MED SURG HESI V2 - 2024 ACTUAL EXAMI
What information should the nurse include in the teaching plan of a client diagnosed
with GERD?
A. Sleep without pillows
B. Adjust food intake to three full meals per day with no snacks
C. Minimize symptoms by wearing loose comfortable clothing
D. Avoid participation in any aerobic exercise program - Answers -Minimize symptoms
by wearing loose comfortable clothing
After hospitalization for SIADH, a client develops pontine myelinolysis. Which
intervention should the nurse implement first?
A. Reorient client to room
B. Place a patch on one eye
C. Evaluate clients ability to swallow
D. Perform range of motion exercises - Answers -Reorient client to room
A male client with heart failure calls the clinic and reports that he cannot put his shoes
on because they are too tight. Which additional information should the nurse obtain?
A. What time did he take his medication?
B. Has his weight changed in the last several days?
C. Is he still able to tighten his belt buckle?
D. How many hours did he sleep last night? - Answers -Has his weight changed in the
last several days?
An older adult woman with a long history of COPD is admitted with progressive
shortness of breath and a persistent cough, is anxious, and is complaining of dry mouth.
which intervention should the nurse implement?
A. Administer a prescribed sedative
B. Encourage client to drink water
C. Apply a high flow Venturi mask
D. Assist her to an upright position - Answers -Assist her to an upright position
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 ulcerates. The
nurse moistens an available sterile dressing and places it over the wound. Which
intervention should the nurse implement next.
A. Bring additional sterile dressing supplies to the room.
B. Prepare the client to return to the OR
C. Obtain a sample of the drainage to send to the lab
D. ausculate the abdomen for bowel sounds - Answers -Bring additional sterile dressing
supplies to the room
, A client with carcinoma of the lung is complaining of weakness and has a serum sodium
level of 117/meq. Which nursing problem should the nurse include in the clients plan of
care.
A. Altered urinary elimination
B. Impaired gas exchange
C. Fluid volume excess
D. Decreased cardiac output - Answers -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 pounds. After ruling out
substance withdrawal, the MD suspects hyperthyroidisms and admits her for testing.
which action should the nurse do?
A. Begin preparing the client for thyroidectomy procedure
B. Space the clients care to provide periods of rest
C. Assess the client for hyperactive bowel sounds
D. Provide warm blanket to prevent heat loss - Answers -Assess the client for
hyperactive bowel sounds
The nurse is teaching a client with glomerulonephritis about self care. Which dietary
recommendations should the nurse encourage the client to follow.
A. increase intake of high-fiber foods, such as bran cereal.
B. Restrict protein intake by limiting meals and other high-protein foods
C. limit oral fluid intake of 500/ml/day
D. Increase intake of potassium rich foods such as bananas and cantaloupe - Answers -
Restrict protein intake by limiting meals and other high-protein foods
An overweight young adult male who was recently diagnosed with type 2 DM 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.
A.Check his fingerstick glucose
B. Assess his skin temperature and moisture
C. Measure his pulse and BP
D. Document anxiety on the surgical checklist
E. Administer a PRN dose of regular insulin - Answers -Check his fingerstick glucose,
assess his skin temperature and moisture, measure his pulse and BP
A client with Cushing Syndrome is recovering from an elective laparoscopic procedure.
which assessment finding warrants immediate intervention by the nurse?
A. Irregular apical pulse
B. Purple marks on skin of the abdomen
C. Quarter sized blood spot on the dressing
D. Pitting ankle edema - Answers -Irregular apical pulse
What information should the nurse include in the teaching plan of a client diagnosed
with GERD?
A. Sleep without pillows
B. Adjust food intake to three full meals per day with no snacks
C. Minimize symptoms by wearing loose comfortable clothing
D. Avoid participation in any aerobic exercise program - Answers -Minimize symptoms
by wearing loose comfortable clothing
After hospitalization for SIADH, a client develops pontine myelinolysis. Which
intervention should the nurse implement first?
A. Reorient client to room
B. Place a patch on one eye
C. Evaluate clients ability to swallow
D. Perform range of motion exercises - Answers -Reorient client to room
A male client with heart failure calls the clinic and reports that he cannot put his shoes
on because they are too tight. Which additional information should the nurse obtain?
A. What time did he take his medication?
B. Has his weight changed in the last several days?
C. Is he still able to tighten his belt buckle?
D. How many hours did he sleep last night? - Answers -Has his weight changed in the
last several days?
An older adult woman with a long history of COPD is admitted with progressive
shortness of breath and a persistent cough, is anxious, and is complaining of dry mouth.
which intervention should the nurse implement?
A. Administer a prescribed sedative
B. Encourage client to drink water
C. Apply a high flow Venturi mask
D. Assist her to an upright position - Answers -Assist her to an upright position
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 ulcerates. The
nurse moistens an available sterile dressing and places it over the wound. Which
intervention should the nurse implement next.
A. Bring additional sterile dressing supplies to the room.
B. Prepare the client to return to the OR
C. Obtain a sample of the drainage to send to the lab
D. ausculate the abdomen for bowel sounds - Answers -Bring additional sterile dressing
supplies to the room
, A client with carcinoma of the lung is complaining of weakness and has a serum sodium
level of 117/meq. Which nursing problem should the nurse include in the clients plan of
care.
A. Altered urinary elimination
B. Impaired gas exchange
C. Fluid volume excess
D. Decreased cardiac output - Answers -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 pounds. After ruling out
substance withdrawal, the MD suspects hyperthyroidisms and admits her for testing.
which action should the nurse do?
A. Begin preparing the client for thyroidectomy procedure
B. Space the clients care to provide periods of rest
C. Assess the client for hyperactive bowel sounds
D. Provide warm blanket to prevent heat loss - Answers -Assess the client for
hyperactive bowel sounds
The nurse is teaching a client with glomerulonephritis about self care. Which dietary
recommendations should the nurse encourage the client to follow.
A. increase intake of high-fiber foods, such as bran cereal.
B. Restrict protein intake by limiting meals and other high-protein foods
C. limit oral fluid intake of 500/ml/day
D. Increase intake of potassium rich foods such as bananas and cantaloupe - Answers -
Restrict protein intake by limiting meals and other high-protein foods
An overweight young adult male who was recently diagnosed with type 2 DM 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.
A.Check his fingerstick glucose
B. Assess his skin temperature and moisture
C. Measure his pulse and BP
D. Document anxiety on the surgical checklist
E. Administer a PRN dose of regular insulin - Answers -Check his fingerstick glucose,
assess his skin temperature and moisture, measure his pulse and BP
A client with Cushing Syndrome is recovering from an elective laparoscopic procedure.
which assessment finding warrants immediate intervention by the nurse?
A. Irregular apical pulse
B. Purple marks on skin of the abdomen
C. Quarter sized blood spot on the dressing
D. Pitting ankle edema - Answers -Irregular apical pulse
