HESI MED SURG FINAL RN V2 (ACTUAL 2024 EXAM) QUESTIONS AND CORRECT DET A ILED ANSWERS AGRADE RATED Pulmonary artery wedge pressure(SWAN GANZ) - ANSWER ✔✔Assess/monitor for dysrhythmias Pt w/ dysrhythmias - ANSWER ✔✔Calciumof 7.2 (low) MI - ANSWER ✔✔LOW Cardiac output Renal Failure - ANSWER ✔✔45% BUN S/S of shock - ANSWER ✔✔hypotension, thready pulse How to check for Carbon monoxide poisoning - ANSWER ✔✔cherry mouth or tongue Paracentesis - ANSWER ✔✔Empty bladder completely before procedure Pt has angina - ANSWER ✔✔pain radiates to left arm Pt has increased abdominalgirth Pos -op surgery - ANSWER ✔✔call MD ARDS (acute respiratory distress syndrome) - ANSWER ✔✔Patient using abdominal muscles to breath A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the best initial nursing action? - ANSWER ✔✔Observe the co lor, consistency, and amount of sputum A client is brought to the ED by ambulance in cardiac arrest with cardiopulmonary resuscitation (CPR) in progress.The client is intubated and is receiving 100% oxygen per self -inflating (ambu) bag. The nurse determine s that the client is cyanotic, cold, and diaphoretic. Which assessment is most important for the nurse to obtain? - ANSWER ✔
✔Breath sounds over bilateral lung field After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a client develops pontine myselinolysis. Which intervention should the nurse implement first? - ANSWER ✔✔Reorient client to his room A male client with heart failure (HF) calls the clinic andreports that he cannot put his shoes on because they aretoo tight. Which a dditional information should the nurseobtain? - ANSWER ✔✔Has his weight changed in the last several days ? An older adult woman with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persist ent cough. She is anxious and is complaining of a dry mouth. Which intervention should the nurse implement? - ANSWER ✔✔Assist her to an upright position A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, product ive cough with thickened tenacious mucous, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self -care? - ANSWER ✔✔Increase the daily intake of oral fluids to liquefy secretions A cardiac catherterization of a client with heart disease indicates the following blockages: 95% proximal left anterior descending (LAD), 99% proximal circumflex, and ?% proximal right coronary artery (RCA). The client later a sks the nurse "what does all this mean for me?" What information should the nurse provide? - ANSWER ✔✔Three main arteries have major blockages, with only 1 to5% of blood flow getting throu gh to the heart muscle . What information should the nurse include in the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD)? - ANSWER ✔✔Minimize symptoms by wearing loose, comfortable clothing The nurse is caring for a client with a lower left lobe pul monary abscess. Which position should the nurse instruct the client to maintain? - ANSWER ✔✔left lateral A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider. - ANSWER ✔✔Yellow sclera While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immedi ate intervention by the nurse? - ANSWER ✔✔Weakened cough effort The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client? - ANSWE R✔✔The xenograft is taken from nonhuman sources A male client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning him, the wound dehiscences and eviscerates. The nurse moistens an available steril e dressing and places it over the wound. What intervention should the nurse implement next? - ANSWER ✔✔Prepare the client to return to the operating room A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117 mEq/ L. Which nursing problem should the nurse include in this client's plan of care? - ANSWER ✔✔Fluid volume excess A female client enters the clinic and insists on being seen. She is weak, nervous, and reports a racing heart beat and recent weight loss of 15 p ounds. After ruling out substance withdrawal, the healthcare provider suspects hyperthyroidism and admits her for further testing. Which action should the nurse implement? - ANSWER ✔✔Space the client's care to provide periods of rest The nurse is teaching a client with glomerulonephritis about self -care. Which dietary recommendations should the nurse encourage the client to follow? - ANSWER ✔✔
Restrict protein intake by limiting meats and other high -protein foods An overweight, young adult made who was recentl y diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions should the nurse implement?(Select all that apply.) - ANSWER ✔✔Check his fingerstick glucose level Assess h is skin temperature and moisture Measure his pulse and blood pressure A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse? - ANSWER ✔
✔Irregular apical pulse An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red and the client reports a burning sensation. What action should the nurse take? - ANSWER ✔✔Continue to monit or the fingers until color returns to normal A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vit al signs are temperature 101F, heart rate 128 beats/minute, respirations28 breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to implement first - ANSWER ✔✔Administer PRN oral antipyretic The nurse is completing th e preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomy under general anesthesia. Which finding warrants notification of the healthcare provider prior to proceeding with the scheduled procedure? - ANSWER ✔✔The client's bloo d pressure reading is 184/88 mm Hg
✔Breath sounds over bilateral lung field After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a client develops pontine myselinolysis. Which intervention should the nurse implement first? - ANSWER ✔✔Reorient client to his room A male client with heart failure (HF) calls the clinic andreports that he cannot put his shoes on because they aretoo tight. Which a dditional information should the nurseobtain? - ANSWER ✔✔Has his weight changed in the last several days ? An older adult woman with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persist ent cough. She is anxious and is complaining of a dry mouth. Which intervention should the nurse implement? - ANSWER ✔✔Assist her to an upright position A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, product ive cough with thickened tenacious mucous, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self -care? - ANSWER ✔✔Increase the daily intake of oral fluids to liquefy secretions A cardiac catherterization of a client with heart disease indicates the following blockages: 95% proximal left anterior descending (LAD), 99% proximal circumflex, and ?% proximal right coronary artery (RCA). The client later a sks the nurse "what does all this mean for me?" What information should the nurse provide? - ANSWER ✔✔Three main arteries have major blockages, with only 1 to5% of blood flow getting throu gh to the heart muscle . What information should the nurse include in the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD)? - ANSWER ✔✔Minimize symptoms by wearing loose, comfortable clothing The nurse is caring for a client with a lower left lobe pul monary abscess. Which position should the nurse instruct the client to maintain? - ANSWER ✔✔left lateral A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider. - ANSWER ✔✔Yellow sclera While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immedi ate intervention by the nurse? - ANSWER ✔✔Weakened cough effort The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client? - ANSWE R✔✔The xenograft is taken from nonhuman sources A male client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning him, the wound dehiscences and eviscerates. The nurse moistens an available steril e dressing and places it over the wound. What intervention should the nurse implement next? - ANSWER ✔✔Prepare the client to return to the operating room A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117 mEq/ L. Which nursing problem should the nurse include in this client's plan of care? - ANSWER ✔✔Fluid volume excess A female client enters the clinic and insists on being seen. She is weak, nervous, and reports a racing heart beat and recent weight loss of 15 p ounds. After ruling out substance withdrawal, the healthcare provider suspects hyperthyroidism and admits her for further testing. Which action should the nurse implement? - ANSWER ✔✔Space the client's care to provide periods of rest The nurse is teaching a client with glomerulonephritis about self -care. Which dietary recommendations should the nurse encourage the client to follow? - ANSWER ✔✔
Restrict protein intake by limiting meats and other high -protein foods An overweight, young adult made who was recentl y diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions should the nurse implement?(Select all that apply.) - ANSWER ✔✔Check his fingerstick glucose level Assess h is skin temperature and moisture Measure his pulse and blood pressure A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse? - ANSWER ✔
✔Irregular apical pulse An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red and the client reports a burning sensation. What action should the nurse take? - ANSWER ✔✔Continue to monit or the fingers until color returns to normal A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vit al signs are temperature 101F, heart rate 128 beats/minute, respirations28 breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to implement first - ANSWER ✔✔Administer PRN oral antipyretic The nurse is completing th e preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomy under general anesthesia. Which finding warrants notification of the healthcare provider prior to proceeding with the scheduled procedure? - ANSWER ✔✔The client's bloo d pressure reading is 184/88 mm Hg
