HESI - Medical Surgical Nursing
test-Exam TEST BANK FOR MEDICAL
SURGICAL NURSING 11TH EDITION
IGNATAVICIUS
A consumer asks the nurse why it's miles important to be weighed each day if he has right-sided
heart failure. What is the nurse's pleasant reaction?
A) "The medical institution calls for that each one inpatients be weighed day by day."
B) "Weight is the pleasant indication that you are gaining or dropping fluid."
C) "You want to lose weight to decrease the occurrence of heart failure."
D) "Daily weights will help us make sure which you're eating properly." - ANS-B
Daily weights are had to report fluid retention or fluid loss. One liter of fluid equals 2.2 kilos.
A purchaser has a deep wound included with a moist-to-damp dressing. Which intervention
does the nurse encompass on this client's care plan?
A) Apply a brand new dressing when the seal breaks and the dressing leaks.
B) Change the dressing whilst the modern-day dressing is saturated.
C) Leave the dressing intact until next week.
D) Change the dressing each 6 hours around the clock. - ANS-D
Wet-to-damp dressings are modified every four to 6 hours to provide maximum débridement.
Synthetic dressings can be left in region for extended intervals of time however want to be
changed if the seal breaks and the exudate is leaking. Dry gauze dressings should be modified
when the outer layer will become saturated.
A consumer has a small-bore nasoenteric feeding tube. The nurse assesses the following
crucial signs: temperature, a hundred.2° F (37.Eight° C); pulse, 112 beats/min; respiratory fee,
22 breaths/min; and blood stress, 106/sixty two mm Hg. Which movement by way of the nurse
takes precedence?
A) Auscultate bowel sounds and sluggish the feeding down.
B) Remove the tube without delay and notify the heath care company.
C) Auscultate lung sounds and obtain oxygen saturation.
D) Add blue dye to the feeding tube formulation. - ANS-C
,The consumer may additionally have aspirated. The nurse must similarly verify the patron's
respiration and oxygenation status. The patron may additionally have another purpose for the
atypical critical symptoms, so the nurse have to not pull out the tube before appearing other
checks. Adding blue dye to the tube feeding formulation is not endorsed to test for aspiration.
Slowing the feeding down will no longer be useful.
A client has a urinary tract contamination. Which assessment with the aid of the nurse is most
beneficial?
A) Palpating and percussing the kidneys and bladder
B) Performing a bladder experiment to assess post-void residual
C) Assessing scientific history and modern-day clinical issues
D) Inquiring about recent travel to overseas international locations - ANS-C
Clients who're severely immune compromised or who have diabetes mellitus are greater
susceptible to fungal urinary tract infection. The nurse ought to check for these elements. A
bodily examination and a put up-void residual may be needed, however no longer until further
statistics is received. Travel to overseas nations probably might now not be as essential,
because even supposing uncovered, the customer needs some diploma of immune compromise
to expand a fungal urinary tract contamination.
A purchaser has a wound on his left trochanter this is four inches in diameter, with black tissue
at the perimeter, and bone is uncovered. Which is the nurse's quality movement?
A) Document as a degree I strain ulcer and follow a transparent dressing.
B) Document as a level II stress ulcer and begin wet-to-dry gauze remedies.
C) Document as a stage IV stress ulcer and prepare the consumer for débridement.
D) Document as a degree III strain ulcer and start antibiotic remedy. - ANS-C
A degree IV ulcer is one in which skin loss is full thickness, with extensive destruction, tissue
necrosis, and/or harm to muscle, bone, or helping structures. Eschar may be present. When the
bone of the trochanter vicinity is seen, tissue loss includes muscle loss. A capacity intervention
includes débridement of the necrotic tissue and a probable graft to sell healing.
A purchaser has been admitted to the intensive care unit with worsening pulmonary
manifestations of heart failure. What is the nurse's fine motion?
A) Administer loop diuretics as prescribed.
B) Begin cardiopulmonary resuscitation (CPR).
C) Promote relaxation and reduce activities.
D) Place the customer in a high Fowler's role. - ANS-A
,The client with worsening coronary heart failure is most at danger for pulmonary edema as a
consequence of fluid retention. Administering diuretics will decrease the fluid overload, thereby
decreasing the occurrence of pulmonary edema. High Fowler's role may help the patron breathe
less difficult but will no longer resolve the hassle. CPR is not warranted in this case. Rest is
crucial for clients with heart failure, however this is not the concern.
A client has been taught to restrict dietary sodium. Which meals choice with the aid of the
customer indicates to the nurse that coaching has been powerful?
A. A grilled cheese sandwich with tomato soup
b. Chinese take-out, consisting of steamed rice
c. A fowl leg, one slice of bread with butter, and steamed carrots
d. Slices of ham and cheese on whole grain crackers - ANS-C
Clients on limited sodium diets normally should avoid processed, smoked, and pickled meals
and people with sauces and other condiments. Foods lowest in sodium include fish, hen, and
fresh produce. The chinese meals possibly would have soy sauce, the tomato soup is
processed, and the crackers are a snack meals - a class of meals regularly excessive in
sodium.
A client has newly identified diabetes. To put off the onset of microvascular and macrovascular
complications in this patron, the nurse stresses that the client take which movement?
A) Restrict fluid intake.
B) Prevent ketosis.
C) Control hyperglycemia.
D) Prevent hypoglycemia. - ANS-C
Hyperglycemia is a essential issue inside the pathogenesis of long-term diabetic complications.
Maintaining tight glycemic manage will assist postpone the onset of headaches. Preventing
hypoglycemia and ketosis, even though vital, isn't as crucial as maintaining every day glycemic
manage. Restricting fluid intake isn't always a part of the remedy plan for clients with diabetes.
A patron has recently been placed on prednisone (Deltasone). What is the best precedence
coaching the nurse will provide?
A) "Take the drug with food or milk."
B) "Report any belly ache or dark-colored vomit."
C) "Expect to revel in weight gain."
D) "Watch your weight loss program whilst on this medicine." - ANS-B
All of these guidelines are suitable to present the patron; however, telling the customer to
document belly pain and dark-colored vomit is maximum critical because these could sign
gastric ulceration.
, A patron is admitted with infection and a high fever. Which checks by means of the nurse take
precedence? (Select all that observe.)
A) Skin turgor
B) Pulse first-rate
C) Blood pressure
D) Bowel sounds
E) Respiratory effort
F) Mental repute - ANS-A, B, C, F
Dehydration can accompany fever, especially if the customer is sweating profusely. Blood
pressure, pulse great, and skin turgor are tests of fluid popularity. Mental fame adjustments can
accompany fluid losses, mainly in older customers.
A purchaser is admitted with left decrease lung pneumonia. Which evaluation finding does the
nurse correlate with this circumstance?
A) Expiratory wheeze on the proper aspect
B) Crackles heard on expiration bilaterally
C) Dullness to percussion on the lower left aspect
D) Crepitus of the pores and skin around the left lung - ANS-C
The client with pneumonia can also have dullness to percussion at the affected aspect. The
different options are all inconsistent with pneumonia.
A patron is being treated for dehydration. Which announcement made by way of the purchaser
suggests expertise of this condition?
A. I will use a salt alternative whilst making and eating my food.
B. I need to drink a quart of water or other liquid every day.
C. I will now not drink liquids after 6 PM so I might not must stand up at night time.
D. I will weigh myself each morning before I consume or drink. - ANS-D
Because 1 L of water weighs 1 kg, trade in frame weight is a good degree of excess fluid loss or
fluid retention. Weight loss greater than zero.5 lb daily is indicative of immoderate fluid loss. The
other statements are not indicative of practices so one can save you dehydration.
A client is hospitalized with a urinary tract contamination (UTI). Which scientific manifestation
indicators the nurse to the opportunity of a worry from the UTI?
A) Hematuria
B) Fever and chills
C) Cloudy, darkish urine
D) Burning on urination - ANS-B
test-Exam TEST BANK FOR MEDICAL
SURGICAL NURSING 11TH EDITION
IGNATAVICIUS
A consumer asks the nurse why it's miles important to be weighed each day if he has right-sided
heart failure. What is the nurse's pleasant reaction?
A) "The medical institution calls for that each one inpatients be weighed day by day."
B) "Weight is the pleasant indication that you are gaining or dropping fluid."
C) "You want to lose weight to decrease the occurrence of heart failure."
D) "Daily weights will help us make sure which you're eating properly." - ANS-B
Daily weights are had to report fluid retention or fluid loss. One liter of fluid equals 2.2 kilos.
A purchaser has a deep wound included with a moist-to-damp dressing. Which intervention
does the nurse encompass on this client's care plan?
A) Apply a brand new dressing when the seal breaks and the dressing leaks.
B) Change the dressing whilst the modern-day dressing is saturated.
C) Leave the dressing intact until next week.
D) Change the dressing each 6 hours around the clock. - ANS-D
Wet-to-damp dressings are modified every four to 6 hours to provide maximum débridement.
Synthetic dressings can be left in region for extended intervals of time however want to be
changed if the seal breaks and the exudate is leaking. Dry gauze dressings should be modified
when the outer layer will become saturated.
A consumer has a small-bore nasoenteric feeding tube. The nurse assesses the following
crucial signs: temperature, a hundred.2° F (37.Eight° C); pulse, 112 beats/min; respiratory fee,
22 breaths/min; and blood stress, 106/sixty two mm Hg. Which movement by way of the nurse
takes precedence?
A) Auscultate bowel sounds and sluggish the feeding down.
B) Remove the tube without delay and notify the heath care company.
C) Auscultate lung sounds and obtain oxygen saturation.
D) Add blue dye to the feeding tube formulation. - ANS-C
,The consumer may additionally have aspirated. The nurse must similarly verify the patron's
respiration and oxygenation status. The patron may additionally have another purpose for the
atypical critical symptoms, so the nurse have to not pull out the tube before appearing other
checks. Adding blue dye to the tube feeding formulation is not endorsed to test for aspiration.
Slowing the feeding down will no longer be useful.
A client has a urinary tract contamination. Which assessment with the aid of the nurse is most
beneficial?
A) Palpating and percussing the kidneys and bladder
B) Performing a bladder experiment to assess post-void residual
C) Assessing scientific history and modern-day clinical issues
D) Inquiring about recent travel to overseas international locations - ANS-C
Clients who're severely immune compromised or who have diabetes mellitus are greater
susceptible to fungal urinary tract infection. The nurse ought to check for these elements. A
bodily examination and a put up-void residual may be needed, however no longer until further
statistics is received. Travel to overseas nations probably might now not be as essential,
because even supposing uncovered, the customer needs some diploma of immune compromise
to expand a fungal urinary tract contamination.
A purchaser has a wound on his left trochanter this is four inches in diameter, with black tissue
at the perimeter, and bone is uncovered. Which is the nurse's quality movement?
A) Document as a degree I strain ulcer and follow a transparent dressing.
B) Document as a level II stress ulcer and begin wet-to-dry gauze remedies.
C) Document as a stage IV stress ulcer and prepare the consumer for débridement.
D) Document as a degree III strain ulcer and start antibiotic remedy. - ANS-C
A degree IV ulcer is one in which skin loss is full thickness, with extensive destruction, tissue
necrosis, and/or harm to muscle, bone, or helping structures. Eschar may be present. When the
bone of the trochanter vicinity is seen, tissue loss includes muscle loss. A capacity intervention
includes débridement of the necrotic tissue and a probable graft to sell healing.
A purchaser has been admitted to the intensive care unit with worsening pulmonary
manifestations of heart failure. What is the nurse's fine motion?
A) Administer loop diuretics as prescribed.
B) Begin cardiopulmonary resuscitation (CPR).
C) Promote relaxation and reduce activities.
D) Place the customer in a high Fowler's role. - ANS-A
,The client with worsening coronary heart failure is most at danger for pulmonary edema as a
consequence of fluid retention. Administering diuretics will decrease the fluid overload, thereby
decreasing the occurrence of pulmonary edema. High Fowler's role may help the patron breathe
less difficult but will no longer resolve the hassle. CPR is not warranted in this case. Rest is
crucial for clients with heart failure, however this is not the concern.
A client has been taught to restrict dietary sodium. Which meals choice with the aid of the
customer indicates to the nurse that coaching has been powerful?
A. A grilled cheese sandwich with tomato soup
b. Chinese take-out, consisting of steamed rice
c. A fowl leg, one slice of bread with butter, and steamed carrots
d. Slices of ham and cheese on whole grain crackers - ANS-C
Clients on limited sodium diets normally should avoid processed, smoked, and pickled meals
and people with sauces and other condiments. Foods lowest in sodium include fish, hen, and
fresh produce. The chinese meals possibly would have soy sauce, the tomato soup is
processed, and the crackers are a snack meals - a class of meals regularly excessive in
sodium.
A client has newly identified diabetes. To put off the onset of microvascular and macrovascular
complications in this patron, the nurse stresses that the client take which movement?
A) Restrict fluid intake.
B) Prevent ketosis.
C) Control hyperglycemia.
D) Prevent hypoglycemia. - ANS-C
Hyperglycemia is a essential issue inside the pathogenesis of long-term diabetic complications.
Maintaining tight glycemic manage will assist postpone the onset of headaches. Preventing
hypoglycemia and ketosis, even though vital, isn't as crucial as maintaining every day glycemic
manage. Restricting fluid intake isn't always a part of the remedy plan for clients with diabetes.
A patron has recently been placed on prednisone (Deltasone). What is the best precedence
coaching the nurse will provide?
A) "Take the drug with food or milk."
B) "Report any belly ache or dark-colored vomit."
C) "Expect to revel in weight gain."
D) "Watch your weight loss program whilst on this medicine." - ANS-B
All of these guidelines are suitable to present the patron; however, telling the customer to
document belly pain and dark-colored vomit is maximum critical because these could sign
gastric ulceration.
, A patron is admitted with infection and a high fever. Which checks by means of the nurse take
precedence? (Select all that observe.)
A) Skin turgor
B) Pulse first-rate
C) Blood pressure
D) Bowel sounds
E) Respiratory effort
F) Mental repute - ANS-A, B, C, F
Dehydration can accompany fever, especially if the customer is sweating profusely. Blood
pressure, pulse great, and skin turgor are tests of fluid popularity. Mental fame adjustments can
accompany fluid losses, mainly in older customers.
A purchaser is admitted with left decrease lung pneumonia. Which evaluation finding does the
nurse correlate with this circumstance?
A) Expiratory wheeze on the proper aspect
B) Crackles heard on expiration bilaterally
C) Dullness to percussion on the lower left aspect
D) Crepitus of the pores and skin around the left lung - ANS-C
The client with pneumonia can also have dullness to percussion at the affected aspect. The
different options are all inconsistent with pneumonia.
A patron is being treated for dehydration. Which announcement made by way of the purchaser
suggests expertise of this condition?
A. I will use a salt alternative whilst making and eating my food.
B. I need to drink a quart of water or other liquid every day.
C. I will now not drink liquids after 6 PM so I might not must stand up at night time.
D. I will weigh myself each morning before I consume or drink. - ANS-D
Because 1 L of water weighs 1 kg, trade in frame weight is a good degree of excess fluid loss or
fluid retention. Weight loss greater than zero.5 lb daily is indicative of immoderate fluid loss. The
other statements are not indicative of practices so one can save you dehydration.
A client is hospitalized with a urinary tract contamination (UTI). Which scientific manifestation
indicators the nurse to the opportunity of a worry from the UTI?
A) Hematuria
B) Fever and chills
C) Cloudy, darkish urine
D) Burning on urination - ANS-B
