NURl 209/l NUR209l HESIl –l (Newl 2026/l
2027l Update)l Medical-Surgicall Nursingl IIl
|l Questionsl &l Answersl |l Gradel A|l 100%l
Correctl (Verifiedl Solutions)-l Fortis
QUESTION
Al clientl whol hasl justl testedl positivel forl humanl immunodeficiencyl virusl (HIV)l doesl
notl appearl tol hearl whatl thel nursel isl sayingl duringl post-testl counseling.l Whichl
informationl shouldl thel nursel offerl tol facilitatel thel client'sl adjustmentl tol HIVl infection?
A)l Informl thel clientl howl tol protectl sexuall andl needle-sharingl partners.l
B)l Teachl thel clientl aboutl thel medicationsl thatl arel availablel forl treatment.l
C)l Identifyl thel needl tol testl othersl whol havel hadl riskyl contactl withl thel client.l
D)l Discussl retestingl tol verifyl thel results,l whichl willl ensurel continuingl contact.
Answer:
D)l Discussl retestingl tol verifyl thel results,l whichl willl ensurel continuingl contact.
Rationale:l Encouragingl retestingl (D)l supportsl hopel andl givesl thel clientl timel tol copel
withl thel diagnosis.l Althoughl post-testl counselingl shouldl includel educationl aboutl (A,l B,l
andl C),l retestingl encouragesl thel clientl tol maintainl medicall follow-upl andl management.
QUESTION
Thel nursel hearsl short,l high-pitchedl soundsl justl beforel thel endl ofl inspirationl inl thel
rightl andl leftl lowerl lobesl whenl auscultatingl al client'sl lungs.l Howl shouldl thisl findingl
bel recorded?
A)l Inspiratoryl wheezesl inl bothl lungs.l
B)l Cracklesl inl thel rightl andl leftl lowerl lobes.l
C)l Abnormall lungl soundsl inl thel basesl ofl bothl lungs.l
D)l Pleurall frictionl rubl inl thel rightl andl leftl lowerl lobes.
Answer:
,B)l Cracklesl inl thel rightl andl leftl lowerl lobes.l
Rationale:l Finel cracklesl (B)l arel short,l high-pitchedl soundsl heardl justl beforel thel endl ofl
inspirationl thatl arel thel resultl ofl rapidl equalizationl ofl pressurel whenl collapsedl alveolil
orl terminall bronchiolesl suddenlyl snapl open.l Wheezingl (A)l isl al continuousl high-pitchedl
squeakingl orl musicall soundl causedl byl rapidl vibrationl ofl bronchiall wallsl thatl arel firstl
evidentl onl expirationl andl mayl bel audible.l Althoughl (C)l describesl anl adventitiousl lungl
sound,l thisl documentationl isl vague.l (D)l isl al creakingl orl gratingl soundl froml roughened,l
inflamedl surfacesl ofl thel pleural rubbingl togetherl heardl duringl inspiration,l expiration,l andl
withl nol changel duringl coughing.
QUESTION
Al clientl asksl thel nursel aboutl thel purposel ofl beginningl chemotherapyl (CT)l becausel thel
tumorl isl stilll veryl small.l Whichl informationl supportsl thel explanationl thatl thel nursel
shouldl provide?
A)l Sidel effectsl arel lessl likelyl ifl therapyl isl startedl early.l
B)l Collaterall circulationl increasesl asl thel tumorl grows.l
C)l Sensitivityl ofl cancerl cellsl tol CTl isl basedl onl celll cyclel rate.l
D)l Thel celll countl ofl thel tumorl reducesl byl halfl withl eachl dose.
Answer:
D)l Thel celll countl ofl thel tumorl reducesl byl halfl withl eachl dose.
Rationale:l Initiatingl chemotherapyl whilel thel tumorl isl smalll providesl al betterl chancel ofl
eradicatingl alll cancerl cellsl becausel 50%l ofl cancerl cellsl orl tumorl cellsl arel killedl withl
eachl dose.l (A,l B,l andl C)l varyl basedl onl thel typel ofl cancer.
QUESTION
Thel nursel isl caringl forl al clientl withl non-Hodgkin'sl lymphomal whol isl receivingl
chemotherapy.l Laboratoryl resultsl reveall al plateletl countl ofl 10,000/ml.l Whatl actionl
shouldl thel nursel implement?
A)l Encouragel fluidsl tol 3000l ml/day.l
B)l Checkl stoolsl forl occultl blood.l
C)l Providel orall hygienel everyl 2l hours.l
D)l Checkl forl feverl everyl 4l hours.
Answer:
,B)l Checkl stoolsl forl occultl blood.l
Rationale:l Plateletl countsl lessl thanl 100,000/mm3l arel indicativel ofl thrombocytopenia,l al
commonl sidel effectl ofl chemotherapy.l Al clientl withl thrombocytopenial shouldl bel
assessedl frequentlyl forl occultl bleedingl inl thel emesis,l sputum,l fecesl (B),l urine,l
nasogastricl secretions,l orl wounds.l (A)l doesl notl minimizel thel riskl forl bleedingl
associatedl withl thrombocytopenia.l (C)l mayl causel increasedl bleedingl inl al clientl withl
thromobcytopenia.l (D)l assessesl forl infection,l notl riskl forl bleeding.
QUESTION
Thel nursel isl caringl forl al clientl withl endl stagel liverl diseasel whol isl beingl assessedl forl
thel presencel ofl asterixis.l Tol assessl thel clientl forl asterixis,l whatl positionl shouldl thel
nursel askl thel clientl tol demonstrate?
A)l Extendl thel leftl arml laterallyl withl thel leftl palml upward.l
B)l Extendl thel arm,l dorsiflexl thel wrist,l andl extendl thel fingers.l
C)l Extendl thel armsl andl holdl thisl positionl forl 30l seconds.l
D)l Extendl armsl withl bothl legsl adductedl tol shoulderl width.
Answer:
B)l Extendl thel arm,l dorsiflexl thel wrist,l andl extendl thel fingers.
Rationale:l Asterixisl (flappingl tremor,l liverl flap)l isl al hand-flappingl tremorl thatl isl oftenl
seenl frequentlyl inl hepaticl encephalopathy.l Thel tremorl isl inducedl byl extendingl thel arml
andl dorsiflexingl thel wristl causingl rapid,l non-rhythmicl extensionl andl flexionl ofl thel
wristl whilel attemptingl tol holdl positionl (B).l (A,l C,l andl D)l dol notl illicitl axterixis.
QUESTION
Duringl thel assessmentl ofl al clientl whol isl 24l hoursl post-hemicolectomyl withl al
temporaryl colostomy,l thel nursel determinesl thatl thel client'sl stomal isl dryl andl darkl redl
inl color.l Whatl actionl shouldl thel nursel implement?
A)l Notifyl thel surgeon.l
B)l Documentl thel assessment.l
C)l Securel al colostomyl pouchl overl thel stoma.l
D)l Placel petrolatuml gauzel dressingl overl thel stoma.
Answer:
A)l Notifyl thel surgeon.l
, *l Thel stomal shouldl appearl reddishl pinkl andl moist,l whichl indicatesl circulatoryl
perfusionl tol thel surgicall diversionl ofl thel intestine.l Ifl thel stomal becomesl dry,l firm,l
flaccid,l orl isl darkl redl orl purple,l thel stomal isl ischemic,l andl thel surgeonl shouldl bel
notifiedl immediatelyl (A).l Althoughl (B,l C,l andl D)l mayl bel implemented,l thel findingsl
requirel immediatel medicall attention.
QUESTION
Whatl assessmentl findingl shouldl thel nursel identifyl thatl indicatesl al clientl withl anl acutel
asthmal exacerbationl isl beginningl tol improvel afterl treatment?
A)l Wheezingl becomesl louder.l
B)l Coughl remainsl unproductive.l
C)l Vesicularl breathl soundsl decrease.l
D)l Bronchodilatorsl stimulatel coughing.
Answer:
A)l Wheezingl becomesl louder.
l
*l Inl anl acutel asthmal attack,l airl flowl mayl bel sol significantlyl restrictedl thatl wheezingl
isl diminished.l Ifl thel clientl isl successfullyl respondingl tol bronchodilatorsl andl respiratoryl
treatments,l wheezingl becomesl louderl (A)l asl airl flowl increasesl inl thel airways.l Asl thel
airwaysl openl andl mucousl isl mobilizedl inl responsel tol treatment,l thel coughl becomesl
morel productive,l notl (B).l Vesicularl soundsl arel soft,l low-pitched,l gentle,l rustlingl soundsl
heardl overl lungl fieldsl (C)l andl isl notl anl indicatorl ofl improvementl duringl asthmal
treatment.l Bronchodilatorsl dol notl stimulatel coughingl (D).
QUESTION
Al clientl isl admittedl tol thel emergencyl departmentl afterl beingl lostl forl fourl daysl whilel
hikingl inl al nationall forest.l Uponl reviewl ofl thel laboratoryl results,l thel nursel determinesl
thel client'sl seruml levell forl thyroid-stimulatingl hormonel (TSH)l isl elevated.l Whichl
additionall assessmentl shouldl thel nursel make?
A)l Bodyl massl index.l
B)l Skinl elasticityl andl turgor.l
C)l Thoughtl processesl andl speech.l
D)l Exposurel tol coldl environmentall temperatures.
Answer:
2027l Update)l Medical-Surgicall Nursingl IIl
|l Questionsl &l Answersl |l Gradel A|l 100%l
Correctl (Verifiedl Solutions)-l Fortis
QUESTION
Al clientl whol hasl justl testedl positivel forl humanl immunodeficiencyl virusl (HIV)l doesl
notl appearl tol hearl whatl thel nursel isl sayingl duringl post-testl counseling.l Whichl
informationl shouldl thel nursel offerl tol facilitatel thel client'sl adjustmentl tol HIVl infection?
A)l Informl thel clientl howl tol protectl sexuall andl needle-sharingl partners.l
B)l Teachl thel clientl aboutl thel medicationsl thatl arel availablel forl treatment.l
C)l Identifyl thel needl tol testl othersl whol havel hadl riskyl contactl withl thel client.l
D)l Discussl retestingl tol verifyl thel results,l whichl willl ensurel continuingl contact.
Answer:
D)l Discussl retestingl tol verifyl thel results,l whichl willl ensurel continuingl contact.
Rationale:l Encouragingl retestingl (D)l supportsl hopel andl givesl thel clientl timel tol copel
withl thel diagnosis.l Althoughl post-testl counselingl shouldl includel educationl aboutl (A,l B,l
andl C),l retestingl encouragesl thel clientl tol maintainl medicall follow-upl andl management.
QUESTION
Thel nursel hearsl short,l high-pitchedl soundsl justl beforel thel endl ofl inspirationl inl thel
rightl andl leftl lowerl lobesl whenl auscultatingl al client'sl lungs.l Howl shouldl thisl findingl
bel recorded?
A)l Inspiratoryl wheezesl inl bothl lungs.l
B)l Cracklesl inl thel rightl andl leftl lowerl lobes.l
C)l Abnormall lungl soundsl inl thel basesl ofl bothl lungs.l
D)l Pleurall frictionl rubl inl thel rightl andl leftl lowerl lobes.
Answer:
,B)l Cracklesl inl thel rightl andl leftl lowerl lobes.l
Rationale:l Finel cracklesl (B)l arel short,l high-pitchedl soundsl heardl justl beforel thel endl ofl
inspirationl thatl arel thel resultl ofl rapidl equalizationl ofl pressurel whenl collapsedl alveolil
orl terminall bronchiolesl suddenlyl snapl open.l Wheezingl (A)l isl al continuousl high-pitchedl
squeakingl orl musicall soundl causedl byl rapidl vibrationl ofl bronchiall wallsl thatl arel firstl
evidentl onl expirationl andl mayl bel audible.l Althoughl (C)l describesl anl adventitiousl lungl
sound,l thisl documentationl isl vague.l (D)l isl al creakingl orl gratingl soundl froml roughened,l
inflamedl surfacesl ofl thel pleural rubbingl togetherl heardl duringl inspiration,l expiration,l andl
withl nol changel duringl coughing.
QUESTION
Al clientl asksl thel nursel aboutl thel purposel ofl beginningl chemotherapyl (CT)l becausel thel
tumorl isl stilll veryl small.l Whichl informationl supportsl thel explanationl thatl thel nursel
shouldl provide?
A)l Sidel effectsl arel lessl likelyl ifl therapyl isl startedl early.l
B)l Collaterall circulationl increasesl asl thel tumorl grows.l
C)l Sensitivityl ofl cancerl cellsl tol CTl isl basedl onl celll cyclel rate.l
D)l Thel celll countl ofl thel tumorl reducesl byl halfl withl eachl dose.
Answer:
D)l Thel celll countl ofl thel tumorl reducesl byl halfl withl eachl dose.
Rationale:l Initiatingl chemotherapyl whilel thel tumorl isl smalll providesl al betterl chancel ofl
eradicatingl alll cancerl cellsl becausel 50%l ofl cancerl cellsl orl tumorl cellsl arel killedl withl
eachl dose.l (A,l B,l andl C)l varyl basedl onl thel typel ofl cancer.
QUESTION
Thel nursel isl caringl forl al clientl withl non-Hodgkin'sl lymphomal whol isl receivingl
chemotherapy.l Laboratoryl resultsl reveall al plateletl countl ofl 10,000/ml.l Whatl actionl
shouldl thel nursel implement?
A)l Encouragel fluidsl tol 3000l ml/day.l
B)l Checkl stoolsl forl occultl blood.l
C)l Providel orall hygienel everyl 2l hours.l
D)l Checkl forl feverl everyl 4l hours.
Answer:
,B)l Checkl stoolsl forl occultl blood.l
Rationale:l Plateletl countsl lessl thanl 100,000/mm3l arel indicativel ofl thrombocytopenia,l al
commonl sidel effectl ofl chemotherapy.l Al clientl withl thrombocytopenial shouldl bel
assessedl frequentlyl forl occultl bleedingl inl thel emesis,l sputum,l fecesl (B),l urine,l
nasogastricl secretions,l orl wounds.l (A)l doesl notl minimizel thel riskl forl bleedingl
associatedl withl thrombocytopenia.l (C)l mayl causel increasedl bleedingl inl al clientl withl
thromobcytopenia.l (D)l assessesl forl infection,l notl riskl forl bleeding.
QUESTION
Thel nursel isl caringl forl al clientl withl endl stagel liverl diseasel whol isl beingl assessedl forl
thel presencel ofl asterixis.l Tol assessl thel clientl forl asterixis,l whatl positionl shouldl thel
nursel askl thel clientl tol demonstrate?
A)l Extendl thel leftl arml laterallyl withl thel leftl palml upward.l
B)l Extendl thel arm,l dorsiflexl thel wrist,l andl extendl thel fingers.l
C)l Extendl thel armsl andl holdl thisl positionl forl 30l seconds.l
D)l Extendl armsl withl bothl legsl adductedl tol shoulderl width.
Answer:
B)l Extendl thel arm,l dorsiflexl thel wrist,l andl extendl thel fingers.
Rationale:l Asterixisl (flappingl tremor,l liverl flap)l isl al hand-flappingl tremorl thatl isl oftenl
seenl frequentlyl inl hepaticl encephalopathy.l Thel tremorl isl inducedl byl extendingl thel arml
andl dorsiflexingl thel wristl causingl rapid,l non-rhythmicl extensionl andl flexionl ofl thel
wristl whilel attemptingl tol holdl positionl (B).l (A,l C,l andl D)l dol notl illicitl axterixis.
QUESTION
Duringl thel assessmentl ofl al clientl whol isl 24l hoursl post-hemicolectomyl withl al
temporaryl colostomy,l thel nursel determinesl thatl thel client'sl stomal isl dryl andl darkl redl
inl color.l Whatl actionl shouldl thel nursel implement?
A)l Notifyl thel surgeon.l
B)l Documentl thel assessment.l
C)l Securel al colostomyl pouchl overl thel stoma.l
D)l Placel petrolatuml gauzel dressingl overl thel stoma.
Answer:
A)l Notifyl thel surgeon.l
, *l Thel stomal shouldl appearl reddishl pinkl andl moist,l whichl indicatesl circulatoryl
perfusionl tol thel surgicall diversionl ofl thel intestine.l Ifl thel stomal becomesl dry,l firm,l
flaccid,l orl isl darkl redl orl purple,l thel stomal isl ischemic,l andl thel surgeonl shouldl bel
notifiedl immediatelyl (A).l Althoughl (B,l C,l andl D)l mayl bel implemented,l thel findingsl
requirel immediatel medicall attention.
QUESTION
Whatl assessmentl findingl shouldl thel nursel identifyl thatl indicatesl al clientl withl anl acutel
asthmal exacerbationl isl beginningl tol improvel afterl treatment?
A)l Wheezingl becomesl louder.l
B)l Coughl remainsl unproductive.l
C)l Vesicularl breathl soundsl decrease.l
D)l Bronchodilatorsl stimulatel coughing.
Answer:
A)l Wheezingl becomesl louder.
l
*l Inl anl acutel asthmal attack,l airl flowl mayl bel sol significantlyl restrictedl thatl wheezingl
isl diminished.l Ifl thel clientl isl successfullyl respondingl tol bronchodilatorsl andl respiratoryl
treatments,l wheezingl becomesl louderl (A)l asl airl flowl increasesl inl thel airways.l Asl thel
airwaysl openl andl mucousl isl mobilizedl inl responsel tol treatment,l thel coughl becomesl
morel productive,l notl (B).l Vesicularl soundsl arel soft,l low-pitched,l gentle,l rustlingl soundsl
heardl overl lungl fieldsl (C)l andl isl notl anl indicatorl ofl improvementl duringl asthmal
treatment.l Bronchodilatorsl dol notl stimulatel coughingl (D).
QUESTION
Al clientl isl admittedl tol thel emergencyl departmentl afterl beingl lostl forl fourl daysl whilel
hikingl inl al nationall forest.l Uponl reviewl ofl thel laboratoryl results,l thel nursel determinesl
thel client'sl seruml levell forl thyroid-stimulatingl hormonel (TSH)l isl elevated.l Whichl
additionall assessmentl shouldl thel nursel make?
A)l Bodyl massl index.l
B)l Skinl elasticityl andl turgor.l
C)l Thoughtl processesl andl speech.l
D)l Exposurel tol coldl environmentall temperatures.
Answer:
