MED/SURG NCLEX-RN HESI PRACTICE EXAM
Questions With Verified Answers And Explained Solutions
A client on telemetry has a pattern of uncontrolled atrial fibrillation
with a rapid ventricular response. Based on this finding, the nurse
anticipates assisting the physician with which treatment?
A. Administer lidocaine,75 mg intravenous push.
B.Perform synchronized cardioversion.
C
C. Defibrillate the client as soon as possible.
LE
D. Administer atropine, 0.4 mg intravenous push. - ANSWER--B
With uncontrolled atrial fibrillation, the treatment of choice is
synchronized cardioversion (B) to convert the cardiac rhythm
ST
back to normal sinus rhythm. (A) is a medication used for
ventricular dysrhythmias. (C) is not for a client with atrial
fibrillation; it is reserved for clients with life-threatening
BE
dysrhythmias, such as ventricular fibrillation and unstable
ventricular tachycardia. (D) is the drug of choice in symptomatic
sinus bradycardia, not atrial fibrillation.
A 63-year-old client with type 2 diabetes mellitus is admitted for
treatment of an ulcer on the heel of the left foot that has not
healed with wound care. The nurse observes that the entire left
foot is darker in color than the right foot. Which additional
symptom should the nurse expect to find?
A. Pedal pulses will be weak or absent in the left foot.
,B. The client will state that the left foot is usually warm.
C. Flexion and extension of the left foot will be limited.
D. Capillary refill of the client's left toes will be brisk. - ANSWER--A
Symptoms associated with decreased blood supply are weak or
absent pedal and tibial pulses (A). The client with diabetes
experiences vascular scarring as a result of atherosclerotic
changes in the peripheral vessels. This results in compromised
perfusion to the dependent extremities, which further delays
wound healing in the affected foot. Although flexion and extension
C
may be limited (C), depending on the degree of damage, this is
LE
not always the case. (B and D) are signs of adequate perfusion of
the foot, which would not be expected in this client.
ST
A client with cirrhosis develops increasing pedal edema and
ascites. Which dietary modification is most important for the nurse
to teach this client?
BE
A.Avoid high-carbohydrate foods.
B. Decrease intake of fat-soluble vitamins.
C. Decrease caloric intake.
D. Restrict salt and fluid intake. - ANSWER--D
Salt and fluid restrictions are the first dietary modifications for a
client who is retaining fluid as manifested by edema and ascites
(D). (A, B, and C) will not affect fluid retention.
,During report, the nurse learns that a client with tumor lysis
syndrome is receiving an IV infusion containing insulin. Which
assessment should the nurse complete first?
A.Review the client's history for diabetes mellitus.
B.Observe the extremity distal to the IV site.
C.Monitor the client's serum potassium and blood glucose levels.
C
D.Evaluate the client's oxygen saturation and breath sounds. -
LE
ANSWER--C
Clients with tumor lysis syndrome may experience hyperkalemia,
requiring the addition of insulin to the IV solution to reduce the
ST
serum potassium level. It is most important for the nurse to
monitor the client's serum potassium and blood glucose levels to
ensure that they are not at dangerous levels (C). (A, B, and D)
BE
provide valuable assessment data but are of less priority than (C).
A resident in a long-term care facility is diagnosed with hepatitis
B. Which intervention should the nurse implement with the staff
caring for this client?
A.Determine if all employees have had the hepatitis B vaccine
series.
, B.Explain that this type of hepatitis can be transmitted when
feeding the client.
C.Assure the employees that they cannot contract hepatitis B
when providing direct care.
D.Tell the employees that wearing gloves and a gown are
required when providing care. - ANSWER--A
Hepatitis B vaccine should be administered to all health care
providers (A). Hepatitis A (not hepatitis B) can be transmitted by
fecal-oral contamination (B). There is a chance that staff could
C
contract hepatitis B if exposed to the client's blood and/or body
LE
fluids; therefore, (C) is incorrect. There is no need to wear gloves
and gowns except with blood or body fluid contact (D).
ST
The nurse notes that the client's drainage has decreased from 50
to 5 mL/hr 12 hours after chest tube insertion for hemothorax.
What is the best initial action for the nurse to take?
BE
A.Document this expected decrease in drainage.
B.Clamp the chest tube while assessing for air leaks.
C.Milk the tube to remove any excessive blood clot buildup.
D.Assess for kinks or dependent loops in the tubing. - ANSWER--
D
The least invasive nursing action should be performed first to
determine why the drainage has diminished (D). (A) is completed
after assessing for any problems causing the decrease in
Questions With Verified Answers And Explained Solutions
A client on telemetry has a pattern of uncontrolled atrial fibrillation
with a rapid ventricular response. Based on this finding, the nurse
anticipates assisting the physician with which treatment?
A. Administer lidocaine,75 mg intravenous push.
B.Perform synchronized cardioversion.
C
C. Defibrillate the client as soon as possible.
LE
D. Administer atropine, 0.4 mg intravenous push. - ANSWER--B
With uncontrolled atrial fibrillation, the treatment of choice is
synchronized cardioversion (B) to convert the cardiac rhythm
ST
back to normal sinus rhythm. (A) is a medication used for
ventricular dysrhythmias. (C) is not for a client with atrial
fibrillation; it is reserved for clients with life-threatening
BE
dysrhythmias, such as ventricular fibrillation and unstable
ventricular tachycardia. (D) is the drug of choice in symptomatic
sinus bradycardia, not atrial fibrillation.
A 63-year-old client with type 2 diabetes mellitus is admitted for
treatment of an ulcer on the heel of the left foot that has not
healed with wound care. The nurse observes that the entire left
foot is darker in color than the right foot. Which additional
symptom should the nurse expect to find?
A. Pedal pulses will be weak or absent in the left foot.
,B. The client will state that the left foot is usually warm.
C. Flexion and extension of the left foot will be limited.
D. Capillary refill of the client's left toes will be brisk. - ANSWER--A
Symptoms associated with decreased blood supply are weak or
absent pedal and tibial pulses (A). The client with diabetes
experiences vascular scarring as a result of atherosclerotic
changes in the peripheral vessels. This results in compromised
perfusion to the dependent extremities, which further delays
wound healing in the affected foot. Although flexion and extension
C
may be limited (C), depending on the degree of damage, this is
LE
not always the case. (B and D) are signs of adequate perfusion of
the foot, which would not be expected in this client.
ST
A client with cirrhosis develops increasing pedal edema and
ascites. Which dietary modification is most important for the nurse
to teach this client?
BE
A.Avoid high-carbohydrate foods.
B. Decrease intake of fat-soluble vitamins.
C. Decrease caloric intake.
D. Restrict salt and fluid intake. - ANSWER--D
Salt and fluid restrictions are the first dietary modifications for a
client who is retaining fluid as manifested by edema and ascites
(D). (A, B, and C) will not affect fluid retention.
,During report, the nurse learns that a client with tumor lysis
syndrome is receiving an IV infusion containing insulin. Which
assessment should the nurse complete first?
A.Review the client's history for diabetes mellitus.
B.Observe the extremity distal to the IV site.
C.Monitor the client's serum potassium and blood glucose levels.
C
D.Evaluate the client's oxygen saturation and breath sounds. -
LE
ANSWER--C
Clients with tumor lysis syndrome may experience hyperkalemia,
requiring the addition of insulin to the IV solution to reduce the
ST
serum potassium level. It is most important for the nurse to
monitor the client's serum potassium and blood glucose levels to
ensure that they are not at dangerous levels (C). (A, B, and D)
BE
provide valuable assessment data but are of less priority than (C).
A resident in a long-term care facility is diagnosed with hepatitis
B. Which intervention should the nurse implement with the staff
caring for this client?
A.Determine if all employees have had the hepatitis B vaccine
series.
, B.Explain that this type of hepatitis can be transmitted when
feeding the client.
C.Assure the employees that they cannot contract hepatitis B
when providing direct care.
D.Tell the employees that wearing gloves and a gown are
required when providing care. - ANSWER--A
Hepatitis B vaccine should be administered to all health care
providers (A). Hepatitis A (not hepatitis B) can be transmitted by
fecal-oral contamination (B). There is a chance that staff could
C
contract hepatitis B if exposed to the client's blood and/or body
LE
fluids; therefore, (C) is incorrect. There is no need to wear gloves
and gowns except with blood or body fluid contact (D).
ST
The nurse notes that the client's drainage has decreased from 50
to 5 mL/hr 12 hours after chest tube insertion for hemothorax.
What is the best initial action for the nurse to take?
BE
A.Document this expected decrease in drainage.
B.Clamp the chest tube while assessing for air leaks.
C.Milk the tube to remove any excessive blood clot buildup.
D.Assess for kinks or dependent loops in the tubing. - ANSWER--
D
The least invasive nursing action should be performed first to
determine why the drainage has diminished (D). (A) is completed
after assessing for any problems causing the decrease in
