MED-SURG III HESI COMPREHENSIVE
TEST BANK QUESTIONS AND VERIFIED
ANSWERS |GRADE A+| JUST RELEASED
1. A client with Acute Respiratory Distress Syndrome (ARDS) is on mechanical ventilation with
High Positive End-Expiratory Pressure (PEEP). The nurse notes a sudden drop in blood
pressure and decreased breath sounds on the right side. Which action should the nurse take
first?
A. Increase the FIO2 to 100%
B. Prepare for immediate needle thoracostomy
C. Suction the endotracheal tube
D. Obtain a stat arterial blood gas (ABG)
Answer: B
Conceptual Explanation: High PEEP increases the risk of a tension pneumothorax. A
sudden drop in BP and unilateral decreased breath sounds are classic signs, requiring
immediate decompression.
2. A patient in the ICU is being treated for Disseminated Intravascular Coagulation (DIC).
Which laboratory result is the most specific indicator of this condition?
A. Decreased Platelet count
,B. Elevated D-dimer levels
C. Increased Prothrombin Time (PT)
D. Decreased Fibrinogen
Answer: B
Conceptual Explanation: While all these markers may change, the D-dimer is the most
specific for DIC as it indicates excessive fibrinolysis and clot breakdown.
3. The nurse is caring for a client who is 24 hours post-burn injury (45% Total Body Surface
Area). The client’s urine output has dropped to 20 mL/hr. What is the priority nursing
intervention?
A. Increase the rate of IV lactated Ringer’s
B. Administer a diuretic as ordered
C. Check for a kink in the urinary catheter
D. Notify the provider of potential renal failure
Answer: A
Conceptual Explanation: In the emergent phase of a burn, low urine output usually
indicates inadequate fluid resuscitation. Increasing the IV rate is the priority to prevent
hypovolemic shock and AKI.
, 4. A client with a traumatic brain injury has an intracranial pressure (ICP) of 22 mmHg. Which
position is most appropriate for this client?
A. High-Fowler’s with knees flexed
B. Head of bed elevated 30 degrees, head midline
C. Trendelenburg to increase cerebral perfusion
D. Left side-lying with hips flexed
Answer: B
Conceptual Explanation: Elevating the HOB to 30 degrees and keeping the head midline
promotes venous drainage from the brain, helping to lower ICP.
5. During the assessment of a client with a C6 spinal cord injury, the nurse notes a BP of
190/110 mmHg, a pounding headache, and flushing above the level of injury. What is the first
action the nurse should take?
A. Administer PRN nifedipine
B. Check the client’s bladder for distension
C. Notify the rapid response team
D. Place the client in a sitting position
Answer: D
TEST BANK QUESTIONS AND VERIFIED
ANSWERS |GRADE A+| JUST RELEASED
1. A client with Acute Respiratory Distress Syndrome (ARDS) is on mechanical ventilation with
High Positive End-Expiratory Pressure (PEEP). The nurse notes a sudden drop in blood
pressure and decreased breath sounds on the right side. Which action should the nurse take
first?
A. Increase the FIO2 to 100%
B. Prepare for immediate needle thoracostomy
C. Suction the endotracheal tube
D. Obtain a stat arterial blood gas (ABG)
Answer: B
Conceptual Explanation: High PEEP increases the risk of a tension pneumothorax. A
sudden drop in BP and unilateral decreased breath sounds are classic signs, requiring
immediate decompression.
2. A patient in the ICU is being treated for Disseminated Intravascular Coagulation (DIC).
Which laboratory result is the most specific indicator of this condition?
A. Decreased Platelet count
,B. Elevated D-dimer levels
C. Increased Prothrombin Time (PT)
D. Decreased Fibrinogen
Answer: B
Conceptual Explanation: While all these markers may change, the D-dimer is the most
specific for DIC as it indicates excessive fibrinolysis and clot breakdown.
3. The nurse is caring for a client who is 24 hours post-burn injury (45% Total Body Surface
Area). The client’s urine output has dropped to 20 mL/hr. What is the priority nursing
intervention?
A. Increase the rate of IV lactated Ringer’s
B. Administer a diuretic as ordered
C. Check for a kink in the urinary catheter
D. Notify the provider of potential renal failure
Answer: A
Conceptual Explanation: In the emergent phase of a burn, low urine output usually
indicates inadequate fluid resuscitation. Increasing the IV rate is the priority to prevent
hypovolemic shock and AKI.
, 4. A client with a traumatic brain injury has an intracranial pressure (ICP) of 22 mmHg. Which
position is most appropriate for this client?
A. High-Fowler’s with knees flexed
B. Head of bed elevated 30 degrees, head midline
C. Trendelenburg to increase cerebral perfusion
D. Left side-lying with hips flexed
Answer: B
Conceptual Explanation: Elevating the HOB to 30 degrees and keeping the head midline
promotes venous drainage from the brain, helping to lower ICP.
5. During the assessment of a client with a C6 spinal cord injury, the nurse notes a BP of
190/110 mmHg, a pounding headache, and flushing above the level of injury. What is the first
action the nurse should take?
A. Administer PRN nifedipine
B. Check the client’s bladder for distension
C. Notify the rapid response team
D. Place the client in a sitting position
Answer: D
