Med-Surg HESI Practice Questionsand
Verified Answers
A male client with sickle cell anemia, who has been hospitalized for another health
problem, tells the nurse he has had an erection for over 4 hours. What action should the
nurse implement first?
A. Notify the client's healthcare provider.
B. Document the finding in the client record.
C. Prepare a warm enema solution for rectal instillation.
D. Obtain a large bore needle for aspiration of the corpora cavernosa. - ANSWERSA.
Notify the client's healthcare provider
Rationale:
Priapism, a urologic emergency, is common during sickle cell crisis due to sickle cells
clogging the microcirculation in the penis, causing a reduction of blood flow and
oxygenation to the penis, so the healthcare provider should be first notified immediately.
The prescribed therapy may consist of noninvasive measures such as applying ice to
the penis, instilling a warm solution enema to increase outflow in the corpora cavernosa
and giving pain medications. If noninvasive measures do not work, then needle
aspiration of the corpora cavernosa is implemented by the healthcare provider.
The nurse is planning preoperative teaching for a client who will undergo a radical neck
dissection and total laryngectomy. Which information has the greatest priority for this
client?
A. Prognosis after treatment is excellent.
B. Techniques for esophageal speech are relatively easy to learn with practice.
C. The stoma should never be covered after this type of surgery.
D. There is a radical change in appearance as a result of this surgery. - ANSWERSD.
There is a radical change in appearance as a result of this surgery.
Rationale: Radical neck dissection is the removal of lymphatic drainage channels and
nodes, sternocleidomastoid muscle, spinal accessory nerve, jugular vein, and
submandibular area. The overall outcome of this type of surgery causes the neck to be
disfigured, so the radical change in appearance, "Alteration in body image" will be a
priority in the care of this client.
Which intervention should the nurse implement that best confirms placement of an
endotracheal tube (ETT)?
A. Use an end-tital CO2 detector.
B. Ascultate for bilateral breath sounds.
C. Obtain pulse oximeter reading.
D. Check symmetrical chest movement. - ANSWERSA. Use an end-tital CO2 detector.
,Rationale: The end-tidal carbon dioxide detector indicates the prescence of CO2tidalby
a color change or a number indicated on the detector, which is supporting evidence that
the ETT is in the trachea, not the esophagus.
A client with acute osteomyelitis has undergone surgical debridement of the diseased
bone and asks the nurse how long will antibiotics have to be administered. Which
information should the nurse communicate?
A. Oral antibiotics for 2 to 4 months, then for dental procedure prophylaxis.
B. Parenteral antibiotics for 4 to 6 weeks, then oral antibiotics for up to 1 year.
C. Parenteral antibiotics for 4 to 8 weeks, then oral antibiotics for 4 to 8 weeks.
D. Parenteral antibiotics for 2 to 3 weeks, then oral antibiotics for 4 weeks. -
ANSWERSC. Parenteral antibiotics for 4 to 8 weeks, then oral antibiotics for 4 to 8
weeks.
Rationale: Treatment of acute osteomyelitis requires administration of high doses of
parenteral antibiotics for 4 to 8 weeks, followed by oral antibiotics for another 4 to 8
weeks.
When caring for a client with a percutaneous endoscopic gastrostomy (PEG) tube, what
protocols should the nurse implement for intermittent feedings? (Select all that apply.)
Select all that apply
A. Assessing residual amounts once a day.
B. Keeping the head of the bed elevated 30 degrees.
C. Changing the enteral-feeding bag every 24 hours.
D. Checking the placement of the tube by means of gastric aspiration.
E. Flushing the tube with 50 ml of normal saline solution after each feeding. -
ANSWERSB. Keeping the head of the bed elevated 30 degrees.
C. Changing the enteral-feeding bag every 24 hours.
D. Checking the placement of the tube by means of gastric aspiration.
E. Flushing the tube with 50 ml of normal saline solution after each feeding.
Rationale: Keeping the head of the bed elevated 30 degrees, changing the enteral-
feeding bag every 24 hours, checking the placement of the tube by means of gastric
aspiration, and flushing the tube with 50 ml of normal saline solution after each feeding
are interventions used to provide care of the client with a PEG tube. Residual amounts
should be assessed each time, prior to each feeding.
A client with a recent history of blood in his stools is scheduled for a
proctosigmoidoscopy. The nurse should implement which protocols to prepare the client
for this procedure? (Select all that apply.)
Select all that apply
A. Obtain consent for the procedure.
B. Initiate preoperative sedation.
C. Begin fast the morning of the procedure.
D. Administer an enema before the procedure.
, E. Provide a clear-liquid diet 48 hours before the procedure. - ANSWERSA. Obtain
consent for the procedure.
C. Begin fast the morning of the procedure.
D. Administer an enema before the procedure.
E. Provide a clear-liquid diet 48 hours before the procedure.
Rationale: The usual preoperative preparation for proctosigmoidoscopy entails obtaining
the client's consent to the procedure, a clear-liquid diet for 24 to 48 hours prior to the
procedure, administration of an enema, and fasting on the morning of the procedure.
The nurse is assessing a client admitted from the emergency room with gastrointestinal
bleeding related to peptic ulcer disease (PUD). Which physiological factors can produce
ulceration? (Select all that apply.)
Select all that apply
A. Vagal stimulation.
B. An increased level of stress.
C. Decreased duodenal inhibition.
D. Hypersecretion of hydrochloric acid.
E. An increased number of parietal cells. - ANSWERSA. Vagal stimulation.
C. Decreased duodenal inhibition.
D. Hypersecretion of hydrochloric acid.
E. An increased number of parietal cells.
Rationale: Hypersecretion of gastric juices and an increased number of parietal cells
that stimulate secretion are most often the causes of ulceration. Vagal stimulation and
decreased duodenal inhibition also increase the secretion of caustic fluids.
What is the priority nursing action while caring for a client on a ventilator when an
electrical fire occurs in the intensive care unit?
A. Tell another staff member to bring extinguishing equipment to the bedside.
B. Close the doors to the client's area when attempting to extinguish the fire.
C. Use a bag-valve-mask resuscitator while removing the client from the area.
D. Implement an emergency protocol to remove the client from the ventilator. -
ANSWERSC. Use a bag-valve-mask resuscitator while removing the client from the
area.
Rationale: A client on a ventilator should have respirations maintained with a manual
bag-valve-mask resuscitator while being moved away from the oxygen wall outlet and
fire source.
A client who has just tested positive for human immunodeficiency virus (HIV) does not
appear to hear what the nurse is saying during post-test counseling. Which information
should the nurse offer to facilitate the client's adjustment to HIV infection?
A. Inform the client how to protect sexual and needle-sharing partners.
B. Teach the client about the medications that are available for treatment.
C. Identify the need to test others who have had risky contact with the client.
Verified Answers
A male client with sickle cell anemia, who has been hospitalized for another health
problem, tells the nurse he has had an erection for over 4 hours. What action should the
nurse implement first?
A. Notify the client's healthcare provider.
B. Document the finding in the client record.
C. Prepare a warm enema solution for rectal instillation.
D. Obtain a large bore needle for aspiration of the corpora cavernosa. - ANSWERSA.
Notify the client's healthcare provider
Rationale:
Priapism, a urologic emergency, is common during sickle cell crisis due to sickle cells
clogging the microcirculation in the penis, causing a reduction of blood flow and
oxygenation to the penis, so the healthcare provider should be first notified immediately.
The prescribed therapy may consist of noninvasive measures such as applying ice to
the penis, instilling a warm solution enema to increase outflow in the corpora cavernosa
and giving pain medications. If noninvasive measures do not work, then needle
aspiration of the corpora cavernosa is implemented by the healthcare provider.
The nurse is planning preoperative teaching for a client who will undergo a radical neck
dissection and total laryngectomy. Which information has the greatest priority for this
client?
A. Prognosis after treatment is excellent.
B. Techniques for esophageal speech are relatively easy to learn with practice.
C. The stoma should never be covered after this type of surgery.
D. There is a radical change in appearance as a result of this surgery. - ANSWERSD.
There is a radical change in appearance as a result of this surgery.
Rationale: Radical neck dissection is the removal of lymphatic drainage channels and
nodes, sternocleidomastoid muscle, spinal accessory nerve, jugular vein, and
submandibular area. The overall outcome of this type of surgery causes the neck to be
disfigured, so the radical change in appearance, "Alteration in body image" will be a
priority in the care of this client.
Which intervention should the nurse implement that best confirms placement of an
endotracheal tube (ETT)?
A. Use an end-tital CO2 detector.
B. Ascultate for bilateral breath sounds.
C. Obtain pulse oximeter reading.
D. Check symmetrical chest movement. - ANSWERSA. Use an end-tital CO2 detector.
,Rationale: The end-tidal carbon dioxide detector indicates the prescence of CO2tidalby
a color change or a number indicated on the detector, which is supporting evidence that
the ETT is in the trachea, not the esophagus.
A client with acute osteomyelitis has undergone surgical debridement of the diseased
bone and asks the nurse how long will antibiotics have to be administered. Which
information should the nurse communicate?
A. Oral antibiotics for 2 to 4 months, then for dental procedure prophylaxis.
B. Parenteral antibiotics for 4 to 6 weeks, then oral antibiotics for up to 1 year.
C. Parenteral antibiotics for 4 to 8 weeks, then oral antibiotics for 4 to 8 weeks.
D. Parenteral antibiotics for 2 to 3 weeks, then oral antibiotics for 4 weeks. -
ANSWERSC. Parenteral antibiotics for 4 to 8 weeks, then oral antibiotics for 4 to 8
weeks.
Rationale: Treatment of acute osteomyelitis requires administration of high doses of
parenteral antibiotics for 4 to 8 weeks, followed by oral antibiotics for another 4 to 8
weeks.
When caring for a client with a percutaneous endoscopic gastrostomy (PEG) tube, what
protocols should the nurse implement for intermittent feedings? (Select all that apply.)
Select all that apply
A. Assessing residual amounts once a day.
B. Keeping the head of the bed elevated 30 degrees.
C. Changing the enteral-feeding bag every 24 hours.
D. Checking the placement of the tube by means of gastric aspiration.
E. Flushing the tube with 50 ml of normal saline solution after each feeding. -
ANSWERSB. Keeping the head of the bed elevated 30 degrees.
C. Changing the enteral-feeding bag every 24 hours.
D. Checking the placement of the tube by means of gastric aspiration.
E. Flushing the tube with 50 ml of normal saline solution after each feeding.
Rationale: Keeping the head of the bed elevated 30 degrees, changing the enteral-
feeding bag every 24 hours, checking the placement of the tube by means of gastric
aspiration, and flushing the tube with 50 ml of normal saline solution after each feeding
are interventions used to provide care of the client with a PEG tube. Residual amounts
should be assessed each time, prior to each feeding.
A client with a recent history of blood in his stools is scheduled for a
proctosigmoidoscopy. The nurse should implement which protocols to prepare the client
for this procedure? (Select all that apply.)
Select all that apply
A. Obtain consent for the procedure.
B. Initiate preoperative sedation.
C. Begin fast the morning of the procedure.
D. Administer an enema before the procedure.
, E. Provide a clear-liquid diet 48 hours before the procedure. - ANSWERSA. Obtain
consent for the procedure.
C. Begin fast the morning of the procedure.
D. Administer an enema before the procedure.
E. Provide a clear-liquid diet 48 hours before the procedure.
Rationale: The usual preoperative preparation for proctosigmoidoscopy entails obtaining
the client's consent to the procedure, a clear-liquid diet for 24 to 48 hours prior to the
procedure, administration of an enema, and fasting on the morning of the procedure.
The nurse is assessing a client admitted from the emergency room with gastrointestinal
bleeding related to peptic ulcer disease (PUD). Which physiological factors can produce
ulceration? (Select all that apply.)
Select all that apply
A. Vagal stimulation.
B. An increased level of stress.
C. Decreased duodenal inhibition.
D. Hypersecretion of hydrochloric acid.
E. An increased number of parietal cells. - ANSWERSA. Vagal stimulation.
C. Decreased duodenal inhibition.
D. Hypersecretion of hydrochloric acid.
E. An increased number of parietal cells.
Rationale: Hypersecretion of gastric juices and an increased number of parietal cells
that stimulate secretion are most often the causes of ulceration. Vagal stimulation and
decreased duodenal inhibition also increase the secretion of caustic fluids.
What is the priority nursing action while caring for a client on a ventilator when an
electrical fire occurs in the intensive care unit?
A. Tell another staff member to bring extinguishing equipment to the bedside.
B. Close the doors to the client's area when attempting to extinguish the fire.
C. Use a bag-valve-mask resuscitator while removing the client from the area.
D. Implement an emergency protocol to remove the client from the ventilator. -
ANSWERSC. Use a bag-valve-mask resuscitator while removing the client from the
area.
Rationale: A client on a ventilator should have respirations maintained with a manual
bag-valve-mask resuscitator while being moved away from the oxygen wall outlet and
fire source.
A client who has just tested positive for human immunodeficiency virus (HIV) does not
appear to hear what the nurse is saying during post-test counseling. Which information
should the nurse offer to facilitate the client's adjustment to HIV infection?
A. Inform the client how to protect sexual and needle-sharing partners.
B. Teach the client about the medications that are available for treatment.
C. Identify the need to test others who have had risky contact with the client.
