MED SURG 2 HESI TEST BANK REAL EXAM QUESTIONS
AND CORRECT ANSWERS WITH RATIONALES|A+GRADE
1. A client with Cushing's syndrome is recovering from an elective laparoscopic
procedure. Which assessment finding warrant's immediate intervention by the
nurse?
a. Purple marks on skin of the abdomen
b. Irregular apical pulse
c. Quarter size blood spot on dressing
d. Pitting ankle edema - ANS... -b. Irregular apical pulse
2. A client with lung cancer who wears a subcutaneous morphine sulfate patch for
pain is short of breath and is difficult to arouse. When performing a head to toe
assessment, the nurse discovers four analgesic patches on the clients body. Which
intervention should the nurse implement first?
a. Remove all of the morphine patches
b. Administer a narcotic antagonist
c. Apply oxygen per face mask
d. Measure the client's blood pressure - ANS... -b. Administer a narcotic antagonist
3. A client receives prescriptions for a multidrug regimen for the treatment of
tuberculosis. Which information should the nurse prioritize?
a. Adherence to the regimen is imperative
b. Medications should be taken with food
c. Serum liver panels are collected regularly
d. Enhanced sun protection measures will be needed - ANS... -a. Adherence to the
regimen is imperative
4. The nurse is preparing a client for surgery who was admitted to the emergency
center following a motor vehicle collision. The client has an open fracture of the
femur and is bleeding moderately from the bone protrusion site. During the
prescriptive assessment, the nurse determines that the client currently receives
heparin sodium 5,000 units subcutaneously daily. What is the priority nursing
action?
,a. Notify the healthcare provider of the client's medication history
b. Observe the heparin injections sites for signs of bruising
c. Have the client sign the surgical and transfusion permits
d. Ensure that the potential for bleeding is explained to the client - ANS... -a.
Notify the healthcare provider of the client's medication history
5. A client with orthopnea expresses concern about the ability to "get enough air"
during a scheduled thoracentesis. On which information should the nurse's
response be based?
a. A thoracentesis is a brief process that has minimal discomfort
b. Orthopnea is frequently caused by a client's uncontrolled anxiety
c. The procedure is performed with the client in an upright position
d. Extra pillows can be used if needed to elevate the client's head - ANS... -c. The
procedure is performed with the client in an upright position
6. What information should the nurse include in the teaching plan of a client
diagnosed with gastroesophageal reflux disease (GERD)?
a. Sleep without pillows at night to maintain neck alignment
b. Adjust food intake to three full meals per day and no snacks
c. Minimize symptoms by wearing loose, comfortable clothing
d. Avoid participation in any aerobic exercise programs - ANS... -c. Minimize
symptoms by wearing loose, comfortable clothing
7. The nurse is providing teaching to a client with Type 2 diabetes mellitus and
peripheral neuropathy. Which information should the nurse provide?
a. Family members can help with regular foot exams
b. Heating pads are useful if on the low setting
c. Aching feet may be soaked in lukewarm water for one hour or more
d. Shoes should be worn outside the house, but it is fine to be barefoot inside -
ANS... -a. Family members can help with regular foot exams
8. A client in the operating room received succinylcholine. The client is
experiencing muscle rigidity and has an extremely high temperature. What action
should the nurse implement?
a. Hold a prescription for dantrolene until fever is reduced
,b. Prepare ice packs for placement in the clients axillary area
c. Call the PACU nurse to prepare for prolonged ventilator support
d. Determine if prescribed antibiotics were administered preoperatively - ANS... -
b. Prepare ice packs for placement in the clients axillary area
9. The nurse is developing a plan of care for a client who reports blurred vision and
who is newly diagnosed with cardiovascular disease. Which outcome should the
nurse include in the plan of care for this client?
a. The nurse will encourage the client to walk thirty minutes every day
b. The clients family will state signs and symptoms about the disease
c. The clients daily blood pressure will be less than 140/80 this month
d. The client blood pressure readings will be less than 160/90 - ANS... -c. The
clients daily blood pressure will be less than 140/80 this month
10. The family suspects that acquired immune deficiency syndrome (AIDS)
dementia is occuring in their son who is human immunodeficiency virus (HIV)
positive. Which symptoms confirm their suspicions?
a. He has begun to sleep 18 out of 24 hours
b. A change has recently occurred in his handwriting
c. He refuses to see any of his friends or to return their phone calls
d. He exhibits angry outburst when the subject of dying is approached - ANS... -b.
A change has recently occurred in his handwriting
11. A hospitalized client with peripheral arterial disease (PAD) is instructed
regarding leg and foot care. Which statement by the client indicates to the nurse
that learning has occurred?
a. "Whenever I am sitting in a chair I will keep my legs up to reduce swelling"
b. "I can use a mirror to check the bottoms of my feet for any signs of breakdown"
c. "I will try to keep moving if leg pain occurs to help promote good circulation"
d. "I will use my swimming pool early in the day while the water is still very cool"
- ANS... -b. "I can use a mirror to check the bottoms of my feet for any signs of
breakdown"
12. While completing a health assessment for a client with migraine headaches, the
nurse assesses bilateral weakness in the client's hand grips. The client reports joint
pain and trouble twisting a door knob due to weakness. Which action should the
nurse take in response to these findings?
, a. Explain that relief of the migraine pain will reduce related symptoms
b. Gather additional assessment data about the pain and weakness
c. Implement fall precautions to reduce the client's risk for injury
d. Consult with the occupational therapist for a functional assessment - ANS... -d.
Consult with the occupational therapist for a functional assessment
13. The nurse is caring for a client in the post anesthesia care unit (PACU) who
underwent a thoracotomy two hours ago. The nurse observes the following vital
signs: heart rate 140 bpm, respirations 26 breaths/minute and blood pressure
140/90. Which intervention is most important for the nurse to implement?
a. Medicate for pain and monitor vital signs according to protocol
b. Adminsted intravenous fluid bolus as prescribed by the HCP
c. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter.
d. Encourage the client to splint the incision with a pillow to cough and deep
breathe - ANS... -a. Medicate for pain and monitor vital signs
14. An adult is diagnosed with restless leg syndrome and is referred to the sleep
clinic. The HCP prescribed ferrous sulfate 325 PO daily. Which laboratory values
should the nurse monitor ?
a. Platelet count and hematocrit
b. Serum electrolytes
c. Serum iron and ferritin
d. Neutrophils and eosinophils - ANS... -c. Serum iron and ferritin
15. While caring for a client with a full thickness burn covering 40% of the body,
the nurse observes purulent drainage at the wound. Before reporting this finding to
the HCP , the nurse should review which of the client's laboratory values?
a. White blood cell count
b. Platelet count
c. Blood pH level
d. Hematocrit - ANS... -a. White blood cell count
16. A client with a history of type 1 diabetes mellitus (DM) and asthma is
readmitted to the unit for the third time in two months with a current fasting blood
sugar of 325 mg/dl. The client describes to the nurse of not understanding why the
AND CORRECT ANSWERS WITH RATIONALES|A+GRADE
1. A client with Cushing's syndrome is recovering from an elective laparoscopic
procedure. Which assessment finding warrant's immediate intervention by the
nurse?
a. Purple marks on skin of the abdomen
b. Irregular apical pulse
c. Quarter size blood spot on dressing
d. Pitting ankle edema - ANS... -b. Irregular apical pulse
2. A client with lung cancer who wears a subcutaneous morphine sulfate patch for
pain is short of breath and is difficult to arouse. When performing a head to toe
assessment, the nurse discovers four analgesic patches on the clients body. Which
intervention should the nurse implement first?
a. Remove all of the morphine patches
b. Administer a narcotic antagonist
c. Apply oxygen per face mask
d. Measure the client's blood pressure - ANS... -b. Administer a narcotic antagonist
3. A client receives prescriptions for a multidrug regimen for the treatment of
tuberculosis. Which information should the nurse prioritize?
a. Adherence to the regimen is imperative
b. Medications should be taken with food
c. Serum liver panels are collected regularly
d. Enhanced sun protection measures will be needed - ANS... -a. Adherence to the
regimen is imperative
4. The nurse is preparing a client for surgery who was admitted to the emergency
center following a motor vehicle collision. The client has an open fracture of the
femur and is bleeding moderately from the bone protrusion site. During the
prescriptive assessment, the nurse determines that the client currently receives
heparin sodium 5,000 units subcutaneously daily. What is the priority nursing
action?
,a. Notify the healthcare provider of the client's medication history
b. Observe the heparin injections sites for signs of bruising
c. Have the client sign the surgical and transfusion permits
d. Ensure that the potential for bleeding is explained to the client - ANS... -a.
Notify the healthcare provider of the client's medication history
5. A client with orthopnea expresses concern about the ability to "get enough air"
during a scheduled thoracentesis. On which information should the nurse's
response be based?
a. A thoracentesis is a brief process that has minimal discomfort
b. Orthopnea is frequently caused by a client's uncontrolled anxiety
c. The procedure is performed with the client in an upright position
d. Extra pillows can be used if needed to elevate the client's head - ANS... -c. The
procedure is performed with the client in an upright position
6. What information should the nurse include in the teaching plan of a client
diagnosed with gastroesophageal reflux disease (GERD)?
a. Sleep without pillows at night to maintain neck alignment
b. Adjust food intake to three full meals per day and no snacks
c. Minimize symptoms by wearing loose, comfortable clothing
d. Avoid participation in any aerobic exercise programs - ANS... -c. Minimize
symptoms by wearing loose, comfortable clothing
7. The nurse is providing teaching to a client with Type 2 diabetes mellitus and
peripheral neuropathy. Which information should the nurse provide?
a. Family members can help with regular foot exams
b. Heating pads are useful if on the low setting
c. Aching feet may be soaked in lukewarm water for one hour or more
d. Shoes should be worn outside the house, but it is fine to be barefoot inside -
ANS... -a. Family members can help with regular foot exams
8. A client in the operating room received succinylcholine. The client is
experiencing muscle rigidity and has an extremely high temperature. What action
should the nurse implement?
a. Hold a prescription for dantrolene until fever is reduced
,b. Prepare ice packs for placement in the clients axillary area
c. Call the PACU nurse to prepare for prolonged ventilator support
d. Determine if prescribed antibiotics were administered preoperatively - ANS... -
b. Prepare ice packs for placement in the clients axillary area
9. The nurse is developing a plan of care for a client who reports blurred vision and
who is newly diagnosed with cardiovascular disease. Which outcome should the
nurse include in the plan of care for this client?
a. The nurse will encourage the client to walk thirty minutes every day
b. The clients family will state signs and symptoms about the disease
c. The clients daily blood pressure will be less than 140/80 this month
d. The client blood pressure readings will be less than 160/90 - ANS... -c. The
clients daily blood pressure will be less than 140/80 this month
10. The family suspects that acquired immune deficiency syndrome (AIDS)
dementia is occuring in their son who is human immunodeficiency virus (HIV)
positive. Which symptoms confirm their suspicions?
a. He has begun to sleep 18 out of 24 hours
b. A change has recently occurred in his handwriting
c. He refuses to see any of his friends or to return their phone calls
d. He exhibits angry outburst when the subject of dying is approached - ANS... -b.
A change has recently occurred in his handwriting
11. A hospitalized client with peripheral arterial disease (PAD) is instructed
regarding leg and foot care. Which statement by the client indicates to the nurse
that learning has occurred?
a. "Whenever I am sitting in a chair I will keep my legs up to reduce swelling"
b. "I can use a mirror to check the bottoms of my feet for any signs of breakdown"
c. "I will try to keep moving if leg pain occurs to help promote good circulation"
d. "I will use my swimming pool early in the day while the water is still very cool"
- ANS... -b. "I can use a mirror to check the bottoms of my feet for any signs of
breakdown"
12. While completing a health assessment for a client with migraine headaches, the
nurse assesses bilateral weakness in the client's hand grips. The client reports joint
pain and trouble twisting a door knob due to weakness. Which action should the
nurse take in response to these findings?
, a. Explain that relief of the migraine pain will reduce related symptoms
b. Gather additional assessment data about the pain and weakness
c. Implement fall precautions to reduce the client's risk for injury
d. Consult with the occupational therapist for a functional assessment - ANS... -d.
Consult with the occupational therapist for a functional assessment
13. The nurse is caring for a client in the post anesthesia care unit (PACU) who
underwent a thoracotomy two hours ago. The nurse observes the following vital
signs: heart rate 140 bpm, respirations 26 breaths/minute and blood pressure
140/90. Which intervention is most important for the nurse to implement?
a. Medicate for pain and monitor vital signs according to protocol
b. Adminsted intravenous fluid bolus as prescribed by the HCP
c. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter.
d. Encourage the client to splint the incision with a pillow to cough and deep
breathe - ANS... -a. Medicate for pain and monitor vital signs
14. An adult is diagnosed with restless leg syndrome and is referred to the sleep
clinic. The HCP prescribed ferrous sulfate 325 PO daily. Which laboratory values
should the nurse monitor ?
a. Platelet count and hematocrit
b. Serum electrolytes
c. Serum iron and ferritin
d. Neutrophils and eosinophils - ANS... -c. Serum iron and ferritin
15. While caring for a client with a full thickness burn covering 40% of the body,
the nurse observes purulent drainage at the wound. Before reporting this finding to
the HCP , the nurse should review which of the client's laboratory values?
a. White blood cell count
b. Platelet count
c. Blood pH level
d. Hematocrit - ANS... -a. White blood cell count
16. A client with a history of type 1 diabetes mellitus (DM) and asthma is
readmitted to the unit for the third time in two months with a current fasting blood
sugar of 325 mg/dl. The client describes to the nurse of not understanding why the
