NURSING NR324 Med surg HESI exit exam latest test bank
with rationales complete Rated A+
The mother of an adolescent tells the clinic nurse, "My son has athlete's foot, I
have been applying triple antibiotic ointment for two days, but there has been no
improvement." What instruction should the nurse provide?
(ANS- Stop using the ointment and encourage complete drying of the feet and
wearing clean socks.
A 26-year-old female client is admitted to the hospital for treatment of a simple
goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms
indicate to the nurse that the prescribed dosage is too high for this client? The
client experiences
Bradycardia and constipation
Lethargy and lack of appetite
Muscle cramping and dry, flushed skin
Palpitations and shortness of breath
(ANS- Palpitations and shortness of breath
A client with a history of heart failure presents to the clinic with nausea, vomiting,
yellow vision and palpitations. Which finding is most important for the nurse to
assess to the client?
(ANS- Obtain a list of medications taken for cardiac history
The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg
in 250 ml of D5W at 300 mcg/hour. The nurse should program the infusion pump
to deliver how many ml/hour? (Enter numeric value only.)
(ANS- 75
Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour / 1,000
mcg x 250 ml = 3/1 x 25 = 75 ml/hour
,The pathophysiological mechanisms that are responsible for ascites related to liver
failure? (Select all that apply)
(ANS- Fluid shifts from intravascular to interstitial area due to decreased serum
protein
Increased hydrostatic pressure in portal circulation increases fluid shifts into
abdomen
Increased circulating aldosterone levels that increase sodium and water retention
The nurse is auscultating a client's heart sounds. Which description should the
nurse use to document this sound? (Please listen to the audio first to select the
option that applies)
(ANS- Murmur
Rationale: A murmur is auscultated as a swishing sound that is associated with the
blood turbulence created by the heart or valvular defect.
The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM
for an infant. The 500 mg vial is labeled with the instruction to add 5.3 ml diluent
to provide a concentration of 100 mg/ml. How many ml should the nurse
administered for each dose? (Enter numeric value only. If rounding is required,
round to the nearest tenth)
(ANS- 0.4
ationale: 35mg/100mg x 1 = 0.35 = 0.4 ml
The nurse notes that a client has been receiving hydromorphone (Dilaudid) every
six hours for four days. What assessment is most important for the nurse to
complete?
Auscultate the client's bowel sounds
Observe for edema around the ankles
Measure the client's capillary glucose level
Count the apical and radial pulses simultaneously
(ANS- Auscultate the client's bowel sounds
Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and
frequently causes constipation, so it is most important to Auscultate the client's
bowel sounds
,A female client is admitted with end stage pulmonary disease is alert, oriented, and
complaining of shortness of breath. The client tells the nurse that she wants "no
heroic measures" taken if she stops breathing, and she asks the nurse to document
this in her medical record. What action should the nurse implement?
(ANS- Ask the client to discuss "do not resuscitate" with her healthcare provider
A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour
and has developed diarrhea. The client has a new prescription to change the
feeding to half strength. What intervention should the nurse implement?
(ANS- Add equal amounts of water and feeding to a feeding bag and infuse at
50ml/hour
A female client reports that her hair is becoming coarse and breaking off, that the
outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which
follow-up question is best for the nurse to ask?
(ANS- Have you noticed any changes in your fingernails?
Rationale: The pattern of reported manifestations is suggestive of hypothyroidism
Following discharge teaching, a male client with duodenal ulcer tells the nurse the
he will drink plenty of dairy products, such as milk, to help coat and protect his
ulcer. What is the best follow-up action by the nurse?
(ANS- Review with the client the need to avoid foods that are rich in milk and
cream
A male client with hypertension, who received new antihypertensive prescriptions
at his last visit returns to the clinic two weeks later to evaluate his blood pressure
(BP). His BP is 158/106 and he admits that he has not been taking the prescribed
medication because the drugs make him "feel bad". In explaining the need for
hypertension control, the nurse should stress that an elevated BP places the client
at risk for which pathophysiological condition?
(ANS- Stroke secondary to hemorrhage
The nurse observes unlicensed assistive personnel (UAP) positioning a newly
admitted client who has a seizure disorder. The client is supine and the UAP is
placing soft pillows along the side rails. What action should the nurse implement?
(ANS- Instruct the UAP to obtain soft blankets to secure to the side rails instead of
pillows.
An adolescent with major depressive disorder has been taking duloxetine
(Cymbalta) for the past 12 days. Which assessment finding requires immediate
follow-up?
, (ANS- Describes life without purpose
A 60-year-old female client with a positive family history of ovarian cancer has
developed an abdominal mass and is being evaluated for possible ovarian cancer.
Her Papanicolau (Pap) smear results are negative. What information should the
nurse include in the client's teaching plan?
(ANS- Further evaluation involving surgery may be needed
A client who recently underwear a tracheostomy is being prepared for discharge to
home. Which instructions is most important for the nurse to include in the
discharge plan?
(ANS- Teach tracheal suctioning techniques
In assessing an adult client with a partial rebreather mask, the nurse notes that the
oxygen reservoir bag does not deflate completely during inspiration and the client's
respiratory rate is 14 breaths / minute. What action should the nurse implement?
(ANS- Document the assessment data
Rationale: reservoir bag should not deflate completely during inspiration and the
client's respiratory rate is within normal limits.
During shift report, the central electrocardiogram (EKG) monitoring system
alarms. Which client alarm should the nurse investigate firs?
(ANS- Respiratory apnea of 30 seconds
During a home visit, the nurse observed an elderly client with diabetes slip and
fall. What action should the nurse take first?
(ANS- Check the client for lacerations or fractures
At 0600 while admitting a woman for a schedule repeat cesarean section (C-
Section), the client tells the nurse that she drank a cup a coffee at 0400 because she
wanted to avoid getting a headache. Which action should the nurse take first?
(ANS- Inform the anesthesia care provider
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2
heart sounds. To determine if an S3 heart sound is present, what action should the
nurse take first?
(ANS- Listen with the bell at the same location
with rationales complete Rated A+
The mother of an adolescent tells the clinic nurse, "My son has athlete's foot, I
have been applying triple antibiotic ointment for two days, but there has been no
improvement." What instruction should the nurse provide?
(ANS- Stop using the ointment and encourage complete drying of the feet and
wearing clean socks.
A 26-year-old female client is admitted to the hospital for treatment of a simple
goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms
indicate to the nurse that the prescribed dosage is too high for this client? The
client experiences
Bradycardia and constipation
Lethargy and lack of appetite
Muscle cramping and dry, flushed skin
Palpitations and shortness of breath
(ANS- Palpitations and shortness of breath
A client with a history of heart failure presents to the clinic with nausea, vomiting,
yellow vision and palpitations. Which finding is most important for the nurse to
assess to the client?
(ANS- Obtain a list of medications taken for cardiac history
The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg
in 250 ml of D5W at 300 mcg/hour. The nurse should program the infusion pump
to deliver how many ml/hour? (Enter numeric value only.)
(ANS- 75
Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour / 1,000
mcg x 250 ml = 3/1 x 25 = 75 ml/hour
,The pathophysiological mechanisms that are responsible for ascites related to liver
failure? (Select all that apply)
(ANS- Fluid shifts from intravascular to interstitial area due to decreased serum
protein
Increased hydrostatic pressure in portal circulation increases fluid shifts into
abdomen
Increased circulating aldosterone levels that increase sodium and water retention
The nurse is auscultating a client's heart sounds. Which description should the
nurse use to document this sound? (Please listen to the audio first to select the
option that applies)
(ANS- Murmur
Rationale: A murmur is auscultated as a swishing sound that is associated with the
blood turbulence created by the heart or valvular defect.
The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM
for an infant. The 500 mg vial is labeled with the instruction to add 5.3 ml diluent
to provide a concentration of 100 mg/ml. How many ml should the nurse
administered for each dose? (Enter numeric value only. If rounding is required,
round to the nearest tenth)
(ANS- 0.4
ationale: 35mg/100mg x 1 = 0.35 = 0.4 ml
The nurse notes that a client has been receiving hydromorphone (Dilaudid) every
six hours for four days. What assessment is most important for the nurse to
complete?
Auscultate the client's bowel sounds
Observe for edema around the ankles
Measure the client's capillary glucose level
Count the apical and radial pulses simultaneously
(ANS- Auscultate the client's bowel sounds
Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and
frequently causes constipation, so it is most important to Auscultate the client's
bowel sounds
,A female client is admitted with end stage pulmonary disease is alert, oriented, and
complaining of shortness of breath. The client tells the nurse that she wants "no
heroic measures" taken if she stops breathing, and she asks the nurse to document
this in her medical record. What action should the nurse implement?
(ANS- Ask the client to discuss "do not resuscitate" with her healthcare provider
A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour
and has developed diarrhea. The client has a new prescription to change the
feeding to half strength. What intervention should the nurse implement?
(ANS- Add equal amounts of water and feeding to a feeding bag and infuse at
50ml/hour
A female client reports that her hair is becoming coarse and breaking off, that the
outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which
follow-up question is best for the nurse to ask?
(ANS- Have you noticed any changes in your fingernails?
Rationale: The pattern of reported manifestations is suggestive of hypothyroidism
Following discharge teaching, a male client with duodenal ulcer tells the nurse the
he will drink plenty of dairy products, such as milk, to help coat and protect his
ulcer. What is the best follow-up action by the nurse?
(ANS- Review with the client the need to avoid foods that are rich in milk and
cream
A male client with hypertension, who received new antihypertensive prescriptions
at his last visit returns to the clinic two weeks later to evaluate his blood pressure
(BP). His BP is 158/106 and he admits that he has not been taking the prescribed
medication because the drugs make him "feel bad". In explaining the need for
hypertension control, the nurse should stress that an elevated BP places the client
at risk for which pathophysiological condition?
(ANS- Stroke secondary to hemorrhage
The nurse observes unlicensed assistive personnel (UAP) positioning a newly
admitted client who has a seizure disorder. The client is supine and the UAP is
placing soft pillows along the side rails. What action should the nurse implement?
(ANS- Instruct the UAP to obtain soft blankets to secure to the side rails instead of
pillows.
An adolescent with major depressive disorder has been taking duloxetine
(Cymbalta) for the past 12 days. Which assessment finding requires immediate
follow-up?
, (ANS- Describes life without purpose
A 60-year-old female client with a positive family history of ovarian cancer has
developed an abdominal mass and is being evaluated for possible ovarian cancer.
Her Papanicolau (Pap) smear results are negative. What information should the
nurse include in the client's teaching plan?
(ANS- Further evaluation involving surgery may be needed
A client who recently underwear a tracheostomy is being prepared for discharge to
home. Which instructions is most important for the nurse to include in the
discharge plan?
(ANS- Teach tracheal suctioning techniques
In assessing an adult client with a partial rebreather mask, the nurse notes that the
oxygen reservoir bag does not deflate completely during inspiration and the client's
respiratory rate is 14 breaths / minute. What action should the nurse implement?
(ANS- Document the assessment data
Rationale: reservoir bag should not deflate completely during inspiration and the
client's respiratory rate is within normal limits.
During shift report, the central electrocardiogram (EKG) monitoring system
alarms. Which client alarm should the nurse investigate firs?
(ANS- Respiratory apnea of 30 seconds
During a home visit, the nurse observed an elderly client with diabetes slip and
fall. What action should the nurse take first?
(ANS- Check the client for lacerations or fractures
At 0600 while admitting a woman for a schedule repeat cesarean section (C-
Section), the client tells the nurse that she drank a cup a coffee at 0400 because she
wanted to avoid getting a headache. Which action should the nurse take first?
(ANS- Inform the anesthesia care provider
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2
heart sounds. To determine if an S3 heart sound is present, what action should the
nurse take first?
(ANS- Listen with the bell at the same location
