a sliding scale
A client with metastatic cancer who was taking hydromorphone
(Dilaudid) PO at home is not receiving the medication IV while in
the hospital. To evaluate if the client is receiving an equianalgesic
dose of the Dilaudid, what assessment should the nurse complete?
pain scale
The nurse observes a newly-employed unlicensed assistive personnel
(UAP) taking an elderly client’s blood pressure. The nurse says,
“You need to start over. The blood pressure reading you obtained
was falsely high for that client.” What is the most likely explanation
for the erroneous reading?
The size of the cuff used was too small for this adult client’s arm
Which activity is best for the nurse to initiate with a depressed
client?
Make cut-out cookies
A postoperative client returns to the nursing unit following a
ureterolithotomy via a flank incision. Which potential nursing
END OF
PAGE
1
, MED SURG HESI BSN LATEST
266
problem has the highest priority when planning nursing care for
this client?
Ineffective airway clearance
When the nurse enters the room to change the dressing of a male
client with cancer, he asks, “have you ever been with someone when
they died?” Best response?
“Yes I have. Do you have questions about dying?”
The nurse is assessing a client on the first postoperative day
following thyroid surgery. Which laboratory value is most
important for the nurse to monitor?
calcium
Several clients on a telemetry unit are scheduled for discharge in the
morning, but a telemetry-monitored bed is needed immediately. The
charge nurse should make arrangements to transfer which client to
another medical unit?
Learning to self-administer insulin injections after being diagnosed
with diabetes mellitus
The nurse preceptor is orienting a new graduate nurse to the critical
care unit. The preceptor asks the new graduate to state symptoms
that most likely indicate the beginning of a shock state in a critically
ill client. What findings should the new graduate nurse identify?
Tachycardia, mental status change, and low urine output
END OF
PAGE
2
, MED SURG HESI BSN LATEST
266
A client is diagnosed with a frontal lobe glioma, which is a benign
brain tumor. When teaching the client about the tumor, which
information should the nurse consider?
Personality changes or expressive aphasia are likely.
A client who has suffered 3rd degree burns over 60% of the body is
admitted to the emergency department. The healthcare provider
writes a prescription for “IV Lactated Ringer’s 350 ml/hr”. Which
intervention should the nurse implement?
Obtain an intravenous infusion pump prior to administering the IV.
A client just returned to the nursing unit after surgery, and initial
assessment findings include a pulse rate of 120 beats/minute,
restlessness, cyanosis, and gurgling sounds on inspiration and
expiration. What action should the nurse take first?
Perform oropharyngeal suctioning.
A female client comes to the clinic complaining of fatigue and
inability to sleep because she is the full-time caretaker for a 22-year-
old son who was paralyzed by a motor vehicle collision. She adds
that her husband left her because he says he can’t take her behavior
anymore since all she does is care for their son. What intervention
should the nurse implement?
Acknowledge the client’s stress and suggest that she consider respite
care.
END OF
PAGE
3
, MED SURG HESI BSN LATEST
266
The nurse plans to administer a scheduled dose of metoprolol
(Toprol SR) at 0900 to a client with hypertension. At 0800, the nurse
notes that the client’s telemetry pattern shows a second-degree heart
block with a ventricular rate of 50. What action should the nurse
take?
Hold the scheduled dose of Toprol and notify the healthcare
provider of the telemetry pattern.
In shift report the charge nurse is told of several problems. Which
problem should the nurse address first?
A bucket of water was spilled in the hallway.
After receiving report on an inpatient acute care unit, which client
should the nurse asses first?
with a bowel obstruction due to a volvulus who is experiencing
abdominal rigidity.
A male client diagnosed with gastroesophageal reflux (GERD) often
wakes up at night experiencing heartburn. He tells the nurse that he
sleeps with the head of the bed on blocks, and always drinks a glass
of milk at bedtime to help him fall asleep. How should the nurse
respond?
“Drinking milk before bedtime can increase your symptoms at
night.”
END OF
PAGE
4
