HESI - Medical Surgical Nursing test-Exam
TEST BANK FOR MEDICAL SURGICAL
NURSING 11TH EDITION IGNATAVICIUS
A client has a urinary tract infection. Which assessment by the nurse is most
helpful?
A) Palpating and percussing the kidneys and bladder
B) Performing a bladder scan to assess post-void residual
C) Assessing medical history and current medical problems
D) Inquiring about recent travel to foreign countries - Correct AnswerC
Clients who are severely immune compromised or who have diabetes mellitus are
more prone to fungal urinary tract infection. The nurse should assess for these
factors. A physical examination and a post-void residual may be needed, but not
until further information is obtained. Travel to foreign countries probably would
not be as important, because even if exposed, the client needs some degree of
immune compromise to develop a fungal urinary tract infection.
When a diabetic patient asks about maintaining adequate blood glucose levels,
which of the following statements by the nurse relates most directly to the
necessity of maintaining blood glucose levels no lower than about 74 mg/dl?
A) "Without a minimum level of glucose circulating in the blood, erythrocytes
cannot produce ATP."
B) "The presence of glucose in the blood counteracts the formation of lactic acid
and prevents acidosis."
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,C) "The central nervous system cannot store glucose and needs a continuous
supply of glucose for fuel."
D) "Glucose is the only type of fuel used by body cells to produce the energy
needed for physiologic activity." - Correct AnswerC
The brain cannot synthesize or store significant amounts of glucose; thus a
continuous supply from the body's circulation is needed to meet the fuel demands
of the central nervous system.
The nurse is caring for an overweight client who gained 10 pounds during the
previous 2 weeks. The client states that she is hungry all the time and doesn't
understand why. Which assessment finding could explain the client's weight gain
and hunger?
A) The client's glycosylated hemoglobin level is 6%.
B) The client started taking dexamethasone (Decadron) daily.
C) The client started taking naproxen sodium (Naprosyn) daily.
D) The client's thyroxine (T4) level is 8 mcg/dL. - Correct AnswerB
Dexamethasone is a corticosteroid. These drugs alter carbohydrate, protein, and
lipid metabolism, predisposing the client to obesity when taken on a long-term
basis. In addition, corticosteroids increase the client's appetite. Naprosyn is an
NSAID, which can lead to gastric upset and ulceration and decreased appetite and
weight loss. The client's glycosylated hemoglobin and thyroid levels are within
normal limits and would not explain the hunger and weight gain.
The nurse is prioritizing care to prevent pressure sores for a client who is
immobilized. Which interventions are appropriate? (Select all that apply.)
Page 2 of 91
,A) Use a rubber ring to decrease sacral pressure when up in the chair.
B) Place a small pillow between bony surfaces.
C) Keep the heels off the bed surfaces.
D) Use a lift sheet to assist with repositioning.
E) Reposition the client who is in a chair every 2 hours.
F) Elevate the head of the bed to 45 degrees.
G) Limit fluids and proteins in the diet. - Correct AnswerB,C,D
A small pillow decreases the risk for pressure between bony prominences, a lift
sheet decreases friction and shear, and heels have poor circulation and are at high
risk for pressure sores, so they should be kept off hard surfaces. Head of the bed
elevation greater than 30 degrees increases pressure on pelvic soft tissues. Fluids
and proteins are important for maintaining tissue integrity. Clients should be
repositioned every hour while sitting in a chair. A rubber ring impairs capillary
blood flow, increasing the risk for a pressure sore.
A client who first experienced symptoms related to a confirmed thrombotic stroke
2 hours ago is brought to the intensive care unit. Which prescribed medication
does the nurse prepare to administer?
A) Tissue plasminogen activator
B) Heparin sodium
C) Warfarin (Coumadin)
D) Gabapentin (Neurontin) - Correct AnswerA
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, The client who has had a thrombotic stroke has a 3-hour time frame from the
onset of symptoms to receive recombinant tissue plasminogen activator (rt-PA) to
dissolve the cerebral artery occlusion and re-establish blood flow. Clients must
meet eligibility criteria for administration of this therapy. The other medications
do not assist in the re-establishment of blood flow for a client with a confirmed
thrombotic stroke.
A nurse is about to administer the first dose of captopril (Capoten) to a client with
hypertension. Which is the priority nursing intervention?
A) Place the client in Trendelenburg position to facilitate blood flow to the heart.
B) Take the client's apical pulse for 1 full minute before drug administration.
C) Instruct the client to drink 3 L of fluid daily when taking this medication.
D) Educate the client to sit on the side of the bed for a few minutes before rising. -
Correct AnswerD
Angiotensin-converting enzyme (ACE) inhibitors such as captopril can cause severe
hypotension with initial use. The client should be instructed to rise slowly and sit
on the side of the bed for a few minutes to prevent hypotension-induced falls. No
indication is known for assessment of the apical pulse for 1 full minute before
taking captopril. Placing the client in a Trendelenburg position is not indicated. In
case of a precipitous drop in blood pressure, a modified Trendelenburg position
may be used. Adequate fluid intake is necessary but is not the priority in this
situation.
A client who had a stroke is receiving clopidogrel (Plavix). Which adverse effect
does the nurse monitor for in this client?
A) New-onset confusion
Page 4 of 91
TEST BANK FOR MEDICAL SURGICAL
NURSING 11TH EDITION IGNATAVICIUS
A client has a urinary tract infection. Which assessment by the nurse is most
helpful?
A) Palpating and percussing the kidneys and bladder
B) Performing a bladder scan to assess post-void residual
C) Assessing medical history and current medical problems
D) Inquiring about recent travel to foreign countries - Correct AnswerC
Clients who are severely immune compromised or who have diabetes mellitus are
more prone to fungal urinary tract infection. The nurse should assess for these
factors. A physical examination and a post-void residual may be needed, but not
until further information is obtained. Travel to foreign countries probably would
not be as important, because even if exposed, the client needs some degree of
immune compromise to develop a fungal urinary tract infection.
When a diabetic patient asks about maintaining adequate blood glucose levels,
which of the following statements by the nurse relates most directly to the
necessity of maintaining blood glucose levels no lower than about 74 mg/dl?
A) "Without a minimum level of glucose circulating in the blood, erythrocytes
cannot produce ATP."
B) "The presence of glucose in the blood counteracts the formation of lactic acid
and prevents acidosis."
Page 1 of 91
,C) "The central nervous system cannot store glucose and needs a continuous
supply of glucose for fuel."
D) "Glucose is the only type of fuel used by body cells to produce the energy
needed for physiologic activity." - Correct AnswerC
The brain cannot synthesize or store significant amounts of glucose; thus a
continuous supply from the body's circulation is needed to meet the fuel demands
of the central nervous system.
The nurse is caring for an overweight client who gained 10 pounds during the
previous 2 weeks. The client states that she is hungry all the time and doesn't
understand why. Which assessment finding could explain the client's weight gain
and hunger?
A) The client's glycosylated hemoglobin level is 6%.
B) The client started taking dexamethasone (Decadron) daily.
C) The client started taking naproxen sodium (Naprosyn) daily.
D) The client's thyroxine (T4) level is 8 mcg/dL. - Correct AnswerB
Dexamethasone is a corticosteroid. These drugs alter carbohydrate, protein, and
lipid metabolism, predisposing the client to obesity when taken on a long-term
basis. In addition, corticosteroids increase the client's appetite. Naprosyn is an
NSAID, which can lead to gastric upset and ulceration and decreased appetite and
weight loss. The client's glycosylated hemoglobin and thyroid levels are within
normal limits and would not explain the hunger and weight gain.
The nurse is prioritizing care to prevent pressure sores for a client who is
immobilized. Which interventions are appropriate? (Select all that apply.)
Page 2 of 91
,A) Use a rubber ring to decrease sacral pressure when up in the chair.
B) Place a small pillow between bony surfaces.
C) Keep the heels off the bed surfaces.
D) Use a lift sheet to assist with repositioning.
E) Reposition the client who is in a chair every 2 hours.
F) Elevate the head of the bed to 45 degrees.
G) Limit fluids and proteins in the diet. - Correct AnswerB,C,D
A small pillow decreases the risk for pressure between bony prominences, a lift
sheet decreases friction and shear, and heels have poor circulation and are at high
risk for pressure sores, so they should be kept off hard surfaces. Head of the bed
elevation greater than 30 degrees increases pressure on pelvic soft tissues. Fluids
and proteins are important for maintaining tissue integrity. Clients should be
repositioned every hour while sitting in a chair. A rubber ring impairs capillary
blood flow, increasing the risk for a pressure sore.
A client who first experienced symptoms related to a confirmed thrombotic stroke
2 hours ago is brought to the intensive care unit. Which prescribed medication
does the nurse prepare to administer?
A) Tissue plasminogen activator
B) Heparin sodium
C) Warfarin (Coumadin)
D) Gabapentin (Neurontin) - Correct AnswerA
Page 3 of 91
, The client who has had a thrombotic stroke has a 3-hour time frame from the
onset of symptoms to receive recombinant tissue plasminogen activator (rt-PA) to
dissolve the cerebral artery occlusion and re-establish blood flow. Clients must
meet eligibility criteria for administration of this therapy. The other medications
do not assist in the re-establishment of blood flow for a client with a confirmed
thrombotic stroke.
A nurse is about to administer the first dose of captopril (Capoten) to a client with
hypertension. Which is the priority nursing intervention?
A) Place the client in Trendelenburg position to facilitate blood flow to the heart.
B) Take the client's apical pulse for 1 full minute before drug administration.
C) Instruct the client to drink 3 L of fluid daily when taking this medication.
D) Educate the client to sit on the side of the bed for a few minutes before rising. -
Correct AnswerD
Angiotensin-converting enzyme (ACE) inhibitors such as captopril can cause severe
hypotension with initial use. The client should be instructed to rise slowly and sit
on the side of the bed for a few minutes to prevent hypotension-induced falls. No
indication is known for assessment of the apical pulse for 1 full minute before
taking captopril. Placing the client in a Trendelenburg position is not indicated. In
case of a precipitous drop in blood pressure, a modified Trendelenburg position
may be used. Adequate fluid intake is necessary but is not the priority in this
situation.
A client who had a stroke is receiving clopidogrel (Plavix). Which adverse effect
does the nurse monitor for in this client?
A) New-onset confusion
Page 4 of 91
