Page 1 of 162
MEDICAL
SURGICAL HESI PN WITH RATIONALE GRADED A+
TESTED AND APPROVED!!!
A nurse is preparing to obtain a postprandial blood glucose level from a client who has
diabetes mellitus. Which of the following actions should the nurse take?
a) Apply the first drop of blood to the test strip.
b) Clean the client's finger with hexachlorophene.
c) Prick the central tip of the client's finger.
d) Hold the client's finger in a dependent position. -- ANSWER--D. Hold the client's finger in
a dependent position.
Rationale:
The nurse should clean the client's finger with an alcohol swab and prick the side of the
finger, not the central tip, to obtain a postprandial blood glucose level.
The nurse should not apply the first drop of blood to the test strip since the alcohol could
cause false reading.
Hexachlorophene is not recommended for cleaning the client's finger as it can cause tissue
damage.
, Page 2 of 162
TEST
A nurse is reinforcing teaching with a client about breast self-examinations. Which of the
following statements by the client indicates an understanding of the teaching?
a) "It is common for one breast to be larger than the other."
b) "It is common for the skin on my breasts to dimple."
c) "I will perform breast exams the day my period begins."
d) "I will perform breast exams every other month." -- ANSWER--A. "It is common for one
breast to be larger than the other."
Rationale:
It is normal to have asymmetrical breasts, usually, the left breast is bigger than the right.
This is because of the difference in the percentage of breast tissues and fatty tissues, that's
why they react differently to hormonal changes.
"Dimpling on the skin on breasts is NOT common" Physician consultation should be taken
regarding this as it can be a sign of breast cancer.
"Self-breast exams are recommended to be performed after a week when the period starts."
The rest of the month breasts reamain tender due to hormone fluctuation.
"Self-Breast exams should be performed every month." For women in reproductive age
usually after a week when the period starts and at the same day of every month for women
who have attained menopause.
, Page 3 of 162
A nurse is reinforcing teaching with a client who has a new ileostomy. Which of the
following statements by the client indicates an understanding of the teaching?
a) "I will need to empty the bag every 4 to 6 hours."
b) "I will use moisturizing soap to clean around the stoma before applying the bag."
c) "I will use a skin sealant before I apply the bag."
d) "I will cut the wafer opening one-fourth of an
inch larger than the stoma." -- ANSWER--C. "I will use a skin sealant before I apply the
bag."
Rationale:
An ileostomy is an opening in the belly that's made during surgery to allow waste to pass out
of the body. It requires special care to keep the skin around it clean and prevent infection. A
skin sealant can protect the skin from irritation and help the bag stick better. The other
statements are incorrect because:
a) You may need to empty the bag more often than every 4 to 6 hours, depending on
how much waste you produce.
b) You should not use moisturizing soap to clean around the stoma, as it can leave a
residue that interferes with the bag's adhesion. You should use plain water or mild soap and
rinse well.
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d) You should cut the wafer opening to fit snugly around the stoma, not larger than it. A larger
opening can expose the skin to waste and cause irritation
TEST
A nurse is assisting in the plan of care for a client who is dehydrated and is receiving IV fluid
replacement. Which of the following interventions should the nurse contribute to the plan of
care?
a) Offer oral fluids every 4 hr.
b) Check for neck vein distention.
c) Limit oral fluids prior to bedtime.
d) Monitor pulse pressure every 6 hr. -- ANSWER--B. Check for neck vein distention.
Rational:
Neck vein distention might be a sign of congestion of fluid in the vascular system, which can
occur when a person is receiving excessive IV fluids.
Offering oral fluids every 4 hours may be appropriate for a patient who is mildly dehydrated
and able to tolerate oral intake, but it is not recommended for a patient who is severely
dehydrated and receiving IV fluid replacement.
MEDICAL
SURGICAL HESI PN WITH RATIONALE GRADED A+
TESTED AND APPROVED!!!
A nurse is preparing to obtain a postprandial blood glucose level from a client who has
diabetes mellitus. Which of the following actions should the nurse take?
a) Apply the first drop of blood to the test strip.
b) Clean the client's finger with hexachlorophene.
c) Prick the central tip of the client's finger.
d) Hold the client's finger in a dependent position. -- ANSWER--D. Hold the client's finger in
a dependent position.
Rationale:
The nurse should clean the client's finger with an alcohol swab and prick the side of the
finger, not the central tip, to obtain a postprandial blood glucose level.
The nurse should not apply the first drop of blood to the test strip since the alcohol could
cause false reading.
Hexachlorophene is not recommended for cleaning the client's finger as it can cause tissue
damage.
, Page 2 of 162
TEST
A nurse is reinforcing teaching with a client about breast self-examinations. Which of the
following statements by the client indicates an understanding of the teaching?
a) "It is common for one breast to be larger than the other."
b) "It is common for the skin on my breasts to dimple."
c) "I will perform breast exams the day my period begins."
d) "I will perform breast exams every other month." -- ANSWER--A. "It is common for one
breast to be larger than the other."
Rationale:
It is normal to have asymmetrical breasts, usually, the left breast is bigger than the right.
This is because of the difference in the percentage of breast tissues and fatty tissues, that's
why they react differently to hormonal changes.
"Dimpling on the skin on breasts is NOT common" Physician consultation should be taken
regarding this as it can be a sign of breast cancer.
"Self-breast exams are recommended to be performed after a week when the period starts."
The rest of the month breasts reamain tender due to hormone fluctuation.
"Self-Breast exams should be performed every month." For women in reproductive age
usually after a week when the period starts and at the same day of every month for women
who have attained menopause.
, Page 3 of 162
A nurse is reinforcing teaching with a client who has a new ileostomy. Which of the
following statements by the client indicates an understanding of the teaching?
a) "I will need to empty the bag every 4 to 6 hours."
b) "I will use moisturizing soap to clean around the stoma before applying the bag."
c) "I will use a skin sealant before I apply the bag."
d) "I will cut the wafer opening one-fourth of an
inch larger than the stoma." -- ANSWER--C. "I will use a skin sealant before I apply the
bag."
Rationale:
An ileostomy is an opening in the belly that's made during surgery to allow waste to pass out
of the body. It requires special care to keep the skin around it clean and prevent infection. A
skin sealant can protect the skin from irritation and help the bag stick better. The other
statements are incorrect because:
a) You may need to empty the bag more often than every 4 to 6 hours, depending on
how much waste you produce.
b) You should not use moisturizing soap to clean around the stoma, as it can leave a
residue that interferes with the bag's adhesion. You should use plain water or mild soap and
rinse well.
, Page 4 of 162
d) You should cut the wafer opening to fit snugly around the stoma, not larger than it. A larger
opening can expose the skin to waste and cause irritation
TEST
A nurse is assisting in the plan of care for a client who is dehydrated and is receiving IV fluid
replacement. Which of the following interventions should the nurse contribute to the plan of
care?
a) Offer oral fluids every 4 hr.
b) Check for neck vein distention.
c) Limit oral fluids prior to bedtime.
d) Monitor pulse pressure every 6 hr. -- ANSWER--B. Check for neck vein distention.
Rational:
Neck vein distention might be a sign of congestion of fluid in the vascular system, which can
occur when a person is receiving excessive IV fluids.
Offering oral fluids every 4 hours may be appropriate for a patient who is mildly dehydrated
and able to tolerate oral intake, but it is not recommended for a patient who is severely
dehydrated and receiving IV fluid replacement.
