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HESI Med Surg Practice Exam Question
and Answers 202 5
Which assessment is most important for the nurse to perform on a client who is hospitalized for Guillain-Barre syndrome that is rapidly progressing? Respiratory effort. Unsteady gait. Intensity of pain. Ability to eat. - ✔ Respiratory effort. Guillain-Barre syndrome causes paralysis or weakness that typically starts at the feet and progresses upwards. As the condition progresses, the nurse must ensure that the client is able to breathe effectively. A male client comes into the clinic with a history of penile discharge with painful, burning urination. Which action should the nurse implement? Collect a culture of the penile discharge. Palpate the inguinal lymph nodes gently. Observe for scrotal swelling and redness. Express the discharge to determine color. - ✔ Collect a culture of the penile discharge. Penile discharge with painful urination is commonly associated with gonorrhea. The nurse should collect a culture of the penile discharge to determine the cause of these symptoms. The cause must be determined or confirmed through culture to identify the organism and ensure effective treatment. A client with history of atrial fibrillation is admitted to the telemetry unit with sudden onset of shortness of breath. The nurse observes a new irregular heart rhythm and should perform which assessment at this time? Check for a pulse deficit. Palpate the apical impulse. Inspect jugular vein pulse. Examine for a carotid bruit. - ✔ Check for a pulse deficit. A client with a past history of atrial fibrillation may return to that rhythm. Any signs of atrial fibrillation, such as sudden onset shortness of breath, requires further
investigation. The nurse should assess this client for a pulse deficit because this condition occurs with atrial fibrillation. Which client should be further assessed for an ectopic pregnancy? A 24-year-old with shoulder and lower abdominal quadrant pain. A 33-year-old with intermittent lower abdominal cramping. A 20-year-old with fever and right lower abdominal colic. A 40-year-old with jaundice and right lower abdominal pain. - ✔ A 24-year-old with shoulder and lower abdominal quadrant pain. A 24-year-old with sudden onset of lower abdominal quadrant pain should be assessed for an ectopic pregnancy. The pain can also be referred to the shoulder and may be associated with vaginal bleeding. Which dietary assessment finding is most important for the nurse to address when caring for a client with diabetic nephropathy? Drinks a six pack of beer every day. Enjoys a hamburger once a month. Eats fortified breakfast cereal daily. Consumes beans and rice every day. - ✔ Drinks a six pack of beer every day. Drinking six beers every day is the dietary assessment finding most important for the nurse to address when caring for a client with diabetic nephropathy. The usual can of beer is 12 ounces (355 mL). Clients with diabetes are recommended to drink no more than 12 ounces of beer per day because beer contains carbohydrates that can create unhealthy fluctuations in blood glucose and promote poor glucose control. Nephropathy is exacerbated by poor blood glucose control. Which assessment finding is of greatest concern to the nurse who is caring for a client with stomatitis? Cough brought on by swallowing. Sore throat caused by speaking. Painful and dry oral cavity. Unintended weight loss. - ✔ Cough brought on by swallowing. A cough brought on by swallowing is a sign of dysphagia, which is a finding of particular concern in a client with stomatitis. Dysphagia can cause numerous problems, including airway obstruction, and should be reported to the healthcare provider immediately. The nurse is teaching a client diagnosed with peripheral arterial disease. Which genitourinary system complication should the nurse include in the teaching?
A pneumothorax (partial or complete lung collapse) is the potential complication of a thoracentesis. Manifestations of a pneumothorax include new onset of a nagging cough, tachycardia, and an increased shallow respiration rate. While caring for a client who has esophageal varices, which nursing intervention is most important for the registered nurse (RN) to implement? Monitor infusing IV fluids and any replacement blood products. Prepare for esophagogastroduodenoscopy (EGD). Maintain the client on strict bedrest. Insert a nasogastric tube (NGT) for intermittent suction. - ✔ Monitor infusing IV fluids and any replacement blood products. Maintaining hemodynamic stability in a client with esophageal varicescan precipitatea life-threatening crisis if esophageal varies leak or rupture and can result in hemorrhage. The priority is assessing and monitoring infusions of IV fluids and any replacement blood products. The registered nurse (RN) is caring for a client who developed oliguria and was diagnosed with sepsis and dehydration 48 hours ago. Which assessment finding indicates to the RN that the client is stabilizing? Urine output of 40 mL/hour. Apical pulse 100 and blood pressure 76/42. Urine specific gravity 1.001. Tented skin on dorsal surface of hands. - ✔ Urine output of 40 mL/hour. A decrease in urinary output is a sign of dehydration. When the urine output returns to a normal range, 40 mL/hour, the client's kidneys are perfusing adequately and indicates the client's status is stablizing. After a liver biopsy is performed at the bedside, the registered nurse (RN) is assigned the care of the client. Which nursing intervention is most important for the RN to implement? Position client on left side with pillow placed under the costal margin. Assist the client with voiding immediately after the procedure. Evaluate vital signs q10 to 20 minutes for 2 hours after procedure. Ambulate client 3 times in first hour with pillow held at abdomen. - ✔ Evaluate vital signs q10 to 20 minutes for 2 hours after procedure. Vital signs should be checked every 10 to 20 minutes to assess for bleeding after biopsy of the liver, which is highly vascular. The client should be positioned on the right side with a pillow or sandbag under the costal margin and supporting the biopsy site.
The client should be maintained on bedrest for several hours to decrease the risk of bleeding from the biopsy site. The registered nurse (RN) is caring for a client with aplastic anemia who is hospitalized for weight loss and generalized weakness. Laboratory values show a white blood count (WBC) of 2,500/mm 3 and a platelet countof 160,000/mm 3. Which intervention is the primary focus in the client's plan of care for the RN to implement? Assist with frequent ambulation. Encourage visitors to visit. Maintain strict protective precautions. Avoid peripheral injections. - ✔ Maintain strict protective precautions. The client should be under strict protective transmission precautions because the WBC values are low and normal WBC levels are 4,000-10,000/mm3, so the client is an increased high risk for infection. The registered nurse (RN) is caring for a young adult who is having an oral glucose tolerance tests (OGTT). Which laboratory result should the RN assess as a normal value for the two hour postprandial result? 140 mg/dl. 160 mg/dl. 180 mg/dl. 200 mg/dl. - ✔ 140 mg/dl. The two hour postprandial level should be less 140 mg/dl for a young adult client. The registered nurse (RN) is caring for an older client who recently experienced a fractured pelvis from a fall. Which assessment finding is most important for the RN to report the healthcare provider? Lower back pain. Headache of 7 on scale 1 to 10. Blood pressure of 140/98. Dyspnea. - ✔ Dyspnea A client with a large bone fracture is at risk for intramedullary fat leaking into the blood stream and becoming embolic. Dyspnea is an indication of fat embolism to the lungs and should be reported to the healthcare provider immediately.
Chronic bronchitis. Gastroesophageal reflux disease (GERD). Heart failure (HF). Chronic pancreatitis. - ✔ Heart failure (HF) Paroxysmal nocturnal dyspnea is classic sign of heart failure and is secondary to fluid overload associated with heart failure which causes pulmonary edema. A client is recently diagnosed with systemic lupus erythematosus (SLE) and the registered nurse (RN) is assessing for common complications. Which symptom should the RN instruct the client to report immediately? Fever related to infection. Weight loss and anorexia. Depressed mood. Break in tissue integrity. - ✔ Fever related to infection Secondary infections are a major concern with SLE clients due to the use of corticosteroids and chemotherapeutic agents, which suppresses the immune system, so reporting fever and infections should be reported immediately. A male client is admitted after falling from his bed. The healthcare provider (HCP) tells the family that he has an incomplete fracture of the humerus. The family ask the RN what this means. Which explanation by the nurse accurately describes the client's fracture? Straight fracture line that is also a simple, closed fracture. Nondisplaced fracture line that wraps around the bone. A complete fracture that also punctures the skin. A fracture that bends or splinters part of the bone. - ✔ A fracture that bends or splinters part of the bone An incomplete fracture occurs when part of the bone is splintered (broken) and it has not gone completely through the thickness of the bone. The registered nurse (RN) is caring for a client who has a closed head injury from a motor vehicle collision. Which finding would indicate to the nurse that the client is at risk for diabetes insipidus (DI)? High fever. Low blood pressure. Muscle rigidity. Polydipsia. - ✔ Polydipsia
A characteristic finding of DI is excretion of large quantities of urine (5 to 20L/day), and most clients compensate for fluid loss by drinking large amounts of water (polydipsia). DI can occur when there has been damage or injury to the pituitary gland or hypothalamus as a result of head trauma, tumor or an illness such as meningitis. This damage interrupts the ADH production, storage and release causing the excessive urination and thirst. The registered nurse (RN) is assisting the healthcare provider (HCP) with the removal of a chest tube. Which intervention has the highest priority and should be anticipated by the RN after the removal of the chest tube? Prepare the client for chest x-ray at the bedside. Review arterial blood gases after removal. Elevate the head of bed to 45 degrees. Assist with disassembling the drainage system. - ✔ Prepare the client for chest x-ray at the bedside. A chest x-ray should be performed immediately after the removal of a chest tube to ensure lung expansion has been maintained after its removal. A client with chest pain, dizziness, and vomiting for the last 2 hours is admitted for evaluation for Acute Coronary Syndrome (ACS). Which cardiac biomarker should the registered nurse (RN) anticipate to be elevated if the client experienced myocardial damage? Creatine Kinase (CK-MB). Serum troponin. Myoglobin. Ischemia modified albumin. - ✔ Serum troponin. Troponin is the most sensitive and specific test for myocardial damage. Troponin elevation is more specific than CK-MB. A female client is recently diagnosed with Sarcoidosis. The client tells the registered nurse (RN) that she does not understand why she has this. When teaching the client, the RN should include that sarcoidosis most commonly occurs with which ethnic group of women? African American women. Caucasian women. Asian women. Hispanic women. - ✔ African American women.
- Older males.
- Adolescent males. Hypoestrogenism and alkalotic urine are other age-related factors put older women at the highest risk for UTIs. School age girls (6 to 12 years) are at risk for UTIs due to a higher prevalence to taking baths instead of showers, but these risks can be controlled in this population as well as hypoestrogenism and alkalotic urine. Older men are at risk due to possible obstruction of the bladder due to benign prostatic hypertrophy (BPH). Adolescent males (12 to 19 years) are the lowest at risk for a UTI. A female client admitted with abdominal pain is diagnosed with cholelithiasis. The client asks the registered nurse (RN) what she should expect as a common treatment. What recommended plan of care should the nurse provide the client? Rest with liquid diet only. Drugs such as ursodiol. Cholecystectomy via laparoscopy. LaVeen vena caval shunt. - ✔ Cholecystectomy via laparoscopy. The nurse should explain to the client that gall bladder surgical removal is most often recommended via laparoscopic excision. Which action should the nurse implement on the scheduled day of surgery for a client with type 1 diabetes mellitus (DM)? Obtain a prescription for an adjusted dose of insulin. Administer an oral anti-diabetic agent. Give an insulin dose using parameters of a sliding scale. Withhold insulin while the client is NPO. - ✔ Obtain a prescription for an adjusted dose of insulin. Stressors, such as surgery, increase serum glucose levels. A client with type 1 DM who is NPO for scheduled surgery should receive a prescribed adjusted dose of insulin. A young adult female reports that she is experiencing a lack of appetite, hypersomnia, stress incontinence, and heart palpitations. Which symptom is characteristic of premenstrual syndrome? Heart palpitations. Anorexia. Hypersomnia. Stress incontinence. - ✔ Heart palpitations
Characteristic features of premenstrual syndrome include heart palpitations, sleeplessness, increased appetite and food cravings, and oliguria or enuresis. Which preexisting diagnosis places a client at greatest risk of developing superior vena cava syndrome? Carotid stenosis. Steatosis hepatitis. Metastatic cancer. Clavicular fracture. - ✔ Metastatic cancer. Superior vena cava syndrome occurs when the superior vena cava (SVC) is compressed by outside structures, such as a growing tumor that impedes the return blood flow to the heart. Superior vena cava syndrome is likely to occur with metastatic cancer from a primary tumor in the upper lobe of the right lung that compresses the superior vena cava. When planning care for a client with right renal calculi, which nursing diagnosis has the highest priority? Acute pain related to movement of the stone. Impaired urinary elimination related to obstructed flow of urine. Risk for infection related to urinary stasis. Deficient knowledge related to need for prevention of recurrence of calculi. - ✔ Acute pain related to movement of the stone. The nursing diagnosis of the highest priority is "Acute pain related the the renal calculi's movement". The nurse should explain to a client with lung cancer that pleurodesis is performed to achieve which expected outcome? Prevent the formation of effusion fluid. Remove fluid from the intrapleural space. Debulk tumor to maintain patency of air passages. Relieve empyema after pneumonectomy. - ✔ Prevent the formation of effusion fluid. Instillation of a sclerosing agent to create pleurodesis is aimed at preventing the formation of a pleural effusion by causing the pleural spaces sealed together, thereby preventing the accumulation of pleural fluid. The PET (positron emission tomography) scan is commonly used with oncology clients to provide for which diagnostic information?
Immediate action is required for findings of a mediastinal shift, which can precipitate life- threatening cardiovascular collapse as the great cardiac vessels become kinked and compressed due to the tension pneumothorax. The nurse is caring for a client who returns to the unit following a colonoscopy. Which finding should the nurse report to the healthcare provider immediately? Large amounts of expelled flatus with mucus. Tympanic abdomen and hyperactive bowel sounds. Increased abdominal pain with rebound tenderness. Complaint of feeling weak with watery diarrheal stools. - ✔ Increased abdominal pain with rebound tenderness. Positive rebound tenderness following a colonoscopy may be an indication of a perforation and the development of peritonitis and requires follow-up immediately. A client with acute appendicitis is experiencing anxiety and loss of sleep about missing final examination week at college. Which outcome is most important for the nurse to include in the plan of care? Sleep 6 to 8 hours. Achieve a sense of control. Utilize problem solving skills. Increase focus of attention. - ✔ Achieve a sense of control. The experience of psychological discomfort may be as real as physical pain for the client and should be seen as a priority in care. Because the client is experiencing anxiety, achieving a sense of control is the overall outcome of this client's nursing care plan. A client with type II diabetes arrives at the clinic with a blood glucose of 50 mg/dL. The nurse provides the client with 6 ounces of orange juice. In 15 minutes the client's capillary glucose is 74 mg/dL. What action should the nurse take? Obtain a specimen for serum glucose level. Administer insulin per sliding scale. Provide cheese and bread to eat. Collect a glycosylated hemoglobin specimen. - ✔ Provide cheese and bread to eat Once blood glucose is greater than 70 mg/dL, the client should eat a regularly scheduled meal or a snack that contains protein and carbohydrates to help prevent hypoglycemia from recurring.
The unlicensed assistive personnel (UAP) reports that an 87-year-old client who is sitting in a chair at the bedside has an oral temperature of 97.2°F (36.4°C). Which intervention should the nurse implement? Document the temperature reading on the vital sign graphic sheet. Report the temperature to the healthcare provider immediately. Instruct the UAP to take the client's temperature again in 30 minutes. Advise the UAP to assist the client in returning to bed. - ✔ Document the temperature reading on the vital sign graphic sheet. A subnormal oral temperature of 97.2°F (36.4°C) is a common finding in elderly clients, so the nurse should document the findings and continue with the plan of care. The nurse is assessing a client who is bedfast and refuses to turn or move from a supine position. How should the nurse assess the client for possible dependent edema? Compress the flank and upper buttocks. Measure the client's abdominal girth. Gently palpate the lower abdomen. Apply light pressure over the shins. - ✔ Compress the flank and upper buttocks. Dependent edema collects in dependent areas, such as the flank and upper buttocks of the client who is persistently flat in bed. By compressing these areas, the nurse can determine if any pitting edema is present. An 85-year-old male client comes to the clinic for his annual physical exam and renewal of antihypertensive medication prescriptions. The client's radial pulse rate is 104 beats/minute. Which additional assessment should the nurse complete? Palpate the pedal pulse volume. Count the brachial pulse rate. Measure the blood pressure. Assess for a carotid bruit. - ✔ Measure the blood pressure. Elderly clients who take antihypertensive medications often experience side effects, such as hypotension, which causes tachycardia, a compensatory mechanism to maintain adequate cardiac output, so the client's blood pressure should be measured. The nurse is completing the health assessment of a 79-year-old client who denies any significant health problems. Which finding requires the most immediate follow-up assessment? Kyphosis with a reduction in height. Dilated superficial veins on both legs.
The nurse is teaching a client about precautions for a new prescription for lovastatin. Which symptom should the nurse instruct the client to report to the healthcare provider immediately? Terrible nightmares. Increased nocturia. Severe muscle pain. Visual disturbances. - ✔ Severe muscle pain. A potential, serious side effect of statin therapy that is used to lower both LDL-C and triglyceride levels is rhabdomyolysis, which is manifested by severe muscle pain and aching. The nurse is caring for a client who is two days postoperative. Which observation should alert the nurse to call the Rapid Response Team (RRT)? Fresh bleeding noted on abdominal surgical wound dressing. Pulse change from 85 to160 beats/minute lasting more than 10 minutes. Temperature of 103.1 F (39.5 C) and white blood cell (WBC) count of 16,000 mm3. Weakness, diaphoresis, reports of feeling faint. BP 100/56 mmHg. - ✔ Pulse change from 85 to160 beats/minute lasting more than 10 minutes. The RRT should be called to intervene for a postoperative client with an acute life- threatening change, such as a pulse change resulting in tachycardia for a prolonged time period. A client is admitted after blunt abdominal injury. Which assessment finding requires immediate action by the nurse? Radiating abdominal pain with left lower quadrant palpation. Grimacing after palpation of the right hypochondriac region. Rebound tenderness with abdominal palpation. Bluish periumbilical skin discoloration. - ✔ Bluish periumbilical skin discoloration. Immediate action is indicated for intraperitoneal hemorrhage which causes periumbilical discoloration and indicates the presence of a splenic rupture, a life-threatening complication of blunt abdominal injury. Based on an analysis of the client's rhythm, atrial fibrillation, the nurse should prepare the client for which treatment protocol? Diuretic therapy. Pacemaker implantation.
Anticoagulation therapy. Cardiac catheterization. - ✔ Anticoagulation therapy. The client is experiencing atrial fibrillation, and the nurse should prepare the client for anticoagulation therapy which should be prescribed before rhythm control therapies to prevent cardioembolic events which result from blood pooling in the fibrillating atria. The nurse is preparing a client for orthopedic surgery on the left leg and completing a safety checklist before transport to the operating room. Which items should the nurse remove from the client? (Select all that apply.) Nail polish. Hearing aid. Wedding band. Left leg brace. Contact lenses. Partial dentures. - ✔ Nail polish. Hearing aid. Contact lenses. Partial dentures. The removal of nail polish provides a more accurate pulse oximetry readings and evaluation of capillary refill. Hearing aids, contact lenses, and partial dentures are removed to prevent damage, loss or misplacement, or injury during surgery. Ideally, give the client's significant other the contact lenses if they are not the disposable ones, hearing aids and partial dentures once placed in an appropriate labeled container to hold for safe keeping. If no significant other is not able to hold onto the items, then secured them in an appropriate and safe place. The nurse obtains a client's history that includes right mastectomy and radiation therapy for breast cancer 10 years ago. Which current health problem should the nurse consider is a consequence of the radiation therapy? Asthma. Myocardial infarction. Chronic esophagitis with gastroesophageal reflux. Pathologic fracture of two ribs on the right chest. - ✔ Pathologic fracture of two ribs on the right chest. The ribs lie in the radiation pathway and lose density over time, becoming thin and brittle, so the occurrence of two right-sided ribs with pathological fractures resulting without evidence of trauma is related to radiation damage.
A 49-year-old with pancreatitis complaining of unrelenting abdominal pain. A 55-year-old newly admitted client complaining of jaw pain and indigestion. - ✔ A 55-year-old newly admitted client complaining of jaw pain and indigestion. The 55-year-old client should be assessed first to rule out cardiac involvement because jaw pain and indigestion are common descriptors of myocardial injury. A female client with hyperesthesia on the oncology unit is using a transcutaneous electrical nerve stimulation (TENS) unit for chronic pain. Which nursing activity should the nurse implement instead of delegating to a practical nurse (PN)? Determine the client's level of discomfort using a pain rating scale. Ask the client about her past experience with chronic pain. Observe the client's facial expressions for pain and discomfort. Evaluate the client's ability to adjust the voltage to control pain. - ✔ Evaluate the client's ability to adjust the voltage to control pain. The oncology nurse has the knowledge and experience with the use of a transcutaneous electrical nerve stimulation (TENS) unit for chronic pain relief, so the nurse should evaluate the client's skill in effectively controlling the pain by adjusting the voltage. A Korean-American client, who speaks very little English, is being discharged following surgery. Which nurse should the nurse manager assign to provide the discharge instructions for the client? A graduate registered nurse (RN) with three weeks of experience. The registered nurse (RN) case-manager for the unit with 1 year's experience. A "floating" registered nurse (RN) with five years of nursing experience. An Korean-American practical nurse (PN) with six years of nursing experience. - ✔ The registered nurse (RN) case-manager for the unit with 1 year's experience. The RN case-manager is the best qualified nurse to assess and provide discharge educational needs, obtain resources for the client, enhance coordination of care, and prevent fragmentation of care. A client with a history of hypertension, myocardial infarction, and heart failure is admitted to the surgical intensive care unit after coronary artery bypass surgery graft (CABG). The nurse determines the client's serum potassium level is 4.5 mEq/L. What action should the nurse implement? Notify the healthcare provider. Decrease the IV solution flow rate. Document the finding as the only action. Administer potassium replacement as prescribed. - ✔ Document the finding as the only action.
Coronary artery bypass surgery graft (CABG) places a client at risk for hypokalemia from hemodilution, nasogastric suction, or diuretic therapy, so the serum potassium level is maintained between 4 and 5 mEq/L to avoid dysrhythmias. Documentation of the normal finding is indicated at this time. A client who returns to the unit after having a percutaneous transluminal coronary angioplasty (PTCA) complains of acute chest pain. What action should the nurse implement next? Inform the healthcare provider. Obtain a 12-lead electrocardiogram. Give a sublingual nitroglycerin tablet. Administer prescribed analgesic. - ✔ Give a sublingual nitroglycerin tablet. After a percutaneous transluminal coronary angioplasty (PTCA), a client who experiences acute chest pain may be experiencing cardiac ischemia related to restenosis, stent thrombosis, or acute coronary syndrome involving any coronary artery. The first action is to administer nitroglycerin to dilate the coronary arteries and increase myocardial oxygenation. A client who is admitted to the coronary care unit with a myocardial infarction (MI) begins to develop increased pulmonary congestion, an increase in heart rate from 80 to 102 beats per minute, and cold, clammy skin. What action should the nurse implement? Notify the healthcare provider. Increase the IV flow rate. Place the client in the supine position. Prepare the client for an emergency echocardiography. - ✔ Notify the healthcare provider. Increased pulmonary congestion, increased heart rate, and cold, clammy skin in a client with a myocardial infarction indicate impending cardiogenic shock related to heart failure, a common complication of MI. The healthcare provider should be notified immediately for emergency interventions of this life-threatening complication. A 24-year-old female client diagnosed with a human papillomavirus infection (HPV) is angry at her ex-boyfriend and says she is not going to tell him that he is infected. What response is best for the nurse to provide? "You do not have to tell him because this is not a reportable disease." "Because there is no cure for this disease, telling him is of no benefit to him or to you." "Even though you are angry, he should be told, so he can take precautions to prevent the spread of infection."
