Med Surg HESI Exam V1 - UP-TO-DATE EXAM
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Section 1: Cardiovascular Disorders
Question 1
A client with chronic obstructive pulmonary disease (COPD) has an SpO2 of 86% on 2
L/min oxygen. What is the priority nursing action?
A) Increase oxygen to 4 L/min
B) Notify the healthcare provider
C) Position the client in high Fowler's
D) Administer a bronchodilator
Correct Answer: B) Notify the healthcare provider
Rationale: An SpO2 of 86% indicates significant hypoxia in a COPD client. Increasing
oxygen without provider guidance risks CO2 retention and respiratory depression in clients
with chronic hypercapnia. Notification ensures safe management and potential
adjustment of oxygen therapy .
Question 2
A client with heart failure reports a 3-pound weight gain in 24 hours. What should the
nurse do first?
A) Administer furosemide as prescribed
B) Assess for peripheral edema
C) Restrict fluid intake
D) Notify the healthcare provider
Correct Answer: B) Assess for peripheral edema
,Rationale: Rapid weight gain in heart failure suggests fluid retention. Assessing for
peripheral edema provides data to guide further action and determine the severity of fluid
overload before implementing interventions .
Question 3
A client with heart failure has crackles in both lung bases and peripheral edema. Which
nursing intervention should the nurse implement first?
A) Administer digoxin as ordered
B) Check blood pressure
C) Obtain daily weight
D) Elevate the head of the bed
Correct Answer: D) Elevate the head of the bed
Rationale: The priority intervention for a client with pulmonary congestion is to elevate the
head of the bed to improve breathing and oxygenation. Airway and breathing always take
priority. After positioning, the nurse can administer medications and assess further .
Question 4
A client with hypertension is prescribed lisinopril. Which adverse effect should the nurse
teach the client to report immediately?
A) Dry cough
B) Headache
C) Swelling of the face, lips, or tongue
D) Dizziness
Correct Answer: C) Swelling of the face, lips, or tongue
Rationale: Angioedema (swelling of the face, lips, tongue, or airway) is a serious adverse
effect of ACE inhibitors that can compromise the airway. Clients should be instructed to
seek emergency care immediately if this occurs .
,Question 5
A client with atrial fibrillation is prescribed warfarin. Which international normalized ratio
(INR) indicates therapeutic anticoagulation?
A) 1.0-1.5
B) 1.5-2.0
C) 2.0-3.0
D) 3.5-4.5
Correct Answer: C) 2.0-3.0
Rationale: For most indications, including atrial fibrillation, the therapeutic INR range is
2.0-3.0. For mechanical heart valves, the target INR may be higher (2.5-3.5). INRs below
2.0 increase stroke risk; INRs above 3.0 increase bleeding risk .
Question 6
A client with heart failure is prescribed furosemide. Which laboratory value requires the
most immediate intervention?
A) Serum sodium of 135 mEq/L
B) Serum potassium of 3.0 mEq/L
C) Serum creatinine of 1.2 mg/dL
D) Blood glucose of 110 mg/dL
Correct Answer: B) Serum potassium of 3.0 mEq/L
Rationale: Furosemide is a loop diuretic that causes potassium wasting. Hypokalemia
(normal range 3.5-5.0 mEq/L) can lead to cardiac dysrhythmias, especially in patients
taking digoxin. A potassium level of 3.0 mEq/L requires immediate intervention .
Question 7
A client with peripheral artery disease (PAD) complains of leg pain when walking that
resolves with rest. What is this symptom called?
A) Rest pain
B) Paresthesia
, C) Intermittent claudication
D) Venous stasis
Correct Answer: C) Intermittent claudication
Rationale: Intermittent claudication is muscle pain (usually in the calves) that occurs with
exercise and resolves with rest. It is caused by inadequate blood flow to meet the
metabolic demands of exercising muscles in patients with PAD .
Question 8
A client with angina is prescribed nitroglycerin transdermal patch. Which instruction
should the nurse include?
A) Apply the patch to the same site daily
B) Leave the patch on for 24 hours
C) Apply the patch over a hairless area and shave if necessary
D) Remove the patch for 10-12 hours each day to prevent tolerance
Correct Answer: D) Remove the patch for 10-12 hours each day to prevent
tolerance
Rationale: To prevent tolerance, nitroglycerin patches should be removed for 10-12 hours
each day (usually at night). The patch should be applied to a clean, dry, hairless area and
rotated to different sites .
Section 2: Respiratory Disorders
Question 9
A client with asthma has bronchoconstriction with increased mucus production. What is
the priority nursing intervention?
A) Administer oral corticosteroids
B) Administer bronchodilators as prescribed
C) Encourage fluid intake
D) Monitor oxygen saturation
QUESTIONS AND 100% ACCURATE SOLUTIONS
| Question And VERIFIED ANSWERS - INSTANT
PDF DOWNLOAD.
Section 1: Cardiovascular Disorders
Question 1
A client with chronic obstructive pulmonary disease (COPD) has an SpO2 of 86% on 2
L/min oxygen. What is the priority nursing action?
A) Increase oxygen to 4 L/min
B) Notify the healthcare provider
C) Position the client in high Fowler's
D) Administer a bronchodilator
Correct Answer: B) Notify the healthcare provider
Rationale: An SpO2 of 86% indicates significant hypoxia in a COPD client. Increasing
oxygen without provider guidance risks CO2 retention and respiratory depression in clients
with chronic hypercapnia. Notification ensures safe management and potential
adjustment of oxygen therapy .
Question 2
A client with heart failure reports a 3-pound weight gain in 24 hours. What should the
nurse do first?
A) Administer furosemide as prescribed
B) Assess for peripheral edema
C) Restrict fluid intake
D) Notify the healthcare provider
Correct Answer: B) Assess for peripheral edema
,Rationale: Rapid weight gain in heart failure suggests fluid retention. Assessing for
peripheral edema provides data to guide further action and determine the severity of fluid
overload before implementing interventions .
Question 3
A client with heart failure has crackles in both lung bases and peripheral edema. Which
nursing intervention should the nurse implement first?
A) Administer digoxin as ordered
B) Check blood pressure
C) Obtain daily weight
D) Elevate the head of the bed
Correct Answer: D) Elevate the head of the bed
Rationale: The priority intervention for a client with pulmonary congestion is to elevate the
head of the bed to improve breathing and oxygenation. Airway and breathing always take
priority. After positioning, the nurse can administer medications and assess further .
Question 4
A client with hypertension is prescribed lisinopril. Which adverse effect should the nurse
teach the client to report immediately?
A) Dry cough
B) Headache
C) Swelling of the face, lips, or tongue
D) Dizziness
Correct Answer: C) Swelling of the face, lips, or tongue
Rationale: Angioedema (swelling of the face, lips, tongue, or airway) is a serious adverse
effect of ACE inhibitors that can compromise the airway. Clients should be instructed to
seek emergency care immediately if this occurs .
,Question 5
A client with atrial fibrillation is prescribed warfarin. Which international normalized ratio
(INR) indicates therapeutic anticoagulation?
A) 1.0-1.5
B) 1.5-2.0
C) 2.0-3.0
D) 3.5-4.5
Correct Answer: C) 2.0-3.0
Rationale: For most indications, including atrial fibrillation, the therapeutic INR range is
2.0-3.0. For mechanical heart valves, the target INR may be higher (2.5-3.5). INRs below
2.0 increase stroke risk; INRs above 3.0 increase bleeding risk .
Question 6
A client with heart failure is prescribed furosemide. Which laboratory value requires the
most immediate intervention?
A) Serum sodium of 135 mEq/L
B) Serum potassium of 3.0 mEq/L
C) Serum creatinine of 1.2 mg/dL
D) Blood glucose of 110 mg/dL
Correct Answer: B) Serum potassium of 3.0 mEq/L
Rationale: Furosemide is a loop diuretic that causes potassium wasting. Hypokalemia
(normal range 3.5-5.0 mEq/L) can lead to cardiac dysrhythmias, especially in patients
taking digoxin. A potassium level of 3.0 mEq/L requires immediate intervention .
Question 7
A client with peripheral artery disease (PAD) complains of leg pain when walking that
resolves with rest. What is this symptom called?
A) Rest pain
B) Paresthesia
, C) Intermittent claudication
D) Venous stasis
Correct Answer: C) Intermittent claudication
Rationale: Intermittent claudication is muscle pain (usually in the calves) that occurs with
exercise and resolves with rest. It is caused by inadequate blood flow to meet the
metabolic demands of exercising muscles in patients with PAD .
Question 8
A client with angina is prescribed nitroglycerin transdermal patch. Which instruction
should the nurse include?
A) Apply the patch to the same site daily
B) Leave the patch on for 24 hours
C) Apply the patch over a hairless area and shave if necessary
D) Remove the patch for 10-12 hours each day to prevent tolerance
Correct Answer: D) Remove the patch for 10-12 hours each day to prevent
tolerance
Rationale: To prevent tolerance, nitroglycerin patches should be removed for 10-12 hours
each day (usually at night). The patch should be applied to a clean, dry, hairless area and
rotated to different sites .
Section 2: Respiratory Disorders
Question 9
A client with asthma has bronchoconstriction with increased mucus production. What is
the priority nursing intervention?
A) Administer oral corticosteroids
B) Administer bronchodilators as prescribed
C) Encourage fluid intake
D) Monitor oxygen saturation
