HESI Med Surg 100 Practice Exam ( Update) Questions and Verified Answers

HESI Med Surg 10 0 Practice Exam (2023 2024 Update) Questions and Verified Answers 1. The nurse is caring for a client who is 1 day post -acute myocardial infarction. The client is receiving oxygen at 2 L/min via nasal cannula and has a peripheral saline lock. The nurse notes that the client is having eight premature ventricular contractions (PVCs) per minute. Which intervention should the nurse implement first? A. Obtain an IV pump for antiarrhythmic infusion. B. Increase the client's oxygen flow rate. C. Prepare for immediate countershock. D. Gather equipment for endotracheal intubation. : B. Increase t he client's oxygen flow rate. Rationale: Increasing the oxygen flow rate (B) provides more oxygen to the client's myocardium and may decrease myocardial irritability as manifested by the frequent PVCs. (A) can be delegated and is a lower priority action th an (B). Defibrillation may eventually be necessary, but (C) is not the immediate treatment for frequent PVCs. (D) may become necessary if the client stops breathing, but is not indicated at this time. 2. The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is very restless and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which intervention should the nurse implement first? A. Measure the urine specific gravity. B. Obtain IV fl uids for infusion per protocol. C. Prepare for insertion of a central venous catheter. D. Auscultate the client's breath sounds.: B. Obtain IV fluids for infusion per protocol. Rationale: The client is at risk for hypovolemic shock because of the postoperative status and is exhibiting early signs of shock. A priority intervention is the initiation of IV fluids (B) to restore tissue perfusion. (A, C, and D) are all important interventions, but are of less priority than (B). 3. The nurse is assessing a male client with acute pancreatitis. Which finding requires the most immediate intervention by the nurse? A. The client's amylase level is three times higher than the normal level. B. While the nurse is taking the client's blood pressure, he has a carpal spasm. C. On a 1 to 10 scale, the client tells the nurse that his epigastric pain is at 7. D. The client states that he will continue to drink alcohol after going home .: B. While the nurse is taking the clie nt's blood pressure, he has a carpal spasm. Rationale: A positive Trousseau sign (B) indicates hypocalcemia and always requires further assessment and intervention, regardless of the cause (40% to 75% of those with acute pancreatitis experience hypocalcemi a, which can have serious, systemic effects). A key diagnostic finding of pancreatitis is serum amylase and lipase levels that are two to five times higher than the normal value (A). Severe boring pain is an expected symptom for this diagnosis (C), but dea ling with the hypocalcemia is a priority over administering an analgesic. Long -term planning and teaching (D) do not have the same immediate importance as a positive Trousseau sign. 4. An 81 -year -old male client has emphysema. He lives at home with his cat and manages self -care with no difficulty. When making a home visit, the nurse notices that this client's tongue is somewhat cracked and his eyeballs appear sunken into his head. Which nursing intervention is indicated? A. Help the client determine ways to in crease his fluid intake. B. Obtain an appointment for the client to have an eye examination. C. Instruct the client to use oxygen at night and increase the humidification. D. Schedule the client for tests to determine his sensitivity to cat hair.: A. Help the clien t determine ways to increase his fluid intake. Rationale: Clients with COPD should ingest 3 L of fluids daily but may experience a fluid deficit because of shortness of breath. The nurse should suggest creative methods to increase the intake of fluids (A), such as having fruit juices in disposable containers read ily available. (B) is not indicated. Humidified oxygen will not effectively treat the client's fluid deficit, and there is no indication that the client needs supplemental oxygen at night (C). These symptoms are not indicative of (D) and may unnecessarily upset the client, who depends on his pet for socialization. 5. When a nurse assesses a client receiving total parenteral nutrition (TPN), which laboratory value is most important for the nurse to monitor regularly? A. Albumin B. Calcium C. Glucose D. Alkaline phosph atase: C. Glucose Rationale: TPN solutions contain high concentrations of glucose, so the blood glucose level is often monitored as often as q6h because of the risk for hyperglycemia (C). (A) is monitored periodically because an increase in the albumin lev el, a serum protein, is generally a desired effect of TPN. (B) may be added to TPN solutions, but calcium imbalances are not generally a risk during TPN administration. (D) may be decreased in the client with malnutrition who receives TPN, but abnormal val ues, reflecting liver or bone disorders, are not a common complication of TPN administration. 6. The nurse is caring for a client with a fractured right elbow. Which assessment finding has the highest priority and requires immediate intervention? A. Ecchymosi s over the right elbow area B. Deep unrelenting pain in the right arm C. An edematous right elbow D. The presence of crepitus in the right elbow: B. Deep unrelenting pain in the right arm Rationale: Compartment syndrome is a condition involving increased pressure and constriction of the nerves and vessels within an anatomic compartment, causing pain uncontrolled by opioids, and neurovascular compromise (B). (A) is an expected finding. (C) related to c ompartment syndrome cannot be seen, and any visible edema is an expected finding related to the injury. (D) is an expected finding. 7. An older male client comes to the outpatient clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg that is warm to the touch, and the nurse suspects that the client may have thrombophlebitis. Which addi tional assessment is most important for the nurse to perform? A. Measure the client's calf circumference. B. Auscultate the client's breath sounds. C. Observe for ecchymosis and petechiae. D. Obtain the client's blood pressure.: B. Auscultate the client's breath sound s. Rationale: All these techniques provide useful assessment data. The most important is to auscultate the client's breath sounds (B) because the client may have a pulmonary embolus secondary to the thrombophlebitis. (A) may provide data that support the n urse's suspicion of thrombophlebitis. (C) is the least helpful assessment because bruising is not a typical finding associated with thrombophlebitis. (D) is always useful in evaluating the client's response to a problem but is of less immediate priority th an breath sound auscultation. 8. A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff?