Med Surg HESI V2 Exam Testbank - UP-TO-
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Question 1
What information should the nurse include in the teaching plan of a client
diagnosed with GERD?
A. Sleep without pillows
B. Adjust food intake to three full meals per day with no snacks
C. Minimize symptoms by wearing loose comfortable clothing
D. Avoid participation in any aerobic exercise program
Correct Answer: C. Minimize symptoms by wearing loose comfortable clothing
Explanation: Wearing loose, comfortable clothing helps minimize abdominal pressure that
can exacerbate GERD symptoms. Tight clothing around the waist increases intra-
abdominal pressure, promoting acid reflux. Clients should also elevate the head of the bed,
eat small frequent meals, and avoid lying down after eating .
Question 2
After hospitalization for SIADH, a client develops pontine myelinolysis. Which
intervention should the nurse implement first?
,A. Reorient client to room
B. Place a patch on one eye
C. Evaluate client's ability to swallow
D. Perform range of motion exercises
Correct Answer: A. Reorient client to room
Explanation: Pontine myelinolysis is a neurological complication associated with rapid
correction of hyponatremia. The priority nursing intervention is safety and orientation.
Reorienting the client to their environment addresses the potential for confusion and
disorientation associated with this condition .
Question 3
A male client with heart failure calls the clinic and reports that he cannot put his
shoes on because they are too tight. Which additional information should the
nurse obtain?
A. What time did he take his medication?
B. Has his weight changed in the last several days?
C. Is he still able to tighten his belt buckle?
D. How many hours did he sleep last night?
Correct Answer: B. Has his weight changed in the last several days?
Explanation: Weight gain is a key indicator of fluid retention in heart failure patients. Tight
shoes suggest peripheral edema, indicating worsening fluid overload. Daily weight
monitoring is essential; a 2-3 pound gain in 24 hours or 5 pounds in a week should be
reported .
Question 4
An older adult woman with a long history of COPD is admitted with progressive
shortness of breath, a persistent cough, anxiety, and dry mouth. Which
intervention should the nurse implement?
,A. Administer a prescribed sedative
B. Encourage client to drink water
C. Apply a high flow Venturi mask
D. Assist her to an upright position
Correct Answer: D. Assist her to an upright position
Explanation: For COPD patients with shortness of breath, positioning is the priority
intervention. An upright position (high Fowler's) promotes lung expansion, facilitates
diaphragmatic breathing, and reduces work of breathing. This is more immediately
beneficial than fluids, while sedatives may depress respiration in COPD patients .
Question 5
A client with a history of asthma and bronchitis arrives at the clinic with shortness
of breath, productive cough with thickening mucous, and the inability to walk up a
flight of stairs without experiencing breathlessness. Which action is most
important for the nurse to instruct the client about self-care?
A. Increase daily intake of oral fluids to liquefy secretions
B. Avoid crowded enclosed areas to reduce pathogens exposure
C. Call the clinic if undesirable side effects occur from medications
D. Use bronchodilators before activities
Correct Answer: A. Increase daily intake of oral fluids to liquefy secretions
Explanation: Thick, tenacious mucus is a hallmark of bronchitis and asthma exacerbations.
Increasing oral fluid intake (2-3 L daily unless contraindicated) helps thin secretions,
making them easier to expectorate. This promotes airway clearance and improves
breathing .
Question 6
, A client with Cholelithiasis has a gallstone lodged in the common bile duct and is
unable to eat or drink without becoming nauseous and vomiting. Which finding
should the nurse report to the healthcare provider?
A. Belching
B. Amber urine
C. Yellow sclera
D. Flatulence
Correct Answer: C. Yellow sclera
Explanation: Yellow sclera indicates jaundice, which occurs when a gallstone obstructs the
common bile duct, causing bile to back up into the liver and bloodstream. This is a critical
finding requiring immediate HCP notification as it indicates biliary obstruction that can
lead to liver damage .
Question 7
While caring for a client with Amyotrophic lateral sclerosis (ALS), a nurse performs
a neurological assessment every 4 hours. Which assessment finding warrants
immediate intervention by the nurse?
A. Inappropriate laughter
B. Increasing anxiety
C. Weakened cough effort
D. Asymmetrical weakness
Correct Answer: C. Weakened cough effort
Explanation: In ALS, weakened cough effort is a priority concern as it indicates declining
respiratory muscle function. This puts the client at high risk for aspiration, pneumonia, and
respiratory failure. Immediate intervention is needed to prevent airway compromise .
Question 8
DATE EXAM QUESTIONS AND 100%
ACCURATE SOLUTIONS | Question And
VERIFIED ANSWERS - INSTANT PDF
DOWNLOAD.
Question 1
What information should the nurse include in the teaching plan of a client
diagnosed with GERD?
A. Sleep without pillows
B. Adjust food intake to three full meals per day with no snacks
C. Minimize symptoms by wearing loose comfortable clothing
D. Avoid participation in any aerobic exercise program
Correct Answer: C. Minimize symptoms by wearing loose comfortable clothing
Explanation: Wearing loose, comfortable clothing helps minimize abdominal pressure that
can exacerbate GERD symptoms. Tight clothing around the waist increases intra-
abdominal pressure, promoting acid reflux. Clients should also elevate the head of the bed,
eat small frequent meals, and avoid lying down after eating .
Question 2
After hospitalization for SIADH, a client develops pontine myelinolysis. Which
intervention should the nurse implement first?
,A. Reorient client to room
B. Place a patch on one eye
C. Evaluate client's ability to swallow
D. Perform range of motion exercises
Correct Answer: A. Reorient client to room
Explanation: Pontine myelinolysis is a neurological complication associated with rapid
correction of hyponatremia. The priority nursing intervention is safety and orientation.
Reorienting the client to their environment addresses the potential for confusion and
disorientation associated with this condition .
Question 3
A male client with heart failure calls the clinic and reports that he cannot put his
shoes on because they are too tight. Which additional information should the
nurse obtain?
A. What time did he take his medication?
B. Has his weight changed in the last several days?
C. Is he still able to tighten his belt buckle?
D. How many hours did he sleep last night?
Correct Answer: B. Has his weight changed in the last several days?
Explanation: Weight gain is a key indicator of fluid retention in heart failure patients. Tight
shoes suggest peripheral edema, indicating worsening fluid overload. Daily weight
monitoring is essential; a 2-3 pound gain in 24 hours or 5 pounds in a week should be
reported .
Question 4
An older adult woman with a long history of COPD is admitted with progressive
shortness of breath, a persistent cough, anxiety, and dry mouth. Which
intervention should the nurse implement?
,A. Administer a prescribed sedative
B. Encourage client to drink water
C. Apply a high flow Venturi mask
D. Assist her to an upright position
Correct Answer: D. Assist her to an upright position
Explanation: For COPD patients with shortness of breath, positioning is the priority
intervention. An upright position (high Fowler's) promotes lung expansion, facilitates
diaphragmatic breathing, and reduces work of breathing. This is more immediately
beneficial than fluids, while sedatives may depress respiration in COPD patients .
Question 5
A client with a history of asthma and bronchitis arrives at the clinic with shortness
of breath, productive cough with thickening mucous, and the inability to walk up a
flight of stairs without experiencing breathlessness. Which action is most
important for the nurse to instruct the client about self-care?
A. Increase daily intake of oral fluids to liquefy secretions
B. Avoid crowded enclosed areas to reduce pathogens exposure
C. Call the clinic if undesirable side effects occur from medications
D. Use bronchodilators before activities
Correct Answer: A. Increase daily intake of oral fluids to liquefy secretions
Explanation: Thick, tenacious mucus is a hallmark of bronchitis and asthma exacerbations.
Increasing oral fluid intake (2-3 L daily unless contraindicated) helps thin secretions,
making them easier to expectorate. This promotes airway clearance and improves
breathing .
Question 6
, A client with Cholelithiasis has a gallstone lodged in the common bile duct and is
unable to eat or drink without becoming nauseous and vomiting. Which finding
should the nurse report to the healthcare provider?
A. Belching
B. Amber urine
C. Yellow sclera
D. Flatulence
Correct Answer: C. Yellow sclera
Explanation: Yellow sclera indicates jaundice, which occurs when a gallstone obstructs the
common bile duct, causing bile to back up into the liver and bloodstream. This is a critical
finding requiring immediate HCP notification as it indicates biliary obstruction that can
lead to liver damage .
Question 7
While caring for a client with Amyotrophic lateral sclerosis (ALS), a nurse performs
a neurological assessment every 4 hours. Which assessment finding warrants
immediate intervention by the nurse?
A. Inappropriate laughter
B. Increasing anxiety
C. Weakened cough effort
D. Asymmetrical weakness
Correct Answer: C. Weakened cough effort
Explanation: In ALS, weakened cough effort is a priority concern as it indicates declining
respiratory muscle function. This puts the client at high risk for aspiration, pneumonia, and
respiratory failure. Immediate intervention is needed to prevent airway compromise .
Question 8
