HESI - Medical Surgical Nursing test-Exam TEST
BANK FOR MEDICAL SURGICAL NURSING 11TH
EDITION IGNATAVICIUS
.A client asks the nurse why it is important to be weighed every day if he has
right-sided heart failure. What is the nurse's best response?
A) "The hospital requires that all inpatients be weighed daily."
B) "Weight is the best indication that you are gaining or losing fluid."
C) "You need to lose weight to decrease the incidence of heart failure."
D) "Daily weights will help us make sure that you're eating properly." -
ANSWER-B
Daily weights are needed to document fluid retention or fluid loss. One liter of
fluid equals 2.2 pounds.
.A client has a deep wound covered with a wet-to-damp dressing. Which
intervention does the nurse include on this client's care plan?
A) Apply a new dressing when the seal breaks and the dressing leaks.
B) Change the dressing when the current dressing is saturated.
C) Leave the dressing intact until next week.
D) Change the dressing every 6 hours around the clock. - ANSWER-D
,Wet-to-damp dressings are changed every 4 to 6 hours to provide maximum
débridement. Synthetic dressings can be left in place for extended periods of
time but need to be changed if the seal breaks and the exudate is leaking. Dry
gauze dressings should be changed when the outer layer becomes saturated.
.A client has a small-bore nasoenteric feeding tube. The nurse assesses the
following vital signs: temperature, 100.2° F (37.8° C); pulse, 112 beats/min;
respiratory rate, 22 breaths/min; and blood pressure, 106/62 mm Hg. Which
action by the nurse takes priority?
A) Auscultate bowel sounds and slow the feeding down.
B) Remove the tube immediately and notify the heath care provider.
C) Auscultate lung sounds and obtain oxygen saturation.
D) Add blue dye to the feeding tube formula. - ANSWER-C
The client may have aspirated. The nurse should further assess the client's
respiratory and oxygenation status. The client may have another reason for the
abnormal vital signs, so the nurse should not pull out the tube before
performing other assessments. Adding blue dye to the tube feeding formula is
not recommended to check for aspiration. Slowing the feeding down will not be
helpful.
.A client has a urinary tract infection. Which assessment by the nurse is most
helpful?
A) Palpating and percussing the kidneys and bladder
B) Performing a bladder scan to assess post-void residual
C) Assessing medical history and current medical problems
,D) Inquiring about recent travel to foreign countries - ANSWER-C
Clients who are severely immune compromised or who have diabetes mellitus
are more prone to fungal urinary tract infection. The nurse should assess for
these factors. A physical examination and a post-void residual may be needed,
but not until further information is obtained. Travel to foreign countries
probably would not be as important, because even if exposed, the client needs
some degree of immune compromise to develop a fungal urinary tract infection.
.A client has a wound on his left trochanter that is 4 inches in diameter, with
black tissue at the perimeter, and bone is exposed. Which is the nurse's best
action?
A) Document as a stage I pressure ulcer and apply a transparent dressing.
B) Document as a stage II pressure ulcer and start wet-to-dry gauze treatments.
C) Document as a stage IV pressure ulcer and prepare the client for
débridement.
D) Document as a stage III pressure ulcer and start antibiotic therapy. -
ANSWER-C
A stage IV ulcer is one in which skin loss is full thickness, with extensive
destruction, tissue necrosis, and/or damage to muscle, bone, or supporting
structures. Eschar may be present. When the bone of the trochanter area is
visible, tissue loss includes muscle loss. A potential intervention consists of
débridement of the necrotic tissue and a possible graft to promote healing.
.A client has been admitted to the intensive care unit with worsening
pulmonary manifestations of heart failure. What is the nurse's best action?
, A) Administer loop diuretics as prescribed.
B) Begin cardiopulmonary resuscitation (CPR).
C) Promote rest and minimize activities.
D) Place the client in a high Fowler's position. - ANSWER-A
The client with worsening heart failure is most at risk for pulmonary edema as a
consequence of fluid retention. Administering diuretics will decrease the fluid
overload, thereby decreasing the incidence of pulmonary edema. High Fowler's
position might help the client breathe easier but will not solve the problem. CPR
is not warranted in this situation. Rest is important for clients with heart failure,
but this is not the priority.
.A client has been taught to restrict dietary sodium. Which food selection by the
client indicates to the nurse that teaching has been effective?
a. a grilled cheese sandwich with tomato soup
b. Chinese take-out, including steamed rice
c. a chicken leg, one slice of bread with butter, and steamed carrots
d. slices of ham and cheese on whole grain crackers - ANSWER-C
Clients on restricted sodium diets generally should avoid processed, smoked,
and pickled foods and those with sauces and other condiments. Foods lowest in
sodium include fish, poultry, and fresh produce. The chinese food likely would
have soy sauce, the tomato soup is processed, and the crackers are a snack food
- a category of foods often high in sodium.
BANK FOR MEDICAL SURGICAL NURSING 11TH
EDITION IGNATAVICIUS
.A client asks the nurse why it is important to be weighed every day if he has
right-sided heart failure. What is the nurse's best response?
A) "The hospital requires that all inpatients be weighed daily."
B) "Weight is the best indication that you are gaining or losing fluid."
C) "You need to lose weight to decrease the incidence of heart failure."
D) "Daily weights will help us make sure that you're eating properly." -
ANSWER-B
Daily weights are needed to document fluid retention or fluid loss. One liter of
fluid equals 2.2 pounds.
.A client has a deep wound covered with a wet-to-damp dressing. Which
intervention does the nurse include on this client's care plan?
A) Apply a new dressing when the seal breaks and the dressing leaks.
B) Change the dressing when the current dressing is saturated.
C) Leave the dressing intact until next week.
D) Change the dressing every 6 hours around the clock. - ANSWER-D
,Wet-to-damp dressings are changed every 4 to 6 hours to provide maximum
débridement. Synthetic dressings can be left in place for extended periods of
time but need to be changed if the seal breaks and the exudate is leaking. Dry
gauze dressings should be changed when the outer layer becomes saturated.
.A client has a small-bore nasoenteric feeding tube. The nurse assesses the
following vital signs: temperature, 100.2° F (37.8° C); pulse, 112 beats/min;
respiratory rate, 22 breaths/min; and blood pressure, 106/62 mm Hg. Which
action by the nurse takes priority?
A) Auscultate bowel sounds and slow the feeding down.
B) Remove the tube immediately and notify the heath care provider.
C) Auscultate lung sounds and obtain oxygen saturation.
D) Add blue dye to the feeding tube formula. - ANSWER-C
The client may have aspirated. The nurse should further assess the client's
respiratory and oxygenation status. The client may have another reason for the
abnormal vital signs, so the nurse should not pull out the tube before
performing other assessments. Adding blue dye to the tube feeding formula is
not recommended to check for aspiration. Slowing the feeding down will not be
helpful.
.A client has a urinary tract infection. Which assessment by the nurse is most
helpful?
A) Palpating and percussing the kidneys and bladder
B) Performing a bladder scan to assess post-void residual
C) Assessing medical history and current medical problems
,D) Inquiring about recent travel to foreign countries - ANSWER-C
Clients who are severely immune compromised or who have diabetes mellitus
are more prone to fungal urinary tract infection. The nurse should assess for
these factors. A physical examination and a post-void residual may be needed,
but not until further information is obtained. Travel to foreign countries
probably would not be as important, because even if exposed, the client needs
some degree of immune compromise to develop a fungal urinary tract infection.
.A client has a wound on his left trochanter that is 4 inches in diameter, with
black tissue at the perimeter, and bone is exposed. Which is the nurse's best
action?
A) Document as a stage I pressure ulcer and apply a transparent dressing.
B) Document as a stage II pressure ulcer and start wet-to-dry gauze treatments.
C) Document as a stage IV pressure ulcer and prepare the client for
débridement.
D) Document as a stage III pressure ulcer and start antibiotic therapy. -
ANSWER-C
A stage IV ulcer is one in which skin loss is full thickness, with extensive
destruction, tissue necrosis, and/or damage to muscle, bone, or supporting
structures. Eschar may be present. When the bone of the trochanter area is
visible, tissue loss includes muscle loss. A potential intervention consists of
débridement of the necrotic tissue and a possible graft to promote healing.
.A client has been admitted to the intensive care unit with worsening
pulmonary manifestations of heart failure. What is the nurse's best action?
, A) Administer loop diuretics as prescribed.
B) Begin cardiopulmonary resuscitation (CPR).
C) Promote rest and minimize activities.
D) Place the client in a high Fowler's position. - ANSWER-A
The client with worsening heart failure is most at risk for pulmonary edema as a
consequence of fluid retention. Administering diuretics will decrease the fluid
overload, thereby decreasing the incidence of pulmonary edema. High Fowler's
position might help the client breathe easier but will not solve the problem. CPR
is not warranted in this situation. Rest is important for clients with heart failure,
but this is not the priority.
.A client has been taught to restrict dietary sodium. Which food selection by the
client indicates to the nurse that teaching has been effective?
a. a grilled cheese sandwich with tomato soup
b. Chinese take-out, including steamed rice
c. a chicken leg, one slice of bread with butter, and steamed carrots
d. slices of ham and cheese on whole grain crackers - ANSWER-C
Clients on restricted sodium diets generally should avoid processed, smoked,
and pickled foods and those with sauces and other condiments. Foods lowest in
sodium include fish, poultry, and fresh produce. The chinese food likely would
have soy sauce, the tomato soup is processed, and the crackers are a snack food
- a category of foods often high in sodium.
