MED SURG 2 HESI TEST BANK
REAL EXAM 100+ QUESTIONS
AND CORRECT ANSWERS WITH
RATIONALES|AGRADE
1. A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which
assessment finding warrant's immediate intervention by the nurse?
a. Purple marks on skin of the abdomen
b. Irregular apical pulse
c. Quarter size blood spot on dressing
d. Pitting ankle edema - ANSWER-b. Irregular apical pulse
2. A client with lung cancer who wears a subcutaneous morphine sulfate patch for pain is short of breath
and is difficult to arouse. When performing a head to toe assessment, the nurse discovers four analgesic
patches on the clients body. Which intervention should the nurse implement first?
a. Remove all of the morphine patches
b. Administer a narcotic antagonist
c. Apply oxygen per face mask
d. Measure the client's blood pressure - ANSWER-b. Administer a narcotic antagonist
3. A client receives prescriptions for a multidrug regimen for the treatment of tuberculosis. Which
information should the nurse prioritize?
a. Adherence to the regimen is imperative
b. Medications should be taken with food
,c. Serum liver panels are collected regularly
d. Enhanced sun protection measures will be needed - ANSWER-a. Adherence to the regimen is
imperative
4. The nurse is preparing a client for surgery who was admitted to the emergency center following a
motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from
the bone protrusion site. During the prescriptive assessment, the nurse determines that the client
currently receives heparin sodium 5,000 units subcutaneously daily. What is the priority nursing action?
a. Notify the healthcare provider of the client's medication history
b. Observe the heparin injections sites for signs of bruising
c. Have the client sign the surgical and transfusion permits
d. Ensure that the potential for bleeding is explained to the client - ANSWER-a. Notify the healthcare
provider of the client's medication history
5. A client with orthopnea expresses concern about the ability to "get enough air" during a scheduled
thoracentesis. On which information should the nurse's response be based?
a. A thoracentesis is a brief process that has minimal discomfort
b. Orthopnea is frequently caused by a client's uncontrolled anxiety
c. The procedure is performed with the client in an upright position
d. Extra pillows can be used if needed to elevate the client's head - ANSWER-c. The procedure is
performed with the client in an upright position
6. What information should the nurse include in the teaching plan of a client diagnosed with
gastroesophageal reflux disease (GERD)?
a. Sleep without pillows at night to maintain neck alignment
b. Adjust food intake to three full meals per day and no snacks
,c. Minimize symptoms by wearing loose, comfortable clothing
d. Avoid participation in any aerobic exercise programs - ANSWER-c. Minimize symptoms by wearing
loose, comfortable clothing
7. The nurse is providing teaching to a client with Type 2 diabetes mellitus and peripheral neuropathy.
Which information should the nurse provide?
a. Family members can help with regular foot exams
b. Heating pads are useful if on the low setting
c. Aching feet may be soaked in lukewarm water for one hour or more
d. Shoes should be worn outside the house, but it is fine to be barefoot inside - ANSWER-a. Family
members can help with regular foot exams
8. A client in the operating room received succinylcholine. The client is experiencing muscle rigidity and
has an extremely high temperature. What action should the nurse implement?
a. Hold a prescription for dantrolene until fever is reduced
b. Prepare ice packs for placement in the clients axillary area
c. Call the PACU nurse to prepare for prolonged ventilator support
d. Determine if prescribed antibiotics were administered preoperatively - ANSWER-b. Prepare ice packs
for placement in the clients axillary area
9. The nurse is developing a plan of care for a client who reports blurred vision and who is newly
diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for
this client?
a. The nurse will encourage the client to walk thirty minutes every day
b. The clients family will state signs and symptoms about the disease
, c. The clients daily blood pressure will be less than 140/80 this month
d. The client blood pressure readings will be less than 160/90 - ANSWER-c. The clients daily blood
pressure will be less than 140/80 this month
10. The family suspects that acquired immune deficiency syndrome (AIDS) dementia is occuring in their
son who is human immunodeficiency virus (HIV) positive. Which symptoms confirm their suspicions?
a. He has begun to sleep 18 out of 24 hours
b. A change has recently occurred in his handwriting
c. He refuses to see any of his friends or to return their phone calls
d. He exhibits angry outburst when the subject of dying is approached - ANSWER-b. A change has
recently occurred in his handwriting
11. A hospitalized client with peripheral arterial disease (PAD) is instructed regarding leg and foot care.
Which statement by the client indicates to the nurse that learning has occurred?
a. "Whenever I am sitting in a chair I will keep my legs up to reduce swelling"
b. "I can use a mirror to check the bottoms of my feet for any signs of breakdown"
c. "I will try to keep moving if leg pain occurs to help promote good circulation"
d. "I will use my swimming pool early in the day while the water is still very cool" - ANSWER-b. "I can use
a mirror to check the bottoms of my feet for any signs of breakdown"
12. While completing a health assessment for a client with migraine headaches, the nurse assesses
bilateral weakness in the client's hand grips. The client reports joint pain and trouble twisting a door
knob due to weakness. Which action should the nurse take in response to these findings?
a. Explain that relief of the migraine pain will reduce related symptoms
b. Gather additional assessment data about the pain and weakness
REAL EXAM 100+ QUESTIONS
AND CORRECT ANSWERS WITH
RATIONALES|AGRADE
1. A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which
assessment finding warrant's immediate intervention by the nurse?
a. Purple marks on skin of the abdomen
b. Irregular apical pulse
c. Quarter size blood spot on dressing
d. Pitting ankle edema - ANSWER-b. Irregular apical pulse
2. A client with lung cancer who wears a subcutaneous morphine sulfate patch for pain is short of breath
and is difficult to arouse. When performing a head to toe assessment, the nurse discovers four analgesic
patches on the clients body. Which intervention should the nurse implement first?
a. Remove all of the morphine patches
b. Administer a narcotic antagonist
c. Apply oxygen per face mask
d. Measure the client's blood pressure - ANSWER-b. Administer a narcotic antagonist
3. A client receives prescriptions for a multidrug regimen for the treatment of tuberculosis. Which
information should the nurse prioritize?
a. Adherence to the regimen is imperative
b. Medications should be taken with food
,c. Serum liver panels are collected regularly
d. Enhanced sun protection measures will be needed - ANSWER-a. Adherence to the regimen is
imperative
4. The nurse is preparing a client for surgery who was admitted to the emergency center following a
motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from
the bone protrusion site. During the prescriptive assessment, the nurse determines that the client
currently receives heparin sodium 5,000 units subcutaneously daily. What is the priority nursing action?
a. Notify the healthcare provider of the client's medication history
b. Observe the heparin injections sites for signs of bruising
c. Have the client sign the surgical and transfusion permits
d. Ensure that the potential for bleeding is explained to the client - ANSWER-a. Notify the healthcare
provider of the client's medication history
5. A client with orthopnea expresses concern about the ability to "get enough air" during a scheduled
thoracentesis. On which information should the nurse's response be based?
a. A thoracentesis is a brief process that has minimal discomfort
b. Orthopnea is frequently caused by a client's uncontrolled anxiety
c. The procedure is performed with the client in an upright position
d. Extra pillows can be used if needed to elevate the client's head - ANSWER-c. The procedure is
performed with the client in an upright position
6. What information should the nurse include in the teaching plan of a client diagnosed with
gastroesophageal reflux disease (GERD)?
a. Sleep without pillows at night to maintain neck alignment
b. Adjust food intake to three full meals per day and no snacks
,c. Minimize symptoms by wearing loose, comfortable clothing
d. Avoid participation in any aerobic exercise programs - ANSWER-c. Minimize symptoms by wearing
loose, comfortable clothing
7. The nurse is providing teaching to a client with Type 2 diabetes mellitus and peripheral neuropathy.
Which information should the nurse provide?
a. Family members can help with regular foot exams
b. Heating pads are useful if on the low setting
c. Aching feet may be soaked in lukewarm water for one hour or more
d. Shoes should be worn outside the house, but it is fine to be barefoot inside - ANSWER-a. Family
members can help with regular foot exams
8. A client in the operating room received succinylcholine. The client is experiencing muscle rigidity and
has an extremely high temperature. What action should the nurse implement?
a. Hold a prescription for dantrolene until fever is reduced
b. Prepare ice packs for placement in the clients axillary area
c. Call the PACU nurse to prepare for prolonged ventilator support
d. Determine if prescribed antibiotics were administered preoperatively - ANSWER-b. Prepare ice packs
for placement in the clients axillary area
9. The nurse is developing a plan of care for a client who reports blurred vision and who is newly
diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for
this client?
a. The nurse will encourage the client to walk thirty minutes every day
b. The clients family will state signs and symptoms about the disease
, c. The clients daily blood pressure will be less than 140/80 this month
d. The client blood pressure readings will be less than 160/90 - ANSWER-c. The clients daily blood
pressure will be less than 140/80 this month
10. The family suspects that acquired immune deficiency syndrome (AIDS) dementia is occuring in their
son who is human immunodeficiency virus (HIV) positive. Which symptoms confirm their suspicions?
a. He has begun to sleep 18 out of 24 hours
b. A change has recently occurred in his handwriting
c. He refuses to see any of his friends or to return their phone calls
d. He exhibits angry outburst when the subject of dying is approached - ANSWER-b. A change has
recently occurred in his handwriting
11. A hospitalized client with peripheral arterial disease (PAD) is instructed regarding leg and foot care.
Which statement by the client indicates to the nurse that learning has occurred?
a. "Whenever I am sitting in a chair I will keep my legs up to reduce swelling"
b. "I can use a mirror to check the bottoms of my feet for any signs of breakdown"
c. "I will try to keep moving if leg pain occurs to help promote good circulation"
d. "I will use my swimming pool early in the day while the water is still very cool" - ANSWER-b. "I can use
a mirror to check the bottoms of my feet for any signs of breakdown"
12. While completing a health assessment for a client with migraine headaches, the nurse assesses
bilateral weakness in the client's hand grips. The client reports joint pain and trouble twisting a door
knob due to weakness. Which action should the nurse take in response to these findings?
a. Explain that relief of the migraine pain will reduce related symptoms
b. Gather additional assessment data about the pain and weakness
