Med Surg HESI Practice Exam Questions With Rationale Answers

Med Surg HESI Practice Exam The nurse is assisting a client out of bed for the first time after surgery. What action should the nurse do first? - Allow the client to sit with the bed in a high Fowler's position. Rationale The first step is to raise the head of the bed to a high Fowler's position, which allow venous return to compensate from lying flat and the vasodilation effects of perioperative drugs. This helps prevent the client from becoming light-headed and decreases the chance of a client fall. After the fourth dose of gentamicin sulfate (Garamycin) IV, the nurse plans to draw blood samples to determine peak and trough levels. When are the best times to draw these samples? - 5 minutes before and 30 minutes after the next dose. Rationale Peak drug serum levels are achieved 30 minutes after the completion of the IV infusion of gentamicin sulfate. The best time to draw a trough is the closest time to the next administration. In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the laboratory test results to indicate an increased serum level of which substance? - Sodium. Rationale Clients with primary aldosteronism exhibit an increase in serum sodium levels (hypernatremia) and have profound decline in the serum levels of potassium (hypokalemia)--hypertension is the most prominent and universal sign. Antidiuretic hormone is decreased with diabetes insipidus. Glucose is not affected by primary aldosteronism. Which milestone indicates to the nurse successful achievement of young adulthood? - Completes education and becomes self-supporting. Rationale Transitioning through young adulthood is characterized by establishing independence as an adult, and includes developmental tasks such as completing education, beginning a career, and becoming self-supporting (B). (A and C) are characteristic of adolescence. Although strong bonds with parents are an expected finding for this age group, the need for support and approval (D) indicates dependency, which is a developmental delay. The nurse is assessing a client who smokes cigarettes and has been diagnosed with emphysema. Which finding would the nurse expect this client to exhibit? - Normal skin coloring. Rationale The differentiation between the "pink puffer" and the "blue bloater" is a well-known method of differentiating clients exhibiting symptoms of emphysema (normal color but puffing respirations) from those exhibiting symptoms of chronic bronchitis (edematous, cyanotic, shallow respirations). A male client who smokes two packs of cigarettes a day states he understands that smoking cigarettes is contributing to the difficulty that he and his wife are having in getting pregnant and wants to know if other factors could be contributing to their difficulty. What information is best for the nurse to provide? (Select all that apply.) - Alcohol consumption can cause erectile dysfunction. Low testosterone levels affect sperm production. Cessation of smoking improves general health and fertility. Rationale Use of tobacco, alcohol, and marijuana may affect sperm counts. Sperm count is also negatively affected by low testerone levels and obesity. The nurse working on a telemetry unit finds a client unconscious and in pulseless ventricular tachycardia (VT). The client has an implanted automatic defibrillator. What action should the nurse implement? - Shock the client with 200 joules per hospital policy. Rationale The client must be externally shocked 200 joules per hospital policy to restore an effective cardiac rhythm. The automatic defibrillator is obviously malfunctioning. What is the correct procedure for performing an opthalmoscopic examination on a client's right retina? - From a distance of 12 to 15 inches and slightly to the side, shine the light into the client's pupil. Rationale The client should focus on a distant object behind the examiner who should stand at 12-15 inches away and to the side of his/her line of vision. The examiner should hold the ophthalmoscope firmly against his/her face and then direct it at the client's pupil. During lung assessment, the nurse places a stethoscope on a client's chest and instructs him/her to say "99" each time the chest is touched with the stethoscope. What would be the correct interpretation if the nurse hears the spoken words "99" very clearly through the stethoscope? - May indicate pneumonia. Rationale This test (whispered pectoriloquy) demonstrates hyperresonance and helps determine the clarity with which spoken words are heard upon auscultation. Normally, the spoken word is not well transmitted through lung tissue, and is heard as a muffled or unclear transmission of the spoken word. Increased clarity of a spoken word is indicative of some sort of consolidation process (e. g., tumor, pneumonia), and is not a normal finding. In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance? - Potassium. Rationale Clients with primary hyperaldosteronism exhibit a profound decline in the serum levels of potassium (hypokalemia). Hypertension, along with the hypokalemia are the most prominent and universal signs for this condition. If both of these findings are present, there is 50% likelihood the client to be diagnosed with hyperaldosteronism. When teaching diaphragmatic breathing to a client with chronic obstructive pulmonary disease (COPD), which information should the nurse provide? - Place a small book or magazine on the abdomen and make it rise while inhaling deeply. Rationale Diaphragmatic or abdominal breathing uses the diaphragm instead of accessory muscles to achieve maximum inhalation and to slow the respiratory rate. The client should protrude the abdomen on inhalation and contract it with exhalation, so placing a book or magazine, helps the client visualize the rise and fall of the abdomen. A female client taking oral contraceptives reports to the nurse that she is experiencing calf pain. What action should the nurse implement? - Advise the client to notify the healthcare provider for immediate medical attention. Rationale Calf pain is indicative of thrombophlebitis, a serious, life-threatening complication associated with the use of oral contraceptives which requires further assessment and possibly immediate medical intervention. The nurse is providing dietary instructions to a 68-year-old client who is at high risk for development of coronary heart disease (CHD). Which information should the nurse include? - Increase intake of soluble fiber to 10 to 25 grams per day. Rationale To reduce risk factors associated with coronary heart disease, the daily intake of soluble fiber should be increased to between 10 and 25 gm. According to the American Heart Association, soluble fibers helps reduce the LDL cholesterol levels. A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which assessment finding should the nurse expect this client to exhibit? - Lower left quadrant pain and a low-grade fever. Rationale Left lower quadrant pain occurs with diverticulitis because the sigmoid colon is the most common area for diverticula, and the inflammation of diverticula causes a low-grade fever. The nurse is planning care for a client with newly diagnosed diabetes mellitus that requires insulin. Which assessment should the nurse identify before beginning the teaching session? - Willingness of the client to learn the injection sites. Rationale If a client is incapable or does not want to learn, it is unlikely that learning will occur, so motivation is the first factor the nurse should assess before teaching. The nurse is receiving report from surgery about a client with a penrose drain who is to be admitted to the postoperative unit. Before choosing a room for this client, which information is most important for the nurse to obtain? - If the client's wound is infected. Rationale Penrose drains provide a sinus tract or opening and are often used to provide drainage of an abscess. The fact that the client has a penrose drain should alert the nurse to the possibility that the client is infected. To avoid contamination of another postoperative client, it is most for the nurse to verify the condition of the wound and if infected, important to place client in a private room. The nurse is planning care to prevent complication for a client with multiple myeloma. Which intervention is most important for the nurse to include? - Maintain a fluid intake of 3 to 4 L per day. Rationale Multiple myeloma is a malignancy of plasma cells that infiltrate bone causing demineralization and hypercalcemia, so maintaining a urinary output of 1.5 to 2 L per day requires an intake of 3 to 4 L (C) to promote excretion of serum calcium. Although the client is at risk for pathologic fractures due to diffuse osteoporosis, mobilization and weight bearing should be encouraged to promote bone reabsorption of circulating calcium, which can cause renal complications. The nurse working in a postoperative surgical clinic is assessing a woman who had a left radical mastectomy for breast cancer. Which factor puts this client at greatest risk for developing lymphedema? - She sustained an insect bite to her left arm yesterday. Rationale A radical mastectomy interrupts lymph flow, and the increased lymph flow that occurs in response to the insect bite increases the risk for the occurrence of lymphedema. The nurse is assessing a client with bacterial meningitis. Which assessment finding indicates the client may have developed septic emboli? - Cyanosis of the fingertips. Rationale Septic emboli secondary to meningitis commonly lodge in the small arterioles of the extremities, causing a decrease in circulation to the hands which may lead to gangrene. During suctioning, a client with an uncuffed tracheostomy tube begins to cough violently and dislodges the tracheostomy tube. Which action should the nurse implement first? - Attempt to reinsert the tracheostomy tube. Rationale The nurse should attempt to reinsert the tracheostomy tube by using a hemostat to open the tracheostomy or by grasping the retention sutures (if present) to spread the opening in insert a replacement tube (with its obturator) into the stoma. Once in place, the obturator should immediately be removed. In preparing to administer intravenous albumin to a client following surgery, what is the priority nursing intervention? (Select all that apply.) - Set the infusion pump to infuse the albumin within four hours. Administer through a large gauge catheter. Monitor hemoglobin and hematocrit levels. Assess for increased bleeding after administration. Rationale Albumin should be infused within four hours because it does not contain any preservatives. Any fluid remaining after four hours should be discarded. Albumin administration does not require blood typing. Vital signs should be monitored periodically to assess for fluid volume overload. A large gauge catheter allows for fast infusion rate, which may be necessary. Hemodilution may decrease hemoglobin (HgB) and hematocrit (HCT) levels, so the HgB and HCT levels should be monitored. While monitoring for bleeding because of the increased blood volume and blood pressure. Which description of symptoms is characteristic of a client diagnosed with trigeminal neuralgia (tic douloureux)? - Sudden, stabbing, severe pain over the lip and chin. Rationale Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the area innervated by one or more branches of the trigeminal nerve (5th cranial). Women are more often afflicted with this condition and generally occurs in clients over the age of 50 years old.