HESI-RN MED-SURG TEST UPDATE
QUESTIONS AND
ANSWERS WITH COMPLETE
SOLUTIONS GRADED A+ CORRECT
100%
Which foods will the nurse recommend for the client with tuberculosis being discharged
to home? (Select all that apply.)
A.
Bean soup
B.
Spinach
C.
Apples
D.
Bananas
E.
Dark chocolate
F.
Shellfish - CORRECT ANSWES -- A, B, E, F
Rationale:Apples and bananas are good sources of fiber but are low in protein and iron.
The remaining foods are high in iron along with organ meats, all legumes, red meat,
pumpkin seeds, quinoa, turkey, broccoli, and tofu.
Which statement reflects the highest priority nursing diagnosis for an older client
recently admitted to the hospital for a new-onset cardiac dysrhythmia?
A.
Diarrhea related to medication side effects
B.
Anxiety related to fear of recurrent anginal episodes
C.
Altered nutrition related to high serum lipid levels
D.
Risk for injury related to syncope and confusion - CORRECT ANSWES -- D
Rationale:The loss of cardiac function in aging decreases cardiac output, so
dysrhythmias, particularly tachycardias, are poorly tolerated. With onset of a tachycardic
or bradycardic dysrhythmia, cardiac output is compromised further, placing the client at
risk of syncope and falling, as well as confusion. Option A is of high priority but less so
,than maintaining client safety. Clients may experience option B as a result of a newly
diagnosed cardiac condition, but this nursing diagnosis does not have the priority of
option D. Option C also does not have the priority of option D.
The client returns to the unit after abdominal surgery with a 5″ × 9″ absorbent dressing
in place to the mid abdomen. The nurse notes a spot of red staining centrally on the
dressing. What is the nurse's next action?
A.
Note the size of the stain in the chart.
B.
Circle the stain with an ink pen.
C.
Remove the dressing to assess the source of the bleeding.
D.
Place a pressure dressing on the existing dressing. - CORRECT ANSWES -- B
Rationale:By circling the existing stain upon admission to the unit, the nurse can then
assess any increase, though subtle, in the amount of drainage over time. The size of
the stain will need to be noted in the chart, but it is not the first action. The nurse
removes the dressing under the prescription of the health care provider or in an
emergency. Neither of those conditions exist in the question. The dressing in place is an
absorbent dressing. There is no need for a further dressing until the existing dressing
becomes saturated.
For the client undergoing hemodialysis, the nurse suspects the client has an air
embolism. What symptoms lead the nurse to this conclusion? (Select all that apply.)
A.
Dyspnea
B.
B/P 168/92 mm Hg
C.
Chest pain
D.
Anxiety
E.
O2 saturation of 98%
F.
Blue nail beds - CORRECT ANSWES -- A, C, D, F
Rationale:For the client experiencing an air embolism, the nurse will see hypotension
and not hypertension. The O2 saturation will also fall with an air embolism. The
remaining are signs of an air embolism.
The nurse is preparing teaching for nursing students who are participating in a flu
vaccine clinic at a local school. Who should receive the vaccine? (Select all that apply.)
A.
Health care personnel
B.
,Those who are allergic to eggs
C.
Individuals who are over 50 years old
D.
Individuals with chronic health conditions
E.
Those who live in nursing homes
F.
Infants under 6 months of age - CORRECT ANSWES -- A, C, D, E
Rationale:The current recommendation is those who are allergic to eggs can receive the
flu vaccine if it is administered in a healthcare environment that can quickly deliver
treatment for anaphylaxis. Infants over 6 months van receive the flu shot, but not under
6 months. The remaining options are recommended to receive the flu vaccine.
A practical nurse (PN) tells the charge nurse in a long-term facility that she does not
want to be assigned to one particular resident. She reports that the male client keeps
insisting that she is his daughter and begs her to stay in his room. What is the best
managerial decision?
A.
Notify the family that the resident will have to be discharged if his behavior does not
improve.
B.
Notify administration of the PN's insubordination and need for counseling about her
statements.
C.
Ask the PN what she has done to encourage the resident to believe that she is his
daughter.
D.
Reassign the PN until the resident can be assessed more completely for reality
orientation. - CORRECT ANSWES -- D
Rationale:Temporary reassignment is the best option until the resident can be examined
and his medications reviewed. He may have worsening cerebral dysfunction from an
infection or electrolyte imbalance. Option A is not the best option because the family
cannot control the resident's actions. The administration may need to know about the
situation, but not as a case of insubordination. Implying that the PN is somehow
creating the situation is inappropriate until a further evaluation has been conducted.
The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which
symptom of hyperglycemia is an older adult most likely to exhibit?
A.
Polyuria
B.
Polydipsia
C.
Weight loss
D.
, Infection - CORRECT ANSWES -- D
ptoms of hyperglycemia in older adults may include fatigue, infection, and evidence of
neuropathy (e.g., sensory changes). The nurse needs to remember that classic signs
and symptoms of hyperglycemia, such as options A, B, and C and polyphagia, may be
absent in older adults.
A client with chronic asthma is admitted to the PACU complaining of pain at a level of 8
on a 1 to 10 scale, with a blood pressure of 124/78 mm Hg, pulse of 88 beats/min, and
respirations of 20 breaths/min. The PACU recovery prescription is "Morphine, 2 to 4 mg
IV push, while in recovery for pain level over 5." Which action should the nurse take
first?
A.
Give the medication as prescribed to decrease the client's pain.
B.
Call the anesthesia provider for a different medication for pain.
C.
Use nonpharmacologic techniques before giving the medication.
D.
Reassess the pain level in 30 minutes and medicate if it remains elevated. - CORRECT
ANSWES -- B
Rationale:The nurse should call the provider for a different medication because
morphine is a histamine-releasing opioid and should be avoided when the client has
asthma. Option A is unsafe because it puts the client at risk for an asthma exacerbation.
Even if the drug were safe for the client, options C and D both disregard the prescription
and the client's need for pain relief in the immediate postoperative period.
The nurse is interviewing a client who is taking interferon-alfa-2a and ribavirin
combination therapy for hepatitis C. The client reports experiencing overwhelming
feelings of depression. Which action should the nurse take first?
A.
Recommend mental health counseling.
B.
Review the medication actions and interactions.
C.
Assess for the client's daily activity level.
D.
Provide information regarding a support group. - CORRECT ANSWES -- B
Rationale:Interferon-alfa-2a and ribavirin combination therapy can cause severe
depression; therefore, it is most important for the nurse to review the medication effects
and report these to the health care provider. Options A, C, and D might be implemented
after the physiologic aspects of the situation have been assessed.
The nurse in the emergency room assesses a client with a head trauma and notes a
Glasgow Coma Scale (GCS) score of 5. What actions will the nurse take to ensure the
client's safety? (Select all that apply.)
A.
QUESTIONS AND
ANSWERS WITH COMPLETE
SOLUTIONS GRADED A+ CORRECT
100%
Which foods will the nurse recommend for the client with tuberculosis being discharged
to home? (Select all that apply.)
A.
Bean soup
B.
Spinach
C.
Apples
D.
Bananas
E.
Dark chocolate
F.
Shellfish - CORRECT ANSWES -- A, B, E, F
Rationale:Apples and bananas are good sources of fiber but are low in protein and iron.
The remaining foods are high in iron along with organ meats, all legumes, red meat,
pumpkin seeds, quinoa, turkey, broccoli, and tofu.
Which statement reflects the highest priority nursing diagnosis for an older client
recently admitted to the hospital for a new-onset cardiac dysrhythmia?
A.
Diarrhea related to medication side effects
B.
Anxiety related to fear of recurrent anginal episodes
C.
Altered nutrition related to high serum lipid levels
D.
Risk for injury related to syncope and confusion - CORRECT ANSWES -- D
Rationale:The loss of cardiac function in aging decreases cardiac output, so
dysrhythmias, particularly tachycardias, are poorly tolerated. With onset of a tachycardic
or bradycardic dysrhythmia, cardiac output is compromised further, placing the client at
risk of syncope and falling, as well as confusion. Option A is of high priority but less so
,than maintaining client safety. Clients may experience option B as a result of a newly
diagnosed cardiac condition, but this nursing diagnosis does not have the priority of
option D. Option C also does not have the priority of option D.
The client returns to the unit after abdominal surgery with a 5″ × 9″ absorbent dressing
in place to the mid abdomen. The nurse notes a spot of red staining centrally on the
dressing. What is the nurse's next action?
A.
Note the size of the stain in the chart.
B.
Circle the stain with an ink pen.
C.
Remove the dressing to assess the source of the bleeding.
D.
Place a pressure dressing on the existing dressing. - CORRECT ANSWES -- B
Rationale:By circling the existing stain upon admission to the unit, the nurse can then
assess any increase, though subtle, in the amount of drainage over time. The size of
the stain will need to be noted in the chart, but it is not the first action. The nurse
removes the dressing under the prescription of the health care provider or in an
emergency. Neither of those conditions exist in the question. The dressing in place is an
absorbent dressing. There is no need for a further dressing until the existing dressing
becomes saturated.
For the client undergoing hemodialysis, the nurse suspects the client has an air
embolism. What symptoms lead the nurse to this conclusion? (Select all that apply.)
A.
Dyspnea
B.
B/P 168/92 mm Hg
C.
Chest pain
D.
Anxiety
E.
O2 saturation of 98%
F.
Blue nail beds - CORRECT ANSWES -- A, C, D, F
Rationale:For the client experiencing an air embolism, the nurse will see hypotension
and not hypertension. The O2 saturation will also fall with an air embolism. The
remaining are signs of an air embolism.
The nurse is preparing teaching for nursing students who are participating in a flu
vaccine clinic at a local school. Who should receive the vaccine? (Select all that apply.)
A.
Health care personnel
B.
,Those who are allergic to eggs
C.
Individuals who are over 50 years old
D.
Individuals with chronic health conditions
E.
Those who live in nursing homes
F.
Infants under 6 months of age - CORRECT ANSWES -- A, C, D, E
Rationale:The current recommendation is those who are allergic to eggs can receive the
flu vaccine if it is administered in a healthcare environment that can quickly deliver
treatment for anaphylaxis. Infants over 6 months van receive the flu shot, but not under
6 months. The remaining options are recommended to receive the flu vaccine.
A practical nurse (PN) tells the charge nurse in a long-term facility that she does not
want to be assigned to one particular resident. She reports that the male client keeps
insisting that she is his daughter and begs her to stay in his room. What is the best
managerial decision?
A.
Notify the family that the resident will have to be discharged if his behavior does not
improve.
B.
Notify administration of the PN's insubordination and need for counseling about her
statements.
C.
Ask the PN what she has done to encourage the resident to believe that she is his
daughter.
D.
Reassign the PN until the resident can be assessed more completely for reality
orientation. - CORRECT ANSWES -- D
Rationale:Temporary reassignment is the best option until the resident can be examined
and his medications reviewed. He may have worsening cerebral dysfunction from an
infection or electrolyte imbalance. Option A is not the best option because the family
cannot control the resident's actions. The administration may need to know about the
situation, but not as a case of insubordination. Implying that the PN is somehow
creating the situation is inappropriate until a further evaluation has been conducted.
The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which
symptom of hyperglycemia is an older adult most likely to exhibit?
A.
Polyuria
B.
Polydipsia
C.
Weight loss
D.
, Infection - CORRECT ANSWES -- D
ptoms of hyperglycemia in older adults may include fatigue, infection, and evidence of
neuropathy (e.g., sensory changes). The nurse needs to remember that classic signs
and symptoms of hyperglycemia, such as options A, B, and C and polyphagia, may be
absent in older adults.
A client with chronic asthma is admitted to the PACU complaining of pain at a level of 8
on a 1 to 10 scale, with a blood pressure of 124/78 mm Hg, pulse of 88 beats/min, and
respirations of 20 breaths/min. The PACU recovery prescription is "Morphine, 2 to 4 mg
IV push, while in recovery for pain level over 5." Which action should the nurse take
first?
A.
Give the medication as prescribed to decrease the client's pain.
B.
Call the anesthesia provider for a different medication for pain.
C.
Use nonpharmacologic techniques before giving the medication.
D.
Reassess the pain level in 30 minutes and medicate if it remains elevated. - CORRECT
ANSWES -- B
Rationale:The nurse should call the provider for a different medication because
morphine is a histamine-releasing opioid and should be avoided when the client has
asthma. Option A is unsafe because it puts the client at risk for an asthma exacerbation.
Even if the drug were safe for the client, options C and D both disregard the prescription
and the client's need for pain relief in the immediate postoperative period.
The nurse is interviewing a client who is taking interferon-alfa-2a and ribavirin
combination therapy for hepatitis C. The client reports experiencing overwhelming
feelings of depression. Which action should the nurse take first?
A.
Recommend mental health counseling.
B.
Review the medication actions and interactions.
C.
Assess for the client's daily activity level.
D.
Provide information regarding a support group. - CORRECT ANSWES -- B
Rationale:Interferon-alfa-2a and ribavirin combination therapy can cause severe
depression; therefore, it is most important for the nurse to review the medication effects
and report these to the health care provider. Options A, C, and D might be implemented
after the physiologic aspects of the situation have been assessed.
The nurse in the emergency room assesses a client with a head trauma and notes a
Glasgow Coma Scale (GCS) score of 5. What actions will the nurse take to ensure the
client's safety? (Select all that apply.)
A.
