MEDn SURGn RNnBRANDnNEWn HESInEXITnVERSIONn 1n(V1)n TESTn BANK l
MED SURG HESI EXIT EXAM/Latest n n n n
2023/Test Bank n
Following discharge teaching, a male client with duodenal ulcer tells the nurse the he
n n n n n n n n n n n n n
nwill drink plenty of dairy products, such as milk, to help coat and protect his ulcer.
n n n n n n n n n n n n n n n n
What is the best follow-up action by the nurse?
n n n n n n n n
(ANS- Review with the client the need to avoid foods that are rich in milk and cream
n n n n n n n n n n n n n n n n
A male client with hypertension, who received new antihypertensive prescriptions at
n n n n n n n n n n
nhis last visit returns to the clinic two weeks later to evaluate his blood pressure (BP).
n n n n n n n n n n n n n n n
nHis BP is 158/106 and he admits that he has not been taking the prescribed medicati
n n n n n n n n n n n n n n n
on because the drugs make him "feel bad". In explaining the need for hypertension c
n n n n n n n n n n n n n n
ontrol, the nurse should stress that an elevated BP places the client at risk for which
n n n n n n n n n n n n n n n n
pathophysiological condition? n
(ANS- Stroke secondary to hemorrhage
n n n n
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly ad
n n n n n n n n n n n
mitted client who has a seizure disorder. The client is supine and the UAP is placing
n n n n n n n n n n n n n n n n
soft pillows along the side rails. What action should the nurse implement? (ANS-
n n n n n n n n n n n n
Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.
n n n n n n n n n n n n n n n n
An adolescent with major depressive disorder has been taking duloxetine (Cymb
n n n n n n n n n n
alta) for the past 12 days. Which assessment finding requires immediate follow-
n n n n n n n n n n n
up?
(ANS- Describes life without purpose
n n n n
A 60-year-
n
old female client with a positive family history of ovarian cancer has developed an a
n n n n n n n n n n n n n n
bdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (
n n n n n n n n n n n n
Pap) smear results are negative. What information should the nurse include in the cli
n n n n n n n n n n n n n
ent's teaching plan?n n
(ANS- Further evaluation involving surgery may be needed
n n n n n n n
, MEDn SURGn RNnBRANDnNEWn HESInEXITnVERSIONn 1n(V1)n TESTn BANK
A client who recently underwear a tracheostomy is being prepared for discharge to h
n n n n n n n n n n n n n
ome. Which instructions is most important for the nurse to include in the discharge p
n n n n n n n n n n n n n n
lan?
(ANS- Teach tracheal suctioning techniques
n n n n
In assessing an adult client with a partial rebreather mask, the nurse notes that the ox
n n n n n n n n n n n n n n n
ygen reservoir bag does not deflate completely during inspiration and the client's resp
n n n n n n n n n n n n
iratory rate is 14 breaths / minute. What action should the nurse implement? (ANS-
n n n n n n n n n n n n n
nDocument the assessment data n n n
Rationale: reservoir bag should not deflate completely during inspiration and the clie
n n n n n n n n n n n
nt's respiratory rate is within normal limits.
n n n n n n
During shift report, the central electrocardiogram (EKG) monitoring system alar
n n n n n n n n n
ms. Which client alarm should the nurse investigate firs?
n n n n n n n n
(ANS- Respiratory apnea of 30 seconds
n n n n n
During a home visit, the nurse observed an elderly client with diabetes slip and fa
n n n n n n n n n n n n n n
ll. What action should the nurse take first?
n n n n n n n
(ANS- Check the client for lacerations or fractures
n n n n n n n
At 0600 while admitting a woman for a schedule repeat cesarean section (C-
n n n n n n n n n n n n
Section), the client tells the nurse that she drank a cup a coffee at 0400 because she w
n n n n n n n n n n n n n n n n n n
anted to avoid getting a headache. Which action should the nurse take first? (ANS-
n n n n n n n n n n n n n
Inform the anesthesia care provider
n n n n n
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 he
n n n n n n n n n n n n n n n
art sounds. To determine if an S3 heart sound is present, what action should the nurs
n n n n n n n n n n n n n n n
e take first?
n n
(ANS- Listen with the bell at the same location
n n n n n n n n
A 66-year-
n
old woman is retiring and will no longer have a health insurance through her place of
n n n n n n n n n n n n n n n n
employment. Which agency should the client be referred to by the employee health n
n n n n n n n n n n n n n
urse for health insurance needs?
n n n n
(ANS- Medicare n
, MEDn SURGn RNnBRANDnNEWn HESInEXITnVERSIONn 1n(V1)n TESTn BANK
A client who is taking an oral dose of a tetracycline complains of gastrointestinal up
n n n n n n n n n n n n n n
set. What snack should the nurse instruct the client to take with the tetracycline? (AN
n n n n n n n n n n n n n n
S- Toasted wheat bread and jelly
n n n n n
Following a lumbar puncture, a client voices several complaints. What complaint indicat
n n n n n n n n n n n
ed to the nurse that the client is experiencing a complication?
n n n n n n n n n n
(ANS- "I have a headache that gets worse when I sit up"
n n n n n n n n n n n
"I am having pain in my lower back when I move my legs" "
n n n n n n n n n n n n n
My throat hurts when I swallow"
n n n n n
"I feel sick to my stomach and am going to throw up"
n n n n n n n n n n n
An elderly client seems confused and reports the onset of nausea, dysuria, and urgenc
n n n n n n n n n n n n n
y with incontinence. Which action should the nurse implement?
n n n n n n n n
(ANS- Obtain a clean catch mid-stream specimen
n n n n n n
The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foo
n n n n n n n n n n n n n n
ds that are in keeping with the child's dietary restrictions. Which foods are contraind
n n n n n n n n n n n n n
icated for this child? n n n
(ANS- Foods sweetened with aspartame n n n n
Before preparing a client for the first surgical case of the day, a part-
n n n n n n n n n n n n n
time scrub nurse asks the circulating nurse if a 3 minute surgical hand scrub is adequ
n n n n n n n n n n n n n n n
ate preparation for this client. Which response should the circulating nurse provide?
n n n n n n n n n n n
n(ANS- Direct the nurse to continue the surgical hand scrub for a 5 minute duration
n n n n n n n n n n n n n n
Which breakfast selection indicates that the client understands the nurse's instruction
n n n n n n n n n n
s about the dietary management of osteoporosis?
n n n n n n
(ANS- Bagel with jelly and skim milk n n n n n n
The charge nurse of a critical care unit is informed at the beginning of the shift that les
n n n n n n n n n n n n n n n n n
s than the optimal number of registered nurses will be working that shift. In planning
n n n n n n n n n n n n n n n
assignments, which client should receive the most care hours by a registered nurse (R
n n n n n n n n n n n n n
N)?
, MEDn SURGn RNnBRANDnNEWn HESInEXITnVERSIONn 1n(V1)n TESTn BANK
(ANS- An 82-year-old client with Alzheimer's disease newly-
n n n n n n n
fractures femur who has a Foley catheter and soft wrist restrains applied
n n n n n n n n n n n
A mother brings her 6-year-
n n n n
old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon ins
n n n n n n n n n n n n n n n
pection, the nurse notes that the nail went through the shoe and pierced the bottom o
n n n n n n n n n n n n n n n
f the child's foot. Which action should the nurse implement first?
n n n n n n n n n n
-Cleanse the foot with soap and water and apply an antibiotic ointment
n n n n n n n n n n n
-Provide teaching about the need for a tetanus booster within the next 72hours.
n n n n n n n n n n n n
-have the mother check the child's temperature q4h for the next 24 hours
n n n n n n n n n n n n
-
transfer the child to the emergency department to receive a gamma globulin injection
n n n n n n n n n n n n
(ANS- Cleanse the foot with soap and water and apply an antibiotic ointment
n n n n n n n n n n n n
The mother of an adolescent tells the clinic nurse, "My son has athlete's foot, I have
n n n n n n n n n n n n n n n n
been applying triple antibiotic ointment for two days, but there has been no improve
n n n n n n n n n n n n n
ment." What instruction should the nurse provide?
n n n n n n
(ANS-
nStop using the ointment and encourage complete drying of the feet and wearing clea
n n n n n n n n n n n n n
n socks.n
A 26-year- n
old female client is admitted to the hospital for treatment of a simple goiter, and levot
n n n n n n n n n n n n n n n
hyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse t
n n n n n n n n n n n
hat the prescribed dosage is too high for this client? The client experiences
n n n n n n n n n n n n
Bradycardia and constipation n n n
Lethargy and lack of appetite n n n n
Muscle cramping and dry, flushed skin Palp
n n n n n n
itations and shortness of breath n n n n
(ANS- Palpitations and shortness of breath
n n n n n
A client with a history of heart failure presents to the clinic with nausea, vomiting, ye
n n n n n n n n n n n n n n n
llow vision and palpitations. Which finding is most important for the nurse to assess
n n n n n n n n n n n n n n
to the client?
n n
MED SURG HESI EXIT EXAM/Latest n n n n
2023/Test Bank n
Following discharge teaching, a male client with duodenal ulcer tells the nurse the he
n n n n n n n n n n n n n
nwill drink plenty of dairy products, such as milk, to help coat and protect his ulcer.
n n n n n n n n n n n n n n n n
What is the best follow-up action by the nurse?
n n n n n n n n
(ANS- Review with the client the need to avoid foods that are rich in milk and cream
n n n n n n n n n n n n n n n n
A male client with hypertension, who received new antihypertensive prescriptions at
n n n n n n n n n n
nhis last visit returns to the clinic two weeks later to evaluate his blood pressure (BP).
n n n n n n n n n n n n n n n
nHis BP is 158/106 and he admits that he has not been taking the prescribed medicati
n n n n n n n n n n n n n n n
on because the drugs make him "feel bad". In explaining the need for hypertension c
n n n n n n n n n n n n n n
ontrol, the nurse should stress that an elevated BP places the client at risk for which
n n n n n n n n n n n n n n n n
pathophysiological condition? n
(ANS- Stroke secondary to hemorrhage
n n n n
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly ad
n n n n n n n n n n n
mitted client who has a seizure disorder. The client is supine and the UAP is placing
n n n n n n n n n n n n n n n n
soft pillows along the side rails. What action should the nurse implement? (ANS-
n n n n n n n n n n n n
Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.
n n n n n n n n n n n n n n n n
An adolescent with major depressive disorder has been taking duloxetine (Cymb
n n n n n n n n n n
alta) for the past 12 days. Which assessment finding requires immediate follow-
n n n n n n n n n n n
up?
(ANS- Describes life without purpose
n n n n
A 60-year-
n
old female client with a positive family history of ovarian cancer has developed an a
n n n n n n n n n n n n n n
bdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (
n n n n n n n n n n n n
Pap) smear results are negative. What information should the nurse include in the cli
n n n n n n n n n n n n n
ent's teaching plan?n n
(ANS- Further evaluation involving surgery may be needed
n n n n n n n
, MEDn SURGn RNnBRANDnNEWn HESInEXITnVERSIONn 1n(V1)n TESTn BANK
A client who recently underwear a tracheostomy is being prepared for discharge to h
n n n n n n n n n n n n n
ome. Which instructions is most important for the nurse to include in the discharge p
n n n n n n n n n n n n n n
lan?
(ANS- Teach tracheal suctioning techniques
n n n n
In assessing an adult client with a partial rebreather mask, the nurse notes that the ox
n n n n n n n n n n n n n n n
ygen reservoir bag does not deflate completely during inspiration and the client's resp
n n n n n n n n n n n n
iratory rate is 14 breaths / minute. What action should the nurse implement? (ANS-
n n n n n n n n n n n n n
nDocument the assessment data n n n
Rationale: reservoir bag should not deflate completely during inspiration and the clie
n n n n n n n n n n n
nt's respiratory rate is within normal limits.
n n n n n n
During shift report, the central electrocardiogram (EKG) monitoring system alar
n n n n n n n n n
ms. Which client alarm should the nurse investigate firs?
n n n n n n n n
(ANS- Respiratory apnea of 30 seconds
n n n n n
During a home visit, the nurse observed an elderly client with diabetes slip and fa
n n n n n n n n n n n n n n
ll. What action should the nurse take first?
n n n n n n n
(ANS- Check the client for lacerations or fractures
n n n n n n n
At 0600 while admitting a woman for a schedule repeat cesarean section (C-
n n n n n n n n n n n n
Section), the client tells the nurse that she drank a cup a coffee at 0400 because she w
n n n n n n n n n n n n n n n n n n
anted to avoid getting a headache. Which action should the nurse take first? (ANS-
n n n n n n n n n n n n n
Inform the anesthesia care provider
n n n n n
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 he
n n n n n n n n n n n n n n n
art sounds. To determine if an S3 heart sound is present, what action should the nurs
n n n n n n n n n n n n n n n
e take first?
n n
(ANS- Listen with the bell at the same location
n n n n n n n n
A 66-year-
n
old woman is retiring and will no longer have a health insurance through her place of
n n n n n n n n n n n n n n n n
employment. Which agency should the client be referred to by the employee health n
n n n n n n n n n n n n n
urse for health insurance needs?
n n n n
(ANS- Medicare n
, MEDn SURGn RNnBRANDnNEWn HESInEXITnVERSIONn 1n(V1)n TESTn BANK
A client who is taking an oral dose of a tetracycline complains of gastrointestinal up
n n n n n n n n n n n n n n
set. What snack should the nurse instruct the client to take with the tetracycline? (AN
n n n n n n n n n n n n n n
S- Toasted wheat bread and jelly
n n n n n
Following a lumbar puncture, a client voices several complaints. What complaint indicat
n n n n n n n n n n n
ed to the nurse that the client is experiencing a complication?
n n n n n n n n n n
(ANS- "I have a headache that gets worse when I sit up"
n n n n n n n n n n n
"I am having pain in my lower back when I move my legs" "
n n n n n n n n n n n n n
My throat hurts when I swallow"
n n n n n
"I feel sick to my stomach and am going to throw up"
n n n n n n n n n n n
An elderly client seems confused and reports the onset of nausea, dysuria, and urgenc
n n n n n n n n n n n n n
y with incontinence. Which action should the nurse implement?
n n n n n n n n
(ANS- Obtain a clean catch mid-stream specimen
n n n n n n
The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foo
n n n n n n n n n n n n n n
ds that are in keeping with the child's dietary restrictions. Which foods are contraind
n n n n n n n n n n n n n
icated for this child? n n n
(ANS- Foods sweetened with aspartame n n n n
Before preparing a client for the first surgical case of the day, a part-
n n n n n n n n n n n n n
time scrub nurse asks the circulating nurse if a 3 minute surgical hand scrub is adequ
n n n n n n n n n n n n n n n
ate preparation for this client. Which response should the circulating nurse provide?
n n n n n n n n n n n
n(ANS- Direct the nurse to continue the surgical hand scrub for a 5 minute duration
n n n n n n n n n n n n n n
Which breakfast selection indicates that the client understands the nurse's instruction
n n n n n n n n n n
s about the dietary management of osteoporosis?
n n n n n n
(ANS- Bagel with jelly and skim milk n n n n n n
The charge nurse of a critical care unit is informed at the beginning of the shift that les
n n n n n n n n n n n n n n n n n
s than the optimal number of registered nurses will be working that shift. In planning
n n n n n n n n n n n n n n n
assignments, which client should receive the most care hours by a registered nurse (R
n n n n n n n n n n n n n
N)?
, MEDn SURGn RNnBRANDnNEWn HESInEXITnVERSIONn 1n(V1)n TESTn BANK
(ANS- An 82-year-old client with Alzheimer's disease newly-
n n n n n n n
fractures femur who has a Foley catheter and soft wrist restrains applied
n n n n n n n n n n n
A mother brings her 6-year-
n n n n
old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon ins
n n n n n n n n n n n n n n n
pection, the nurse notes that the nail went through the shoe and pierced the bottom o
n n n n n n n n n n n n n n n
f the child's foot. Which action should the nurse implement first?
n n n n n n n n n n
-Cleanse the foot with soap and water and apply an antibiotic ointment
n n n n n n n n n n n
-Provide teaching about the need for a tetanus booster within the next 72hours.
n n n n n n n n n n n n
-have the mother check the child's temperature q4h for the next 24 hours
n n n n n n n n n n n n
-
transfer the child to the emergency department to receive a gamma globulin injection
n n n n n n n n n n n n
(ANS- Cleanse the foot with soap and water and apply an antibiotic ointment
n n n n n n n n n n n n
The mother of an adolescent tells the clinic nurse, "My son has athlete's foot, I have
n n n n n n n n n n n n n n n n
been applying triple antibiotic ointment for two days, but there has been no improve
n n n n n n n n n n n n n
ment." What instruction should the nurse provide?
n n n n n n
(ANS-
nStop using the ointment and encourage complete drying of the feet and wearing clea
n n n n n n n n n n n n n
n socks.n
A 26-year- n
old female client is admitted to the hospital for treatment of a simple goiter, and levot
n n n n n n n n n n n n n n n
hyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse t
n n n n n n n n n n n
hat the prescribed dosage is too high for this client? The client experiences
n n n n n n n n n n n n
Bradycardia and constipation n n n
Lethargy and lack of appetite n n n n
Muscle cramping and dry, flushed skin Palp
n n n n n n
itations and shortness of breath n n n n
(ANS- Palpitations and shortness of breath
n n n n n
A client with a history of heart failure presents to the clinic with nausea, vomiting, ye
n n n n n n n n n n n n n n n
llow vision and palpitations. Which finding is most important for the nurse to assess
n n n n n n n n n n n n n n
to the client?
n n
