HESI -MEDICAL SURGICAL PRACTICE
EXAM//VERIFIED ANSWERS
The nurse is assessing a client's laboratory values following administration of
chemotherapy. Which lab value leads the nurse to suspect that the client is
experiencing tumor lysis syndrome (TLS)?
A. Serum PTT of 10 seconds
B. Serum calcium of 5 mg/dl
C. Oxygen saturation of 90%
D. Hemoglobin of 10 g/dl - ANSWER-B. Serum calcium of 5 mg/dl.
TLS results in hyperkalemia, hypocalcemia, hyperuricemia, and
hyperphosphatemia.
A client is admitted to the hospital with a diagnosis of severe acute diverticulitis.
Which assessment finding should the nurse expect this client to exhibit?
A. Lower left quadrant pain and a low-grade fever
B. Severe pain at McBurney's point and nausea.
,C. Abdominal pain and intermittent tenesmus
D. Exacerbations of severe diarrhea - ANSWER-A. Lower left quadrant pain and a
low-grade fever.
Left lower quadrant pain occurs with diverticulitis because the sigmoid colon is the
most common area for diverticula, and the inflammation of diverticula causes a
low-grade fever.
During CPR, when attempting to ventilate a client's lungs, the nurse notes that the
chest is not moving. What action should the nurse take first?
A. Use a laryngoscope to check for a foreign body lodged in the esophagus.
B. Reposition the head to validate that the head is in the proper position to open the
airway.
C. Turn the client to the side and administer three back blows.
D. Perform a finger sweep of the mouth to remove any vomitus - ANSWER-B.
Reposition the head to validate that the head is in the proper position to open the
airway.
The most frequent cause of inadequate aeration of the client's lungs during CPR is
improper positioning of the head resulting in occlusion of the airway. A foreign
body can occlude the airway, but this is not common unless choking preceded the
cardiac emergency, and should not be the nurse's first action.
, A client is admitted to the hospital with a medical diagnosis of pneumococcal
pneumonia. The nurse knows that the prognosis for gram-negative pneumonias
(such as E. coli, Klebsiella, Pseudomonas, and Proteus) is very poor because:
A. They occur in the lower love alveoli which are more sensitive to infection
B. Gram-negative organisms are more resistant to antibiotic therapy
C. They occur in healthy young adults who have recently been debilitated by an
upper respiratory infection.
D. Gram-negative pneumonias usually affect infants and small children. -
ANSWER-B. Gram-negative organisms are more resistant to antibiotic therapy
The gram-negative organisms are resistant to drug therapy which makes recovery
very difficult. Gram-negative pneumonias affect all lobes of the lung. The mean
age for contracting this type of pneumonia is 50 years, and it usually strikes
debilitated persons such as alcoholics, diabetics, and those with chronic lung
diseases.
A client is placed on a mechanical ventilator following a cerebral hemorrhage, and
vecuronium bromide (Norcuron) 0.04 mg/kg q12 hours IV is prescribed. What is
the priority nursing diagnosis for this client?
A. Impaired communication related to paralysis of skeletal muscles.
B. High risk for infection related to increased intracranial pressure.
EXAM//VERIFIED ANSWERS
The nurse is assessing a client's laboratory values following administration of
chemotherapy. Which lab value leads the nurse to suspect that the client is
experiencing tumor lysis syndrome (TLS)?
A. Serum PTT of 10 seconds
B. Serum calcium of 5 mg/dl
C. Oxygen saturation of 90%
D. Hemoglobin of 10 g/dl - ANSWER-B. Serum calcium of 5 mg/dl.
TLS results in hyperkalemia, hypocalcemia, hyperuricemia, and
hyperphosphatemia.
A client is admitted to the hospital with a diagnosis of severe acute diverticulitis.
Which assessment finding should the nurse expect this client to exhibit?
A. Lower left quadrant pain and a low-grade fever
B. Severe pain at McBurney's point and nausea.
,C. Abdominal pain and intermittent tenesmus
D. Exacerbations of severe diarrhea - ANSWER-A. Lower left quadrant pain and a
low-grade fever.
Left lower quadrant pain occurs with diverticulitis because the sigmoid colon is the
most common area for diverticula, and the inflammation of diverticula causes a
low-grade fever.
During CPR, when attempting to ventilate a client's lungs, the nurse notes that the
chest is not moving. What action should the nurse take first?
A. Use a laryngoscope to check for a foreign body lodged in the esophagus.
B. Reposition the head to validate that the head is in the proper position to open the
airway.
C. Turn the client to the side and administer three back blows.
D. Perform a finger sweep of the mouth to remove any vomitus - ANSWER-B.
Reposition the head to validate that the head is in the proper position to open the
airway.
The most frequent cause of inadequate aeration of the client's lungs during CPR is
improper positioning of the head resulting in occlusion of the airway. A foreign
body can occlude the airway, but this is not common unless choking preceded the
cardiac emergency, and should not be the nurse's first action.
, A client is admitted to the hospital with a medical diagnosis of pneumococcal
pneumonia. The nurse knows that the prognosis for gram-negative pneumonias
(such as E. coli, Klebsiella, Pseudomonas, and Proteus) is very poor because:
A. They occur in the lower love alveoli which are more sensitive to infection
B. Gram-negative organisms are more resistant to antibiotic therapy
C. They occur in healthy young adults who have recently been debilitated by an
upper respiratory infection.
D. Gram-negative pneumonias usually affect infants and small children. -
ANSWER-B. Gram-negative organisms are more resistant to antibiotic therapy
The gram-negative organisms are resistant to drug therapy which makes recovery
very difficult. Gram-negative pneumonias affect all lobes of the lung. The mean
age for contracting this type of pneumonia is 50 years, and it usually strikes
debilitated persons such as alcoholics, diabetics, and those with chronic lung
diseases.
A client is placed on a mechanical ventilator following a cerebral hemorrhage, and
vecuronium bromide (Norcuron) 0.04 mg/kg q12 hours IV is prescribed. What is
the priority nursing diagnosis for this client?
A. Impaired communication related to paralysis of skeletal muscles.
B. High risk for infection related to increased intracranial pressure.
