MED SURG II HESI EVALUATION ACTUAL
QUESTIONS AND ANSWERS SURE A+
✔✔Immediately after a liver biopsy, a client is placed onto the right side. The nurse
explains that the rationale for this positioning is to: - ✔✔Compress blood vessels to
prevent bleeding
✔✔A client is cautioned to avoid vitamin D toxicity while increasing protein intake.
Which nutrient selected by the client indicates to the nurse that the dietary teaching is
understood? - ✔✔Tofu
✔✔A client just has returned from the postanesthesia care unit after having a
laparotomy. Which sign or symptom indicates to the nurse that peristalsis has begun to
return? - ✔✔Borborygmi are auscultated
✔✔A client who is scheduled for a bowel resection is to receive antibiotics
preoperatively. The nurse teaches the client that the purpose of the antibiotics is to help:
- ✔✔Eliminate bacteria from the gastrointestinal (GI) tract
✔✔After sustaining multiple internal injuries when hit by a motor vehicle, a client has a
sudden drop in blood pressure to 80/60 mm Hg. What does the nurse determine
probably caused this response? - ✔✔Reduction in circulating blood volume.
✔✔A nurse completes an admission assessment on a client who is diagnosed with
myasthenia gravis. Which clinical finding is the nurse most likely to identify? -
✔✔Difficulty swallowing saliva
✔✔A client has a permanent sigmoid colostomy as a result of cancer of the rectum. The
primary health care provider prescribes daily colostomy irrigations. The nurse explains
that the primary purpose of these irrigations is to: - ✔✔Establish a regular elimination
schedule
, ✔✔A client is experiencing diplopia, ptosis, and mild dysphagia. Myasthenia gravis is
diagnosed and an anticholinergic medication is prescribed. The nurse is planning care
with the client and spouse. What instruction is the priority? - ✔✔Take the medication
according to a specific schedule
✔✔The nurse is providing postoperative care eight hours after a client had a total
cystectomy and the formation of an ileal conduit. What assessment finding should be
reported immediately? - ✔✔Dusky-colored stoma
✔✔A child with a congenital heart defect has a cardiac catheterization. What is an
essential element of nursing care after this procedure? - ✔✔Monitoring the extremity
distal to the insertion site
✔✔A nurse is caring for a client with a history of chronic obstructive pulmonary disease
(COPD) who develops a pneumothorax and has a chest tube inserted. What is the
primary purpose of the chest tube? - ✔✔Restores negative pressure in the pleural
space
✔✔Potassium supplements are prescribed for a client receiving diuretic therapy. What
client statement indicates that the teaching about potassium supplements is
understood? - ✔✔I will report any abdominal distress."
✔✔A client is hospitalized with a diagnosis of emphysema. The nurse provides teaching
and should begin with which aspect of care? - ✔✔The disease process and breathing
exercises
✔✔A nurse is reviewing the laboratory results of and collecting a health history from a
client with a diagnosis of colitis. Which common clinical manifestation of colitis should
the nurse expect? - ✔✔Weight loss
✔✔A nurse is caring for a client with a hiatal hernia. Which risk factor is associated
most commonly with this diagnosis? - ✔✔Obesity
✔✔A client with rheumatoid arthritis is scheduled to participate in an exercise program
that is established at the extended care facility where the client resides. The nurse
evaluates that the client understands the purpose of the program when the client states:
- ✔✔After I eat breakfast, I do one set of exercises slowly, and then I space the rest of
them throughout the day."
✔✔Six hours after major abdominal surgery, a client complains of severe abdominal
pain and feeling faint. The nurse identifies a thready, rapid pulse. The nurse checks the
Physiological Aspects of Care record and determines that the client can receive another
QUESTIONS AND ANSWERS SURE A+
✔✔Immediately after a liver biopsy, a client is placed onto the right side. The nurse
explains that the rationale for this positioning is to: - ✔✔Compress blood vessels to
prevent bleeding
✔✔A client is cautioned to avoid vitamin D toxicity while increasing protein intake.
Which nutrient selected by the client indicates to the nurse that the dietary teaching is
understood? - ✔✔Tofu
✔✔A client just has returned from the postanesthesia care unit after having a
laparotomy. Which sign or symptom indicates to the nurse that peristalsis has begun to
return? - ✔✔Borborygmi are auscultated
✔✔A client who is scheduled for a bowel resection is to receive antibiotics
preoperatively. The nurse teaches the client that the purpose of the antibiotics is to help:
- ✔✔Eliminate bacteria from the gastrointestinal (GI) tract
✔✔After sustaining multiple internal injuries when hit by a motor vehicle, a client has a
sudden drop in blood pressure to 80/60 mm Hg. What does the nurse determine
probably caused this response? - ✔✔Reduction in circulating blood volume.
✔✔A nurse completes an admission assessment on a client who is diagnosed with
myasthenia gravis. Which clinical finding is the nurse most likely to identify? -
✔✔Difficulty swallowing saliva
✔✔A client has a permanent sigmoid colostomy as a result of cancer of the rectum. The
primary health care provider prescribes daily colostomy irrigations. The nurse explains
that the primary purpose of these irrigations is to: - ✔✔Establish a regular elimination
schedule
, ✔✔A client is experiencing diplopia, ptosis, and mild dysphagia. Myasthenia gravis is
diagnosed and an anticholinergic medication is prescribed. The nurse is planning care
with the client and spouse. What instruction is the priority? - ✔✔Take the medication
according to a specific schedule
✔✔The nurse is providing postoperative care eight hours after a client had a total
cystectomy and the formation of an ileal conduit. What assessment finding should be
reported immediately? - ✔✔Dusky-colored stoma
✔✔A child with a congenital heart defect has a cardiac catheterization. What is an
essential element of nursing care after this procedure? - ✔✔Monitoring the extremity
distal to the insertion site
✔✔A nurse is caring for a client with a history of chronic obstructive pulmonary disease
(COPD) who develops a pneumothorax and has a chest tube inserted. What is the
primary purpose of the chest tube? - ✔✔Restores negative pressure in the pleural
space
✔✔Potassium supplements are prescribed for a client receiving diuretic therapy. What
client statement indicates that the teaching about potassium supplements is
understood? - ✔✔I will report any abdominal distress."
✔✔A client is hospitalized with a diagnosis of emphysema. The nurse provides teaching
and should begin with which aspect of care? - ✔✔The disease process and breathing
exercises
✔✔A nurse is reviewing the laboratory results of and collecting a health history from a
client with a diagnosis of colitis. Which common clinical manifestation of colitis should
the nurse expect? - ✔✔Weight loss
✔✔A nurse is caring for a client with a hiatal hernia. Which risk factor is associated
most commonly with this diagnosis? - ✔✔Obesity
✔✔A client with rheumatoid arthritis is scheduled to participate in an exercise program
that is established at the extended care facility where the client resides. The nurse
evaluates that the client understands the purpose of the program when the client states:
- ✔✔After I eat breakfast, I do one set of exercises slowly, and then I space the rest of
them throughout the day."
✔✔Six hours after major abdominal surgery, a client complains of severe abdominal
pain and feeling faint. The nurse identifies a thready, rapid pulse. The nurse checks the
Physiological Aspects of Care record and determines that the client can receive another
