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MED SURG HESI V2 - 2025/2026
A client with cancer is receiving chemotherapy with a known
vesicant. the clients IV has been in place for 72hrs. The nurse
determines that a new IV site cannot be obtained and leaves
present IV in place. What is greatest clinical risk?
A. impaired skin integrity
B. fluid volume excess
C. Acute pain and anxiety
D. Peripheral neuron vascular dysfunction -
...ANSWER✓✓✓Impaired skin integrity
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 - ...ANSWER✓✓✓Fluid volume
excess
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A client with Cholelithiasis has a gallstone lodged in the common
bile duct and is unable to eat or drink without becoming
nauseous and vomiting. Which finding should the nurse report to
the healthcare provider?
A. Belching
B. Amber urine
C. Yellow sclera
D. Flatulence - ...ANSWER✓✓✓Yellow sclera
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 - ...ANSWER✓✓✓Irregular apical pulse
A cardiac catherization of a client with heart disease indicates
the following blockages: 95% proximal left anterior descending
(LAD), 99% proximal circumflex, and 95% proximal right coronary
artery (RCA) the client later asks the nurse "What does all of that
mean for me?" What information should the nurse provide.
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B. Three main arteries have major blockages, with only 1-5% of
the blood flow getting through to the heart muscles -
...ANSWER✓✓✓Three main arteries have major blockages, with
only 1-5% of the blood flow getting through to the heart muscles
A client being admitted to a surgical unit is being evaluated for
an intestinal obstruction. The HCP prescribes a NG tube to be
inserted and placed to intermittent low wall suction. which
intervention should the nurse implement to facilitate proper tube
placement.
A. Soak NG tube in warm water
B. Insert tube with clients head tilted back
C. Apply suction while inserting tube
D. Elevate head of bed to 60 to 90 degrees -
...ANSWER✓✓✓Elevate head of bed to 60 to 90 degrees
A client who has a history of hyperthyroidism was initially
admitted with lethargy and confusion. Which additional finding
warrants the most immediate action by the nurse?
A. Facial puffiness and periorbital edema
B. Hematocrit of 30%
C. cold and dry skin
D. Further decline in LOC - ...ANSWER✓✓✓Further decline in
LOC
MED SURG HESI V2 - 2025/2026
A client with cancer is receiving chemotherapy with a known
vesicant. the clients IV has been in place for 72hrs. The nurse
determines that a new IV site cannot be obtained and leaves
present IV in place. What is greatest clinical risk?
A. impaired skin integrity
B. fluid volume excess
C. Acute pain and anxiety
D. Peripheral neuron vascular dysfunction -
...ANSWER✓✓✓Impaired skin integrity
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 - ...ANSWER✓✓✓Fluid volume
excess
,2|Page
A client with Cholelithiasis has a gallstone lodged in the common
bile duct and is unable to eat or drink without becoming
nauseous and vomiting. Which finding should the nurse report to
the healthcare provider?
A. Belching
B. Amber urine
C. Yellow sclera
D. Flatulence - ...ANSWER✓✓✓Yellow sclera
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 - ...ANSWER✓✓✓Irregular apical pulse
A cardiac catherization of a client with heart disease indicates
the following blockages: 95% proximal left anterior descending
(LAD), 99% proximal circumflex, and 95% proximal right coronary
artery (RCA) the client later asks the nurse "What does all of that
mean for me?" What information should the nurse provide.
, 3|Page
B. Three main arteries have major blockages, with only 1-5% of
the blood flow getting through to the heart muscles -
...ANSWER✓✓✓Three main arteries have major blockages, with
only 1-5% of the blood flow getting through to the heart muscles
A client being admitted to a surgical unit is being evaluated for
an intestinal obstruction. The HCP prescribes a NG tube to be
inserted and placed to intermittent low wall suction. which
intervention should the nurse implement to facilitate proper tube
placement.
A. Soak NG tube in warm water
B. Insert tube with clients head tilted back
C. Apply suction while inserting tube
D. Elevate head of bed to 60 to 90 degrees -
...ANSWER✓✓✓Elevate head of bed to 60 to 90 degrees
A client who has a history of hyperthyroidism was initially
admitted with lethargy and confusion. Which additional finding
warrants the most immediate action by the nurse?
A. Facial puffiness and periorbital edema
B. Hematocrit of 30%
C. cold and dry skin
D. Further decline in LOC - ...ANSWER✓✓✓Further decline in
LOC
