lOMoARcPSD|5422489
HESI MEDICAL SURGICAL EXAM TEST BANK /ACTUAL df df df df df df
EXAM WITH CORRECT DETAILED AND VERIFIED df df df df df df
ANSWERS/ MEDICAL SURGICAL HESI EXAM df df df df df df
Amale client with sickle cell anemia, who hasbeen hospitalized for another health problem, tells thenurse he has had
df df df df df df df df df df df df df df df df df df df df
an erection for over 4 hours. What action should the nurse implement first?
df df d f df df df df df df df df df df
d f
d f Notify the client’s healthcare provider. df df d f df
d f Document the Finding in the client record. df df df df df df
Prepare a warmenema solution forrectal instillation. df df df df df df df
Obtain a large bore needle foraspiration of the corpora cavernosa.
df df df df df df d f df df df
Explanation
Priapism, aurologic emergency, is common during sickle cell crisis dueto sickle cells clogging the microcirculation
df df df df df df df df df df df df df df df df
in the penis, causing a reduction ofblood ow and oxygenation to the penis, so the
d f df df df df df df df df df df df df df df df
healthcare provider should be rst noti ed immediately. The prescribed therapy may consist of noninvasive
d f df df df df df df d f df df df df df df
measures such as applying ice to the penis, instilling a warm solution enema to increase out ow in the corpora
df d f df df df df df df df d f df df d f df df df df df df df
cavernosa and giving pain medications. Ifnoninvasive measures do not work, then needle aspiration of the
df df df df df d f df df df df df df df df df df
corpora cavernosa is implemented by the healthcare provider.
df df df df d f df df df
Thenurse completes visual inspection ofaclient’s abdomen. Whattechnique should the nurseperform nextin the
df df df df df df df df df df df df df df df df df
abdominal examination?
df df
d f Percussion.
d f Auscultation.
d f
Deeppalpation. Light df df
df palpation.
Explanation
Auscultation ofthe client’s abdomen isperformed next becausemanual manipulation ofthe abdomencan
df df df df df df df df df df d f df df df
stimulate peristalsis and create inaccurate assessment of bowel sounds heard during auscultation.
df d f d f df df d f df df df df df df
Which intervention should the nurse implement that best con rms placement ofan endotracheal tube (ETT)?
df df df df df df df df df df df df df df df
d f d f Use an end-tital CO2 detector.
df df d f df
d f
d f Ascultate for bilateral breath sounds. df df d f df
Obtain pulseoximeter reading. df df df
, lOMoARcPSD|5422489
Check symmetrical chest movement.
df df d f df
Explanation
The end-tidal carbon dioxide detector indicates the prescence of CO2tidalby a color change ora number
df df df df df df df df df df df df df df df
indicated on the detector, which is supporting evidence that the ETTis in the trachea, notthe esophagus.
df df df df df df df df df df df df df df df df df df
Afemale client withtype 2diabetes mellitus reports dysuria. Which assessment ndingis most important for the nurse
df df df df df df df d f df df df df df df df df df df
to report to the healthcare provider?
df df df df df d f
d f Suprapublic pain and distention. df df df
d f Bounding pulse at 100 beats/minute. df df df d f
Fingerstick glucose of300mg/dl. df df df df
df Small vesicular perineal lesions. df df df
Explanation
Elevated ngerstick glucose levels needs to be reported tot he healthcare provider, so a plan of care can be
df d f df df df df df df df df d f df df df df df df df
adjusted to treat the elevated glucose level. Also elevated glucose levels, spills into theurine and provide a
df df df df df df df df df df df df df df df df df df
medium for bacterial growth.
df df df df
Aclient with type II diabetes arrives at the clinic with a blood glucose of50 mg/dL. The nurse provides the client with 6
df df df df df df df df df df df df df df df df df df df df df df df
ounces of orange juice. In 15 minutes the client’s capillary glucose is 74 mg/dL. What action should the nurse
df df df df df df df d f df d f d f df df df df df d f df df
take?
df
d f Obtain a specimen for serum glucose level. df df df df df df
d f Administer insulin per sliding scale. df d f df d f
Provide cheese and bread to eat. df df df df df
Collect a glycosylated hemoglobin specimen.
df df df df df
Explanation
Once blood glucose is greater than 70 mg/dl, the client should eat a regularly scheduled meal ora snack that contains
df df df df df df df df df df df df df df df df df df df df
protein and carbohydrates to help prevent hypoglycemia from recurring.
df df df df df df df df df
A48-year-old client withendometrial canceris being discharged after atotal hysterectomy and bilateral salpingo-
df df df df df df df df df df df df d f df df
oophorectomy.
df
Which client statement indicates that further teaching is needed?
df df df df df df df df
d f "Well, I don’t have to worry about getting pregnant anymore."
df df df df df df df df df
d f "Ican’t waitto go on the cruise that I have planned forthis summer." "I
df df df df df df df df df df df df df df df
df know I will miss having sexual intercourse with my husband."
df df df df df df d f df df
"I have asked my daughter to stay with me next week after I am discharged."
df df df df df df df df df df df df df df
, lOMoARcPSD|5422489
Explanation
Further teaching is needed in response to the client’s misunderstanding ofnot being able to have sexual
df df df df df df df df df d f df df df df df df
intercourse after a hysterectomy, needs to be addressed.
df df df df d f df df df
Aclient asks the nurse about the purpose ofbeginning chemotherapy (CT)because the tumor is still very small. Which
df df df df df df df df df df df df df df df df df df df
information supports the explanation that the nurse should provide?
df df df df df df df df df
d f Side eûects are less likely if therapy is started early.
df d f df df d f df df df d f
d f Collateral circulation increases as the tumor grows. df d f df df df df
Sensitivity of cancer cells to CT is based on cell cycle rate. df df df df df df df df df df df
The cell count ofthe tumor reduces by halfwith each dose.
df df df df df df df df df df df
Explanation df
Initiating chemotherapy while thetumor issmall provides abetter chanceof eradicating all cancercells because
df df df df df df df df df df df df df df df df
50% of cancer cells or tumor cells are killed with each dose.
df df df df df df df df df df df df
Aclient in thepreoperative holding area receives aprescription formidazolam (Versed) IV.Thenurse determines that
df df df df df df df df df df df df df df df df df
the surgical consent form needs to be signed by the client. Which action should the nurse implement?
df df df df df df df df df df df d f df df df df df
d f d f Give the drug and allow the client to read and sign the consent form.
df df df df d f df d f df d f df df df df
d f Counter-sign the client’s initials on the consent form after giving the drug. df df d f d f df df df df d f df df
Withhold thedrug until the client validates understanding ofthe surgical procedure and signs the consent
df df df df df df df df df df df df df df df
form.
df
df Call the healthcare provider to explain the surgical procedure before the client signs the consent.
df df df df df df df df df df df df df df
Explanation
Midazolam, abenzodiazepine sedative, is commonly used forconscious-sedation intraoperatively and
df df df df df df df df df d f
interferes with the client scognition and level ofconsciousness, so the consent form should be signed before the
df df df df df df df df df df df df df df df df df df
drug is administered.
df df df
Which client should the nurse assess rst?
df df df df df df
d f A 27-year-old complaining of severe back pain.
df df d f df df df
d f A 63-year-old complaining of foot and ankle pain.
df df d f df df df df
A49-year-old withpancreatitis complaining of unrelenting abdominal pain.
df df df df df df df df
A55-year-old newly admitted client complaining ofjaw pain and indigestion.
df df df df df df df df df df
Explanation df
The55-year-old client should be assessed rst to rule out cardiac involvement because jaw pain and indigestion are
df df df df df df df df df df df df df df df df df
, lOMoARcPSD|5422489
df common descriptors of myocardial injury. df df df df
What isthe primary nursing problem for aclient with asymptomatic primary syphilis?
df df df df df df df df df df d f df
d f Acute pain. df
d f Risk for injury. df df
Sexual dysfunction. df
df Decientknowledge. df df
Explanation
Anasymptomatic client withprimary syphilis is most likely unawareof this disease, soto prevent transmission to
df df df df df df df df df df df df df df df df df
others and recurrence in the client, the priority nursing diagnosis is de cient knowledge of the disease
df df df df df df d f df d f df df df df df df df df
pathophysiology.
An 85-year-old male client comes to the clinic for his annual physical exam and renewal of antihypertensive
df df df df df df df d f df df df df df df df df
medication prescriptions. Theclient’s radial pulse rate is 104beats/minute. Which additional assessment should the
df df df df df df df df df df df df df df df
nurse complete?
df df
d f Palpate the pedal pulse volume. df df df df
d f Countthe brachial pulse rate. df df df df
df Measure the blood pressure. df df df
Assess fora carotid bruit. df df df d f
Explanation
Elderly clients whotakeantihypertensive medications often experience side eûects, such ashypotension, which
df df df df d f df df df df df df df df
causes tachycardia, a compensatory mechanism to maintain adequate cardiac output, so the client’s blood
df df df df df df df df df df df df df df
pressure should be measured.
df df df df
The nurse assesses a long-term resident ofa nursing home and ndsthe client has a fungal infection (candidiasis)
df df df df df df df df df df df df df df df df df df
beneath both breasts. To prevent nosocomial infection, which protocol should the nurse review with the rest of the
df df df df df df df d f df df df df df df df df df df
staû?
df
Follow contact isolation procedures. df df df
d f Wash hands after caring for the client. df df df df df df
d f
Wear gloves when providing personal care. df df df df df
df Restrict pregnant staû orvisitors into the room. df df df df df df df
Explanation
HESI MEDICAL SURGICAL EXAM TEST BANK /ACTUAL df df df df df df
EXAM WITH CORRECT DETAILED AND VERIFIED df df df df df df
ANSWERS/ MEDICAL SURGICAL HESI EXAM df df df df df df
Amale client with sickle cell anemia, who hasbeen hospitalized for another health problem, tells thenurse he has had
df df df df df df df df df df df df df df df df df df df df
an erection for over 4 hours. What action should the nurse implement first?
df df d f df df df df df df df df df df
d f
d f Notify the client’s healthcare provider. df df d f df
d f Document the Finding in the client record. df df df df df df
Prepare a warmenema solution forrectal instillation. df df df df df df df
Obtain a large bore needle foraspiration of the corpora cavernosa.
df df df df df df d f df df df
Explanation
Priapism, aurologic emergency, is common during sickle cell crisis dueto sickle cells clogging the microcirculation
df df df df df df df df df df df df df df df df
in the penis, causing a reduction ofblood ow and oxygenation to the penis, so the
d f df df df df df df df df df df df df df df df
healthcare provider should be rst noti ed immediately. The prescribed therapy may consist of noninvasive
d f df df df df df df d f df df df df df df
measures such as applying ice to the penis, instilling a warm solution enema to increase out ow in the corpora
df d f df df df df df df df d f df df d f df df df df df df df
cavernosa and giving pain medications. Ifnoninvasive measures do not work, then needle aspiration of the
df df df df df d f df df df df df df df df df df
corpora cavernosa is implemented by the healthcare provider.
df df df df d f df df df
Thenurse completes visual inspection ofaclient’s abdomen. Whattechnique should the nurseperform nextin the
df df df df df df df df df df df df df df df df df
abdominal examination?
df df
d f Percussion.
d f Auscultation.
d f
Deeppalpation. Light df df
df palpation.
Explanation
Auscultation ofthe client’s abdomen isperformed next becausemanual manipulation ofthe abdomencan
df df df df df df df df df df d f df df df
stimulate peristalsis and create inaccurate assessment of bowel sounds heard during auscultation.
df d f d f df df d f df df df df df df
Which intervention should the nurse implement that best con rms placement ofan endotracheal tube (ETT)?
df df df df df df df df df df df df df df df
d f d f Use an end-tital CO2 detector.
df df d f df
d f
d f Ascultate for bilateral breath sounds. df df d f df
Obtain pulseoximeter reading. df df df
, lOMoARcPSD|5422489
Check symmetrical chest movement.
df df d f df
Explanation
The end-tidal carbon dioxide detector indicates the prescence of CO2tidalby a color change ora number
df df df df df df df df df df df df df df df
indicated on the detector, which is supporting evidence that the ETTis in the trachea, notthe esophagus.
df df df df df df df df df df df df df df df df df df
Afemale client withtype 2diabetes mellitus reports dysuria. Which assessment ndingis most important for the nurse
df df df df df df df d f df df df df df df df df df df
to report to the healthcare provider?
df df df df df d f
d f Suprapublic pain and distention. df df df
d f Bounding pulse at 100 beats/minute. df df df d f
Fingerstick glucose of300mg/dl. df df df df
df Small vesicular perineal lesions. df df df
Explanation
Elevated ngerstick glucose levels needs to be reported tot he healthcare provider, so a plan of care can be
df d f df df df df df df df df d f df df df df df df df
adjusted to treat the elevated glucose level. Also elevated glucose levels, spills into theurine and provide a
df df df df df df df df df df df df df df df df df df
medium for bacterial growth.
df df df df
Aclient with type II diabetes arrives at the clinic with a blood glucose of50 mg/dL. The nurse provides the client with 6
df df df df df df df df df df df df df df df df df df df df df df df
ounces of orange juice. In 15 minutes the client’s capillary glucose is 74 mg/dL. What action should the nurse
df df df df df df df d f df d f d f df df df df df d f df df
take?
df
d f Obtain a specimen for serum glucose level. df df df df df df
d f Administer insulin per sliding scale. df d f df d f
Provide cheese and bread to eat. df df df df df
Collect a glycosylated hemoglobin specimen.
df df df df df
Explanation
Once blood glucose is greater than 70 mg/dl, the client should eat a regularly scheduled meal ora snack that contains
df df df df df df df df df df df df df df df df df df df df
protein and carbohydrates to help prevent hypoglycemia from recurring.
df df df df df df df df df
A48-year-old client withendometrial canceris being discharged after atotal hysterectomy and bilateral salpingo-
df df df df df df df df df df df df d f df df
oophorectomy.
df
Which client statement indicates that further teaching is needed?
df df df df df df df df
d f "Well, I don’t have to worry about getting pregnant anymore."
df df df df df df df df df
d f "Ican’t waitto go on the cruise that I have planned forthis summer." "I
df df df df df df df df df df df df df df df
df know I will miss having sexual intercourse with my husband."
df df df df df df d f df df
"I have asked my daughter to stay with me next week after I am discharged."
df df df df df df df df df df df df df df
, lOMoARcPSD|5422489
Explanation
Further teaching is needed in response to the client’s misunderstanding ofnot being able to have sexual
df df df df df df df df df d f df df df df df df
intercourse after a hysterectomy, needs to be addressed.
df df df df d f df df df
Aclient asks the nurse about the purpose ofbeginning chemotherapy (CT)because the tumor is still very small. Which
df df df df df df df df df df df df df df df df df df df
information supports the explanation that the nurse should provide?
df df df df df df df df df
d f Side eûects are less likely if therapy is started early.
df d f df df d f df df df d f
d f Collateral circulation increases as the tumor grows. df d f df df df df
Sensitivity of cancer cells to CT is based on cell cycle rate. df df df df df df df df df df df
The cell count ofthe tumor reduces by halfwith each dose.
df df df df df df df df df df df
Explanation df
Initiating chemotherapy while thetumor issmall provides abetter chanceof eradicating all cancercells because
df df df df df df df df df df df df df df df df
50% of cancer cells or tumor cells are killed with each dose.
df df df df df df df df df df df df
Aclient in thepreoperative holding area receives aprescription formidazolam (Versed) IV.Thenurse determines that
df df df df df df df df df df df df df df df df df
the surgical consent form needs to be signed by the client. Which action should the nurse implement?
df df df df df df df df df df df d f df df df df df
d f d f Give the drug and allow the client to read and sign the consent form.
df df df df d f df d f df d f df df df df
d f Counter-sign the client’s initials on the consent form after giving the drug. df df d f d f df df df df d f df df
Withhold thedrug until the client validates understanding ofthe surgical procedure and signs the consent
df df df df df df df df df df df df df df df
form.
df
df Call the healthcare provider to explain the surgical procedure before the client signs the consent.
df df df df df df df df df df df df df df
Explanation
Midazolam, abenzodiazepine sedative, is commonly used forconscious-sedation intraoperatively and
df df df df df df df df df d f
interferes with the client scognition and level ofconsciousness, so the consent form should be signed before the
df df df df df df df df df df df df df df df df df df
drug is administered.
df df df
Which client should the nurse assess rst?
df df df df df df
d f A 27-year-old complaining of severe back pain.
df df d f df df df
d f A 63-year-old complaining of foot and ankle pain.
df df d f df df df df
A49-year-old withpancreatitis complaining of unrelenting abdominal pain.
df df df df df df df df
A55-year-old newly admitted client complaining ofjaw pain and indigestion.
df df df df df df df df df df
Explanation df
The55-year-old client should be assessed rst to rule out cardiac involvement because jaw pain and indigestion are
df df df df df df df df df df df df df df df df df
, lOMoARcPSD|5422489
df common descriptors of myocardial injury. df df df df
What isthe primary nursing problem for aclient with asymptomatic primary syphilis?
df df df df df df df df df df d f df
d f Acute pain. df
d f Risk for injury. df df
Sexual dysfunction. df
df Decientknowledge. df df
Explanation
Anasymptomatic client withprimary syphilis is most likely unawareof this disease, soto prevent transmission to
df df df df df df df df df df df df df df df df df
others and recurrence in the client, the priority nursing diagnosis is de cient knowledge of the disease
df df df df df df d f df d f df df df df df df df df
pathophysiology.
An 85-year-old male client comes to the clinic for his annual physical exam and renewal of antihypertensive
df df df df df df df d f df df df df df df df df
medication prescriptions. Theclient’s radial pulse rate is 104beats/minute. Which additional assessment should the
df df df df df df df df df df df df df df df
nurse complete?
df df
d f Palpate the pedal pulse volume. df df df df
d f Countthe brachial pulse rate. df df df df
df Measure the blood pressure. df df df
Assess fora carotid bruit. df df df d f
Explanation
Elderly clients whotakeantihypertensive medications often experience side eûects, such ashypotension, which
df df df df d f df df df df df df df df
causes tachycardia, a compensatory mechanism to maintain adequate cardiac output, so the client’s blood
df df df df df df df df df df df df df df
pressure should be measured.
df df df df
The nurse assesses a long-term resident ofa nursing home and ndsthe client has a fungal infection (candidiasis)
df df df df df df df df df df df df df df df df df df
beneath both breasts. To prevent nosocomial infection, which protocol should the nurse review with the rest of the
df df df df df df df d f df df df df df df df df df df
staû?
df
Follow contact isolation procedures. df df df
d f Wash hands after caring for the client. df df df df df df
d f
Wear gloves when providing personal care. df df df df df
df Restrict pregnant staû orvisitors into the room. df df df df df df df
Explanation
