HESI - MEDICAL SURGICAL NURSING
QUESTIONS AND ANSWERS WITH
VERIFIED SOLUTIONS 100%
CORRECT
The sound heard is crackles. Crackles often indicate atelectasis, which can be reversed
by using an incentive spirometer. If no spirometer is available, coughing and deep
breathing is the next best option. This client does not have wheezing, so
bronchodilators are not indicated. IV fluids would not help atelectasis.
A client with a history of heart failure is being discharged. Which priority instruction will
assist the client in the prevention of complications associated with heart failure?
A) "Eat six small meals daily instead of three larger meals."
B) "When you feel short of breath, take an additional diuretic."
C) "Avoid drinking more than 3 quarts of liquids each day."
D) "Weigh yourself daily while wearing the same amount of clothing." - CORRECT
ANSWES -- D
Clients with heart failure are instructed to weigh themselves daily to detect worsening
heart failure early, and thus avoid complications. Other signs of worsening heart failure
include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia.
The nurse assesses a client's legs. Which assessment finding indicates arterial
insufficiency?
A) Pain with activity but not while resting
B) Dependent mottling and absence of hair
C) Full veins present in dependent extremity
D) Ankle discoloration and pitting edema - CORRECT ANSWES -- B
Dependent mottling and absence of hair is an indication of arterial insufficiency. Pain
may be present with activity and at rest. Edema and ankle discoloration would be
indicative of venous insufficiency.
,The nurse is teaching a client with pneumonia ways to clear secretions. Which
intervention is the most effective?
A) Administering an antiemetic medication
B) Increasing fluids to 2 L/day if tolerated
C) Administering an antitussive medication
D) Having the client cough and deep breathe hourly - CORRECT ANSWES -- B
Increasing fluids has been proven to decrease the thickness of secretions, thus allowing
them to be expectorated quickly. The other interventions would not be as effective.
The nurse is assessing a client with left-sided heart failure. What conditions does the
nurse assess for? (Select all that apply.)
A) S3/S4 summation gallop
B) Cough worsens at night
C) Dependent edema
D) Pulmonary crackles
E) Confusion, restlessness
F) Pulmonary hypertension - CORRECT ANSWES -- A,B,D,E
Left-sided failure occurs with a decrease in contractility of the heart or an increase in
afterload. Most of the signs will be noted in the respiratory system. Right-sided failure
occurs with problems from the pulmonary vasculature onward. Signs will be noted
before the right atrium or ventricle.
The nurse assesses the patient and notes all of the following. Select all of the findings
that indicate the systemic manifestations of inflammation.
A) Oral temperature 38.6 F
B) WBC 20
C) Thick, green nasal discharge
D) Patient reports, "I'm tired all the time. I haven't felt like myself in days"
E) Patient complaint of pain at 6 on a 0 to 10 scale on palpation of frontal and maxillary
sinuses - CORRECT ANSWES -- A,B,D
Systemic manifestations of inflammatory response include elevated temperature,
leukocytosis, and malaise and fatigue. Purulent exudates and pain are both considered
local manifestations of inflammation.
A client with chronic obstructive pulmonary disease (COPD) reports social isolation.
What does the nurse encourage the client to do?
A) Participate in community activities.
B) Verbalize his or her thoughts and feelings.
C) Ask the client's physician for an antianxiety agent.
D) Join a support group for people with COPD. - CORRECT ANSWES -- B
,Many clients with moderate to severe COPD become socially isolated because they are
embarrassed by frequent coughing and mucus production. They also can experience
fatigue, which limits their activities. The nurse needs to encourage the client to verbalize
thoughts and feelings so that appropriate interventions can be selected. Joining a
support group would not decrease feelings of social isolation if the client does not
verbalize feelings. Antianxiety agents will not help the client with social isolation.
Encouraging a client to participate in activities without verbalizing concerns also would
not be an effective strategy for decreasing social isolation.
The nurse is assessing a client with lung disease. Which symptom does the nurse
intervene for first?
A) The client's anterior-posterior chest diameter is 2:2.
B) Clubbing of the finger tips is noted.
C) The client is pale.
D) The client has bilateral dependent leg edema. - CORRECT ANSWES -- D
The client with bilateral dependent edema may be developing right-sided heart failure in
response to respiratory disease. This symptom should be investigated right away and
reported to the health care provider. Further assessment is needed. The client with
chronic lung disease may develop increased anterior-posterior diameter and clubbing
as responses to chronic hypoxia. These symptoms do not require immediate
intervention. The client is often pale or has a dusky appearance; this also would not
warrant immediate intervention.
A patient is diagnosed with a sprain to her right ankle after a fall. The patient asks the
nurse about using ice on her injured ankle. The nurse should tell the patient that:
A) ice is not recommended for use on the sprain because it would inhibit the
inflammatory response.
B) ice should be applied for 15 to 20 minutes every 2 to 3 hours over the next 1 to 2
days.
C) she should use ice only when the ankle hurts.
D) she should wrap an ice pack around the injured ankle for the next 24 to 48 hours. -
CORRECT ANSWES -- B
Ice is used on areas of injury during the first 24 to 48 hours after the injury occurs to
prevent damage to surrounding tissues from excessive inflammation. Ice should be
used for a maximum of 20 minutes at a time every 2 to 3 hours. Ice must be used
according to a schedule for it to be effective and not be overused. Using ice more often
or for longer periods of time can cause additional tissue damage. Ice is recommended
to inhibit the inflammatory process from damaging surrounding tissue.
The nurse is assessing a patient for the adequacy of ventilation. What assessment
findings would indicate the patient has good ventilation? (Select all that apply.)
, A) There is presence of quiet, effortless breath sounds at lung base bilaterally.
B) Nail beds are pink with good capillary refill.
C) Trachea is just to the left of the sternal notch.
D) Respiratory rate is 24 breaths/min.
E) The right side of the thorax expands slightly more than the left.
F) Oxygen saturation level is 98%. - CORRECT ANSWES -- A,B,F
Oxygen saturation level should be between 95 and 100%; nail beds should be pink with
capillary refill of about 3 seconds; and breath sounds should be present at base of both
lungs. Normal respiratory rate is between 12 and 20 breaths/min. The trachea should be
in midline with the sternal notch. The thorax should expand equally on both sides.
The nurse is assessing clients on a cardiac unit. Which client does the nurse assess
most carefully for developing left-sided heart failure?
When describing patient education approaches, the nurse educator would explain that
informal teaching is an approach that
a. follows formalized plans
b. has standardized content
c. often occurs one-to-one
d. addresses group needs - CORRECT ANSWES -- C. Informal teaching is
individualized one on one teaching which represents the majority of patient education
done by nurses that occurs when an intervention is explained or a question is
answered. Group needs are often the focus of formal patient education courses or
classes. Informal teaching does not necessarily follow a specific formalized plan. It may
be planned with specific content, but it is individualized responses to patient needs.
Formal teaching involves the use of a curriculum/course plan with standardized content.
A patient expresses a strong interest in returning to their work, family, and hobbies after
having a stroke. Which theory type would the nurse use to develop a plan of care for the
best results of this patient's motivation style?
a. field
b. biological
c. cognitive
d. sociologic - CORRECT ANSWES -- C. Cognitive theorists believe that attention,
relevance, confidence, and satisfaction (ARCS) are the conditions that, when
integrated, motivate someone to learn. Field theorists place significance on how
achievement, power, the need for affiliation, and avoidance motives influence individual
behavior. Sociologic theories are not involved in motivation.
The nurse is assessing a group of clients. Which clients are at greater risk for
hypothermia or frostbite? (select all that apply)
QUESTIONS AND ANSWERS WITH
VERIFIED SOLUTIONS 100%
CORRECT
The sound heard is crackles. Crackles often indicate atelectasis, which can be reversed
by using an incentive spirometer. If no spirometer is available, coughing and deep
breathing is the next best option. This client does not have wheezing, so
bronchodilators are not indicated. IV fluids would not help atelectasis.
A client with a history of heart failure is being discharged. Which priority instruction will
assist the client in the prevention of complications associated with heart failure?
A) "Eat six small meals daily instead of three larger meals."
B) "When you feel short of breath, take an additional diuretic."
C) "Avoid drinking more than 3 quarts of liquids each day."
D) "Weigh yourself daily while wearing the same amount of clothing." - CORRECT
ANSWES -- D
Clients with heart failure are instructed to weigh themselves daily to detect worsening
heart failure early, and thus avoid complications. Other signs of worsening heart failure
include increasing dyspnea, exercise intolerance, cold symptoms, and nocturia.
The nurse assesses a client's legs. Which assessment finding indicates arterial
insufficiency?
A) Pain with activity but not while resting
B) Dependent mottling and absence of hair
C) Full veins present in dependent extremity
D) Ankle discoloration and pitting edema - CORRECT ANSWES -- B
Dependent mottling and absence of hair is an indication of arterial insufficiency. Pain
may be present with activity and at rest. Edema and ankle discoloration would be
indicative of venous insufficiency.
,The nurse is teaching a client with pneumonia ways to clear secretions. Which
intervention is the most effective?
A) Administering an antiemetic medication
B) Increasing fluids to 2 L/day if tolerated
C) Administering an antitussive medication
D) Having the client cough and deep breathe hourly - CORRECT ANSWES -- B
Increasing fluids has been proven to decrease the thickness of secretions, thus allowing
them to be expectorated quickly. The other interventions would not be as effective.
The nurse is assessing a client with left-sided heart failure. What conditions does the
nurse assess for? (Select all that apply.)
A) S3/S4 summation gallop
B) Cough worsens at night
C) Dependent edema
D) Pulmonary crackles
E) Confusion, restlessness
F) Pulmonary hypertension - CORRECT ANSWES -- A,B,D,E
Left-sided failure occurs with a decrease in contractility of the heart or an increase in
afterload. Most of the signs will be noted in the respiratory system. Right-sided failure
occurs with problems from the pulmonary vasculature onward. Signs will be noted
before the right atrium or ventricle.
The nurse assesses the patient and notes all of the following. Select all of the findings
that indicate the systemic manifestations of inflammation.
A) Oral temperature 38.6 F
B) WBC 20
C) Thick, green nasal discharge
D) Patient reports, "I'm tired all the time. I haven't felt like myself in days"
E) Patient complaint of pain at 6 on a 0 to 10 scale on palpation of frontal and maxillary
sinuses - CORRECT ANSWES -- A,B,D
Systemic manifestations of inflammatory response include elevated temperature,
leukocytosis, and malaise and fatigue. Purulent exudates and pain are both considered
local manifestations of inflammation.
A client with chronic obstructive pulmonary disease (COPD) reports social isolation.
What does the nurse encourage the client to do?
A) Participate in community activities.
B) Verbalize his or her thoughts and feelings.
C) Ask the client's physician for an antianxiety agent.
D) Join a support group for people with COPD. - CORRECT ANSWES -- B
,Many clients with moderate to severe COPD become socially isolated because they are
embarrassed by frequent coughing and mucus production. They also can experience
fatigue, which limits their activities. The nurse needs to encourage the client to verbalize
thoughts and feelings so that appropriate interventions can be selected. Joining a
support group would not decrease feelings of social isolation if the client does not
verbalize feelings. Antianxiety agents will not help the client with social isolation.
Encouraging a client to participate in activities without verbalizing concerns also would
not be an effective strategy for decreasing social isolation.
The nurse is assessing a client with lung disease. Which symptom does the nurse
intervene for first?
A) The client's anterior-posterior chest diameter is 2:2.
B) Clubbing of the finger tips is noted.
C) The client is pale.
D) The client has bilateral dependent leg edema. - CORRECT ANSWES -- D
The client with bilateral dependent edema may be developing right-sided heart failure in
response to respiratory disease. This symptom should be investigated right away and
reported to the health care provider. Further assessment is needed. The client with
chronic lung disease may develop increased anterior-posterior diameter and clubbing
as responses to chronic hypoxia. These symptoms do not require immediate
intervention. The client is often pale or has a dusky appearance; this also would not
warrant immediate intervention.
A patient is diagnosed with a sprain to her right ankle after a fall. The patient asks the
nurse about using ice on her injured ankle. The nurse should tell the patient that:
A) ice is not recommended for use on the sprain because it would inhibit the
inflammatory response.
B) ice should be applied for 15 to 20 minutes every 2 to 3 hours over the next 1 to 2
days.
C) she should use ice only when the ankle hurts.
D) she should wrap an ice pack around the injured ankle for the next 24 to 48 hours. -
CORRECT ANSWES -- B
Ice is used on areas of injury during the first 24 to 48 hours after the injury occurs to
prevent damage to surrounding tissues from excessive inflammation. Ice should be
used for a maximum of 20 minutes at a time every 2 to 3 hours. Ice must be used
according to a schedule for it to be effective and not be overused. Using ice more often
or for longer periods of time can cause additional tissue damage. Ice is recommended
to inhibit the inflammatory process from damaging surrounding tissue.
The nurse is assessing a patient for the adequacy of ventilation. What assessment
findings would indicate the patient has good ventilation? (Select all that apply.)
, A) There is presence of quiet, effortless breath sounds at lung base bilaterally.
B) Nail beds are pink with good capillary refill.
C) Trachea is just to the left of the sternal notch.
D) Respiratory rate is 24 breaths/min.
E) The right side of the thorax expands slightly more than the left.
F) Oxygen saturation level is 98%. - CORRECT ANSWES -- A,B,F
Oxygen saturation level should be between 95 and 100%; nail beds should be pink with
capillary refill of about 3 seconds; and breath sounds should be present at base of both
lungs. Normal respiratory rate is between 12 and 20 breaths/min. The trachea should be
in midline with the sternal notch. The thorax should expand equally on both sides.
The nurse is assessing clients on a cardiac unit. Which client does the nurse assess
most carefully for developing left-sided heart failure?
When describing patient education approaches, the nurse educator would explain that
informal teaching is an approach that
a. follows formalized plans
b. has standardized content
c. often occurs one-to-one
d. addresses group needs - CORRECT ANSWES -- C. Informal teaching is
individualized one on one teaching which represents the majority of patient education
done by nurses that occurs when an intervention is explained or a question is
answered. Group needs are often the focus of formal patient education courses or
classes. Informal teaching does not necessarily follow a specific formalized plan. It may
be planned with specific content, but it is individualized responses to patient needs.
Formal teaching involves the use of a curriculum/course plan with standardized content.
A patient expresses a strong interest in returning to their work, family, and hobbies after
having a stroke. Which theory type would the nurse use to develop a plan of care for the
best results of this patient's motivation style?
a. field
b. biological
c. cognitive
d. sociologic - CORRECT ANSWES -- C. Cognitive theorists believe that attention,
relevance, confidence, and satisfaction (ARCS) are the conditions that, when
integrated, motivate someone to learn. Field theorists place significance on how
achievement, power, the need for affiliation, and avoidance motives influence individual
behavior. Sociologic theories are not involved in motivation.
The nurse is assessing a group of clients. Which clients are at greater risk for
hypothermia or frostbite? (select all that apply)
