2024 MS HESI RETAKE REVIEW
EXAM WITH CORRECT ANSWERS
1-
A client with pheocromocytoma reports the onset of a severe headache.
The nurse observes that the client is very diaphoretic. Which assessment
data should the nurse obtain first. - CORRECT-ANSWERSBlood pressure
What instruction should the nurse include in the discharge teaching plan of a
client who had a cataract extraction today?
a. Sexual activities may be resumed upon return home
b. Light housekeeping is permitted but avoid heavy lifting
c. Use a metal eye shield on operative eye during the day
d. Administer eye ointment before applying eye drops - CORRECT-
ANSWERSANS: B
2-
The drainage in the chest tube of a client with emphysema has changed
from clear watery fluid. What action would be best for the nurse to take/ -
CORRECT-ANSWERSMaintain the current IV antibiotic schedule
3-
A client is admitted with a sudden onset of right sided the nurse complete
first? - CORRECT-ANSWERSObserve for peripheral edema
4-
When planning care for a client newly diagnose with open angle glaucoma,
the nurse identifies a priority nursing diagnosis of " Visual sensory/perceptual
alterations". This diagnosis is based on which etiology? - CORRECT-
ANSWERSDecreased peripheral vision
5-
A client in the operating room received succinylcholine. The client is
experiencing muscle rigidity and has an extremely high temperature. What
,action should the nurse implement? - CORRECT-ANSWERSCall the PACU
nurse to prepare for prolonged ventilatory support
Also know that PACU is BP, Respiration and Pulse
6-
A client who is receiving packed red blood cells develops nausea and
vomiting. What action should the nurse take first? - CORRECT-ANSWERSStop
the infusion of blood
Te lo pueden poner como hemodialysis y tambien es STOP transfusion
7-
A client with type 2 diabetes mellitus is admitted to the hospital for
uncontrolled DM. Insulin therapy is initiated with initial dose of Humulin
insulin at 8:00 at 16:00 the client complains of diaphoresis, rapid heart beat,
and feeling shaky. What should the nurse do first? - CORRECT-
ANSWERSDetermine the client current glucose level
8-
After suctioning the patient with an endotracheal tube, which assessment
finding indicates to the nurse that the intervention was effective? -
CORRECT-ANSWERSIncrease in breath sounds
9-
The nurse observes an increase number of blood clots in the drainage tubing
of a client with continuous bladder irrigation following a transurethral
resection of the prostate (TURP). What is the best initial nursing action? -
CORRECT-ANSWERSProvide additional oral fluid intake
Also with TURP you must know that 3l of water a day is needed
10-
Which nursing diagnosis should be selected for a client who is receiving
thrombolytic infusions for treatment of an acute myocardial infarction? -
CORRECT-ANSWERSRisk for injury related to effects of thrombolysis
11-
The nurse is assessing a client who has returned from surgery following a
thoracotomy. Which finding indicates the client is experiencing adequate gas
, exchange? - CORRECT-ANSWERSThe client demonstrates effective coughing
and deep breathing exercises
12-
When caring for a client with nephrotic syndrome which assessment is most
important for the nurse to obtain? - CORRECT-ANSWERSDaily Weight
13-
A client who had a biliopancreatic diversion procedure (BOP) 3 months ago is
admitted with severe dehydration. Which assessment finding warrants
immediate intervention by the nurse? - CORRECT-ANSWERSGastroccult
positive emesis
14-
A female client with possible acute renal failure (ARF) is admitted to the
hospital and mannitol (Osmitrol) is prescribed as a fluid challenge. Prior to
carrying out this prescription, what intervention should the nurse implement?
• No specific nursing action is required
• Instruct the client to empty the bladder
• Collect a clean catch urine specimen
• Obtain vital signs and breath sounds - CORRECT-ANSWERSANS: D
15-
The nurse positions a male client for a lumbar puncture by placing him in the
side-lying position with his knees flexed and pulled toward his trunk. What
action should the nurse implement next?
• Call another nurse to assist the healthcare provider
• Provide a small pillow for the client to curl around
• Instruct the client to perform a Valsalva maneuver
• Support the client's head bent forward to the chest - CORRECT-
ANSWERSANS: D
16-
When teaching a client with osteoporosis to increase weight-bearing
exercise, how should the nurse explain the purpose of this activity?
• Strengthen leg muscles
• Promote venous return
• Increase bone strength
• Restore range of motion - CORRECT-ANSWERSANS: C
17-
EXAM WITH CORRECT ANSWERS
1-
A client with pheocromocytoma reports the onset of a severe headache.
The nurse observes that the client is very diaphoretic. Which assessment
data should the nurse obtain first. - CORRECT-ANSWERSBlood pressure
What instruction should the nurse include in the discharge teaching plan of a
client who had a cataract extraction today?
a. Sexual activities may be resumed upon return home
b. Light housekeeping is permitted but avoid heavy lifting
c. Use a metal eye shield on operative eye during the day
d. Administer eye ointment before applying eye drops - CORRECT-
ANSWERSANS: B
2-
The drainage in the chest tube of a client with emphysema has changed
from clear watery fluid. What action would be best for the nurse to take/ -
CORRECT-ANSWERSMaintain the current IV antibiotic schedule
3-
A client is admitted with a sudden onset of right sided the nurse complete
first? - CORRECT-ANSWERSObserve for peripheral edema
4-
When planning care for a client newly diagnose with open angle glaucoma,
the nurse identifies a priority nursing diagnosis of " Visual sensory/perceptual
alterations". This diagnosis is based on which etiology? - CORRECT-
ANSWERSDecreased peripheral vision
5-
A client in the operating room received succinylcholine. The client is
experiencing muscle rigidity and has an extremely high temperature. What
,action should the nurse implement? - CORRECT-ANSWERSCall the PACU
nurse to prepare for prolonged ventilatory support
Also know that PACU is BP, Respiration and Pulse
6-
A client who is receiving packed red blood cells develops nausea and
vomiting. What action should the nurse take first? - CORRECT-ANSWERSStop
the infusion of blood
Te lo pueden poner como hemodialysis y tambien es STOP transfusion
7-
A client with type 2 diabetes mellitus is admitted to the hospital for
uncontrolled DM. Insulin therapy is initiated with initial dose of Humulin
insulin at 8:00 at 16:00 the client complains of diaphoresis, rapid heart beat,
and feeling shaky. What should the nurse do first? - CORRECT-
ANSWERSDetermine the client current glucose level
8-
After suctioning the patient with an endotracheal tube, which assessment
finding indicates to the nurse that the intervention was effective? -
CORRECT-ANSWERSIncrease in breath sounds
9-
The nurse observes an increase number of blood clots in the drainage tubing
of a client with continuous bladder irrigation following a transurethral
resection of the prostate (TURP). What is the best initial nursing action? -
CORRECT-ANSWERSProvide additional oral fluid intake
Also with TURP you must know that 3l of water a day is needed
10-
Which nursing diagnosis should be selected for a client who is receiving
thrombolytic infusions for treatment of an acute myocardial infarction? -
CORRECT-ANSWERSRisk for injury related to effects of thrombolysis
11-
The nurse is assessing a client who has returned from surgery following a
thoracotomy. Which finding indicates the client is experiencing adequate gas
, exchange? - CORRECT-ANSWERSThe client demonstrates effective coughing
and deep breathing exercises
12-
When caring for a client with nephrotic syndrome which assessment is most
important for the nurse to obtain? - CORRECT-ANSWERSDaily Weight
13-
A client who had a biliopancreatic diversion procedure (BOP) 3 months ago is
admitted with severe dehydration. Which assessment finding warrants
immediate intervention by the nurse? - CORRECT-ANSWERSGastroccult
positive emesis
14-
A female client with possible acute renal failure (ARF) is admitted to the
hospital and mannitol (Osmitrol) is prescribed as a fluid challenge. Prior to
carrying out this prescription, what intervention should the nurse implement?
• No specific nursing action is required
• Instruct the client to empty the bladder
• Collect a clean catch urine specimen
• Obtain vital signs and breath sounds - CORRECT-ANSWERSANS: D
15-
The nurse positions a male client for a lumbar puncture by placing him in the
side-lying position with his knees flexed and pulled toward his trunk. What
action should the nurse implement next?
• Call another nurse to assist the healthcare provider
• Provide a small pillow for the client to curl around
• Instruct the client to perform a Valsalva maneuver
• Support the client's head bent forward to the chest - CORRECT-
ANSWERSANS: D
16-
When teaching a client with osteoporosis to increase weight-bearing
exercise, how should the nurse explain the purpose of this activity?
• Strengthen leg muscles
• Promote venous return
• Increase bone strength
• Restore range of motion - CORRECT-ANSWERSANS: C
17-
