Med-Surg II HESI Test Bank_
Retake on September 2022, all answers verified Correct.
A - A nurse is collecting data from a client who has a possible cataract. Which of the
following manifestations should the nurse expect the client to report?
1) Decreased color perception
2) Loss of peripheral vision
3) Bright flashes of light
4) Eyestrain
A, B - A nurse is assisting with the care of a client immediately following a lumbar
puncture. Which of the following actions should the nurse take? (Select all that apply.)
1) Encourage fluid intake.
2) Monitor the puncture site for hematoma.
3) Insert a urinary catheter.
4) Elevate the client's head of bed.
5) Apply a cervical collar to the client.
A, B, C - A nurse is caring for a client who has Cushing's syndrome. Which of the
following clinical manifestations should the nurse expect to observe? (Select all that
apply.)
1) Buffalo hump
2) Purple striations
3) Moon face
4) Tremors
5) Obese extremities
A, B, C, D - A nurse is collecting data from a client who has an exacerbation of gout.
Which of the following findings should the nurse expect? (Select all that apply.)
1) Edema
2) Erythema
3) Tophi
4) Tight skin
5) Symmetrical joint pain
A, B, C, D - A nurse is collecting data from a client who has emphysema. Which of the
following findings should the nurse expect? (Select all that apply.)
1) Dyspnea
2) Barrel chest
3) Clubbing of the fingers
4) Shallow respirations
5) Bradycardia
A, B, E - A nurse is reinforcing pre-operative teaching for a client who is scheduled for
surgery and is to take hydroxyzine preoperatively. Which of the following effects of the
medication should the nurse include in the teaching? (Select all that apply.)
,1) Decreasing anxiety 2) Controlling emesis
3) Relaxing skeletal muscles
4) Preventing surgical site infections
5) Reducing the amount of narcotics needed for pain relief
A, D - A nurse is caring for a client who is 12 hours postoperative following a
transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with
continuous irrigation. The nurse notes there has not been any urinary output in the last
hour. Which of the following actions should the nurse perform first?
1) Notify the provider.
2) Administer a prescribed analgesic.
3) Offer oral fluids.
4) Determine the patency of the tubing.
A. - A nurse in a provider's office is reinforcing teaching with a client who has anemia
and has been taking ferrous gluconate for several weeks. Which of the following
instructions should the nurse include?
1) Take this medication between meals.
2) Limit intake of Vitamin C while taking this medication.
3) Take this medication with milk.
4) Limit intake of whole grains while taking this medication.
A. - A nurse in a provider's office is reinforcing teaching with a client who has anemia
and has been taking ferrous gluconate for several weeks. Which of the following
instructions should the nurse include?
1) Take this medication between meals.
2) Limit intake of Vitamin C while taking this medication.
3) Take this medication with milk.
4) Limit intake of whole grains while taking this medication.
A. - A nurse is assisting in the care of a client who is 2 hours postoperative following a
wedge resection of the left lung and has a chest tube to suction. Which of the following
is the priority finding the nurse should report to the provider?
1) Abdomen is distended
2) Chest tube drainage of 70 mL in the last hour
3) Subcutaneous emphysema is noted to the left chest wall
4) Pain level of 6 on a 0 to 10 scale
A. - A nurse is assisting with the care of a client who has diabetes insipidus. The nurse
should monitor the client for which of the following manifestations?
1) Hypotension
2) Polyphagia
3) Hyperglycemia
4) Bradycardia
, A. - A nurse is assisting with the care of a client who is postoperative and has a closed-
wound drainage system in place. Which of the following actions should the nurse take?
1) Fully recollapse the reservoir after emptying it.
2) Empty the reservoir once per day.
3) Replace the drainage plug after releasing hand pressure on the device.
4) Irrigate the tubing with sterile normal saline solution at least once every 8 hr.
A. - A nurse is caring for a client during the immediate postoperative period following
thoracic surgery. When administering an opioid analgesic for pain, the nurse should
explain that the medication should have which of the following effects?
1) Reducing anxiety
2) Increasing blood pressure
3) Increasing coughing
4) Increasing the client's respiratory rate
A. - A nurse is caring for a client following an open reduction and internal fixation of a
fractured femur. Which of the following findings is the nurse's priority?
1) Altered level of consciousness
2) Oral temperature of 37.7° C (100° C)
3) Muscle spasms
4) Headache
A. - A nurse is caring for a client immediately following a cardiac catheterization with a
femoral artery approach. Which of the following actions should the nurse take?
1) Check pedal pulses every 15 min.
2) Perform passive range-of-motion for the affected extremity.
3) Remind the client not to turn from side to side.
4) Keep the client in high-Fowler's position for 6 hr.
A. - A nurse is caring for a client newly diagnosed with ovarian cancer. Which of the
following reactions from the client should the nurse initially expect?
1) Denial
2) Bargaining
3) Acceptance
4) Anger
A. - A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a
prescription for a hypothermia blanket. The nurse should monitor the client for which of
the following adverse effects of the hypothermia blanket?
A. Shivering
B. Infection
C. Burns
D. Hypervolemia
Retake on September 2022, all answers verified Correct.
A - A nurse is collecting data from a client who has a possible cataract. Which of the
following manifestations should the nurse expect the client to report?
1) Decreased color perception
2) Loss of peripheral vision
3) Bright flashes of light
4) Eyestrain
A, B - A nurse is assisting with the care of a client immediately following a lumbar
puncture. Which of the following actions should the nurse take? (Select all that apply.)
1) Encourage fluid intake.
2) Monitor the puncture site for hematoma.
3) Insert a urinary catheter.
4) Elevate the client's head of bed.
5) Apply a cervical collar to the client.
A, B, C - A nurse is caring for a client who has Cushing's syndrome. Which of the
following clinical manifestations should the nurse expect to observe? (Select all that
apply.)
1) Buffalo hump
2) Purple striations
3) Moon face
4) Tremors
5) Obese extremities
A, B, C, D - A nurse is collecting data from a client who has an exacerbation of gout.
Which of the following findings should the nurse expect? (Select all that apply.)
1) Edema
2) Erythema
3) Tophi
4) Tight skin
5) Symmetrical joint pain
A, B, C, D - A nurse is collecting data from a client who has emphysema. Which of the
following findings should the nurse expect? (Select all that apply.)
1) Dyspnea
2) Barrel chest
3) Clubbing of the fingers
4) Shallow respirations
5) Bradycardia
A, B, E - A nurse is reinforcing pre-operative teaching for a client who is scheduled for
surgery and is to take hydroxyzine preoperatively. Which of the following effects of the
medication should the nurse include in the teaching? (Select all that apply.)
,1) Decreasing anxiety 2) Controlling emesis
3) Relaxing skeletal muscles
4) Preventing surgical site infections
5) Reducing the amount of narcotics needed for pain relief
A, D - A nurse is caring for a client who is 12 hours postoperative following a
transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with
continuous irrigation. The nurse notes there has not been any urinary output in the last
hour. Which of the following actions should the nurse perform first?
1) Notify the provider.
2) Administer a prescribed analgesic.
3) Offer oral fluids.
4) Determine the patency of the tubing.
A. - A nurse in a provider's office is reinforcing teaching with a client who has anemia
and has been taking ferrous gluconate for several weeks. Which of the following
instructions should the nurse include?
1) Take this medication between meals.
2) Limit intake of Vitamin C while taking this medication.
3) Take this medication with milk.
4) Limit intake of whole grains while taking this medication.
A. - A nurse in a provider's office is reinforcing teaching with a client who has anemia
and has been taking ferrous gluconate for several weeks. Which of the following
instructions should the nurse include?
1) Take this medication between meals.
2) Limit intake of Vitamin C while taking this medication.
3) Take this medication with milk.
4) Limit intake of whole grains while taking this medication.
A. - A nurse is assisting in the care of a client who is 2 hours postoperative following a
wedge resection of the left lung and has a chest tube to suction. Which of the following
is the priority finding the nurse should report to the provider?
1) Abdomen is distended
2) Chest tube drainage of 70 mL in the last hour
3) Subcutaneous emphysema is noted to the left chest wall
4) Pain level of 6 on a 0 to 10 scale
A. - A nurse is assisting with the care of a client who has diabetes insipidus. The nurse
should monitor the client for which of the following manifestations?
1) Hypotension
2) Polyphagia
3) Hyperglycemia
4) Bradycardia
, A. - A nurse is assisting with the care of a client who is postoperative and has a closed-
wound drainage system in place. Which of the following actions should the nurse take?
1) Fully recollapse the reservoir after emptying it.
2) Empty the reservoir once per day.
3) Replace the drainage plug after releasing hand pressure on the device.
4) Irrigate the tubing with sterile normal saline solution at least once every 8 hr.
A. - A nurse is caring for a client during the immediate postoperative period following
thoracic surgery. When administering an opioid analgesic for pain, the nurse should
explain that the medication should have which of the following effects?
1) Reducing anxiety
2) Increasing blood pressure
3) Increasing coughing
4) Increasing the client's respiratory rate
A. - A nurse is caring for a client following an open reduction and internal fixation of a
fractured femur. Which of the following findings is the nurse's priority?
1) Altered level of consciousness
2) Oral temperature of 37.7° C (100° C)
3) Muscle spasms
4) Headache
A. - A nurse is caring for a client immediately following a cardiac catheterization with a
femoral artery approach. Which of the following actions should the nurse take?
1) Check pedal pulses every 15 min.
2) Perform passive range-of-motion for the affected extremity.
3) Remind the client not to turn from side to side.
4) Keep the client in high-Fowler's position for 6 hr.
A. - A nurse is caring for a client newly diagnosed with ovarian cancer. Which of the
following reactions from the client should the nurse initially expect?
1) Denial
2) Bargaining
3) Acceptance
4) Anger
A. - A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a
prescription for a hypothermia blanket. The nurse should monitor the client for which of
the following adverse effects of the hypothermia blanket?
A. Shivering
B. Infection
C. Burns
D. Hypervolemia
