HESI - Medical Surgical Nursing test
A patron asks the nurse why it's miles essential to be weighed every day if he has proper-sided
coronary heart failure. What is the nurse's high-quality response?
A) "The sanatorium calls for that every one inpatients be weighed day by day."
B) "Weight is the first-rate indication that you are gaining or losing fluid."
C) "You need to shed pounds to lower the incidence of coronary heart failure."
D) "Daily weights will help us make sure that you're eating properly." - ANS-B
Daily weights are needed to report fluid retention or fluid loss. One liter of fluid equals 2.2 kilos.
A patron has a deep wound covered with a wet-to-damp dressing. Which intervention does the
nurse encompass on this customer's care plan?
A) Apply a brand new dressing when the seal breaks and the dressing leaks.
B) Change the dressing while the contemporary dressing is saturated.
C) Leave the dressing intact until subsequent week.
D) Change the dressing each 6 hours around the clock. - ANS-D
Wet-to-damp dressings are changed every four to 6 hours to provide maximum débridement.
Synthetic dressings can be left in region for extended durations of time however need to be
changed if the seal breaks and the exudate is leaking. Dry gauze dressings ought to be
modified while the outer layer turns into saturated.
A consumer has a small-bore nasoenteric feeding tube. The nurse assesses the following
crucial signs and symptoms: temperature, 100.2° F (37.8° C); pulse, 112 beats/min; respiration
charge, 22 breaths/min; and blood stress, 106/sixty two mm Hg. Which motion by the nurse
takes precedence?
A) Auscultate bowel sounds and sluggish the feeding down.
B) Remove the tube right away and notify the heath care issuer.
C) Auscultate lung sounds and acquire oxygen saturation.
D) Add blue dye to the feeding tube formula. - ANS-C
The client may also have aspirated. The nurse need to in addition determine the patron's
breathing and oxygenation repute. The patron may also have any other purpose for the strange
vital signs, so the nurse ought to now not pull out the tube before performing different
assessments. Adding blue dye to the tube feeding formulation is not encouraged to check for
aspiration. Slowing the feeding down will not be beneficial.
,A client has a urinary tract contamination. Which evaluation by the nurse is maximum helpful?
A) Palpating and percussing the kidneys and bladder
B) Performing a bladder scan to evaluate put up-void residual
C) Assessing medical records and cutting-edge medical troubles
D) Inquiring approximately recent tour to foreign international locations - ANS-C
Clients who are severely immune compromised or who've diabetes mellitus are extra prone to
fungal urinary tract contamination. The nurse should examine for these elements. A physical
examination and a put up-void residual can be wanted, however now not until further statistics is
obtained. Travel to foreign international locations in all likelihood could no longer be as
essential, because even supposing exposed, the client needs some degree of immune
compromise to broaden a fungal urinary tract infection.
A patron has a wound on his left trochanter that is four inches in diameter, with black tissue at
the fringe, and bone is exposed. Which is the nurse's fine action?
A) Document as a stage I pressure ulcer and follow a transparent dressing.
B) Document as a level II stress ulcer and start moist-to-dry gauze remedies.
C) Document as a level IV stress ulcer and prepare the consumer for débridement.
D) Document as a stage III strain ulcer and start antibiotic remedy. - ANS-C
A level IV ulcer is one in which skin loss is complete thickness, with great destruction, tissue
necrosis, and/or harm to muscle, bone, or supporting structures. Eschar can be gift. When the
bone of the trochanter place is visible, tissue loss includes muscle loss. A capability intervention
consists of débridement of the necrotic tissue and a probable graft to promote recovery.
A client has been admitted to the intensive care unit with worsening pulmonary manifestations
of coronary heart failure. What is the nurse's exceptional movement?
A) Administer loop diuretics as prescribed.
B) Begin cardiopulmonary resuscitation (CPR).
C) Promote relaxation and limit activities.
D) Place the client in a high Fowler's role. - ANS-A
The client with worsening coronary heart failure is maximum at chance for pulmonary edema
resulting from fluid retention. Administering diuretics will decrease the fluid overload, thereby
reducing the prevalence of pulmonary edema. High Fowler's position may assist the patron
breathe less difficult however will not clear up the trouble. CPR isn't warranted in this example.
Rest is critical for clients with heart failure, but this isn't the concern.
A customer has been taught to restrict nutritional sodium. Which meals selection with the aid of
the patron suggests to the nurse that coaching has been effective?
,A. A grilled cheese sandwich with tomato soup
b. Chinese take-out, which includes steamed rice
c. A fowl leg, one slice of bread with butter, and steamed carrots
d. Slices of ham and cheese on whole grain crackers - ANS-C
Clients on limited sodium diets generally need to keep away from processed, smoked, and
pickled ingredients and people with sauces and other condiments. Foods lowest in sodium
include fish, hen, and clean produce. The chinese meals probably might have soy sauce, the
tomato soup is processed, and the crackers are a snack food - a category of meals frequently
excessive in sodium.
A consumer has newly diagnosed diabetes. To delay the onset of microvascular and
macrovascular complications on this customer, the nurse stresses that the purchaser take which
action?
A) Restrict fluid consumption.
B) Prevent ketosis.
C) Control hyperglycemia.
D) Prevent hypoglycemia. - ANS-C
Hyperglycemia is a essential component inside the pathogenesis of long-time period diabetic
complications. Maintaining tight glycemic manage will assist put off the onset of complications.
Preventing hypoglycemia and ketosis, although crucial, isn't as vital as preserving each day
glycemic manipulate. Restricting fluid consumption isn't a part of the treatment plan for clients
with diabetes.
A client has recently been placed on prednisone (Deltasone). What is the very best precedence
preparation the nurse will offer?
A) "Take the drug with meals or milk."
B) "Report any abdominal pain or darkish-coloured vomit."
C) "Expect to enjoy weight gain."
D) "Watch your weight loss plan at the same time as in this medicinal drug." - ANS-B
All of these guidelines are suitable to offer the customer; however, telling the customer to report
stomach pain and darkish-coloured vomit is most crucial because those ought to signal gastric
ulceration.
A customer is admitted with infection and a excessive fever. Which exams by way of the nurse
take priority? (Select all that apply.)
A) Skin turgor
B) Pulse exceptional
C) Blood stress
, D) Bowel sounds
E) Respiratory attempt
F) Mental fame - ANS-A, B, C, F
Dehydration can accompany fever, mainly if the patron is sweating profusely. Blood pressure,
pulse fine, and pores and skin turgor are tests of fluid repute. Mental repute adjustments can
accompany fluid losses, especially in older clients.
A purchaser is admitted with left lower lung pneumonia. Which assessment finding does the
nurse correlate with this condition?
A) Expiratory wheeze on the right side
B) Crackles heard on expiration bilaterally
C) Dullness to percussion at the lower left aspect
D) Crepitus of the pores and skin around the left lung - ANS-C
The client with pneumonia may have dullness to percussion on the affected aspect. The
different alternatives are all inconsistent with pneumonia.
A customer is being dealt with for dehydration. Which declaration made through the customer
indicates information of this condition?
A. I will use a salt substitute when making and ingesting my food.
B. I ought to drink a quart of water or other liquid every day.
C. I will now not drink liquids after 6 PM so I may not should arise at night time.
D. I will weigh myself every morning before I consume or drink. - ANS-D
Because 1 L of water weighs 1 kg, change in body weight is a great degree of extra fluid loss or
fluid retention. Weight loss greater than zero.5 lb each day is indicative of excessive fluid loss.
The different statements are not indicative of practices so one can prevent dehydration.
A patron is hospitalized with a urinary tract contamination (UTI). Which scientific manifestation
signals the nurse to the possibility of a complication from the UTI?
A) Hematuria
B) Fever and chills
C) Cloudy, dark urine
D) Burning on urination - ANS-B
Lower urinary tract infections are rarely related to systemic symptoms of fever and chills. A
patron with a UTI who develops fever and chills should be assessed for the improvement of
pyelonephritis. The other alternatives can be visible with UTI.
A consumer is receiving a chemotherapeutic agent intravenously thru a peripheral line. What is
the nurse's first motion when the consumer reviews burning on the web site?
A patron asks the nurse why it's miles essential to be weighed every day if he has proper-sided
coronary heart failure. What is the nurse's high-quality response?
A) "The sanatorium calls for that every one inpatients be weighed day by day."
B) "Weight is the first-rate indication that you are gaining or losing fluid."
C) "You need to shed pounds to lower the incidence of coronary heart failure."
D) "Daily weights will help us make sure that you're eating properly." - ANS-B
Daily weights are needed to report fluid retention or fluid loss. One liter of fluid equals 2.2 kilos.
A patron has a deep wound covered with a wet-to-damp dressing. Which intervention does the
nurse encompass on this customer's care plan?
A) Apply a brand new dressing when the seal breaks and the dressing leaks.
B) Change the dressing while the contemporary dressing is saturated.
C) Leave the dressing intact until subsequent week.
D) Change the dressing each 6 hours around the clock. - ANS-D
Wet-to-damp dressings are changed every four to 6 hours to provide maximum débridement.
Synthetic dressings can be left in region for extended durations of time however need to be
changed if the seal breaks and the exudate is leaking. Dry gauze dressings ought to be
modified while the outer layer turns into saturated.
A consumer has a small-bore nasoenteric feeding tube. The nurse assesses the following
crucial signs and symptoms: temperature, 100.2° F (37.8° C); pulse, 112 beats/min; respiration
charge, 22 breaths/min; and blood stress, 106/sixty two mm Hg. Which motion by the nurse
takes precedence?
A) Auscultate bowel sounds and sluggish the feeding down.
B) Remove the tube right away and notify the heath care issuer.
C) Auscultate lung sounds and acquire oxygen saturation.
D) Add blue dye to the feeding tube formula. - ANS-C
The client may also have aspirated. The nurse need to in addition determine the patron's
breathing and oxygenation repute. The patron may also have any other purpose for the strange
vital signs, so the nurse ought to now not pull out the tube before performing different
assessments. Adding blue dye to the tube feeding formulation is not encouraged to check for
aspiration. Slowing the feeding down will not be beneficial.
,A client has a urinary tract contamination. Which evaluation by the nurse is maximum helpful?
A) Palpating and percussing the kidneys and bladder
B) Performing a bladder scan to evaluate put up-void residual
C) Assessing medical records and cutting-edge medical troubles
D) Inquiring approximately recent tour to foreign international locations - ANS-C
Clients who are severely immune compromised or who've diabetes mellitus are extra prone to
fungal urinary tract contamination. The nurse should examine for these elements. A physical
examination and a put up-void residual can be wanted, however now not until further statistics is
obtained. Travel to foreign international locations in all likelihood could no longer be as
essential, because even supposing exposed, the client needs some degree of immune
compromise to broaden a fungal urinary tract infection.
A patron has a wound on his left trochanter that is four inches in diameter, with black tissue at
the fringe, and bone is exposed. Which is the nurse's fine action?
A) Document as a stage I pressure ulcer and follow a transparent dressing.
B) Document as a level II stress ulcer and start moist-to-dry gauze remedies.
C) Document as a level IV stress ulcer and prepare the consumer for débridement.
D) Document as a stage III strain ulcer and start antibiotic remedy. - ANS-C
A level IV ulcer is one in which skin loss is complete thickness, with great destruction, tissue
necrosis, and/or harm to muscle, bone, or supporting structures. Eschar can be gift. When the
bone of the trochanter place is visible, tissue loss includes muscle loss. A capability intervention
consists of débridement of the necrotic tissue and a probable graft to promote recovery.
A client has been admitted to the intensive care unit with worsening pulmonary manifestations
of coronary heart failure. What is the nurse's exceptional movement?
A) Administer loop diuretics as prescribed.
B) Begin cardiopulmonary resuscitation (CPR).
C) Promote relaxation and limit activities.
D) Place the client in a high Fowler's role. - ANS-A
The client with worsening coronary heart failure is maximum at chance for pulmonary edema
resulting from fluid retention. Administering diuretics will decrease the fluid overload, thereby
reducing the prevalence of pulmonary edema. High Fowler's position may assist the patron
breathe less difficult however will not clear up the trouble. CPR isn't warranted in this example.
Rest is critical for clients with heart failure, but this isn't the concern.
A customer has been taught to restrict nutritional sodium. Which meals selection with the aid of
the patron suggests to the nurse that coaching has been effective?
,A. A grilled cheese sandwich with tomato soup
b. Chinese take-out, which includes steamed rice
c. A fowl leg, one slice of bread with butter, and steamed carrots
d. Slices of ham and cheese on whole grain crackers - ANS-C
Clients on limited sodium diets generally need to keep away from processed, smoked, and
pickled ingredients and people with sauces and other condiments. Foods lowest in sodium
include fish, hen, and clean produce. The chinese meals probably might have soy sauce, the
tomato soup is processed, and the crackers are a snack food - a category of meals frequently
excessive in sodium.
A consumer has newly diagnosed diabetes. To delay the onset of microvascular and
macrovascular complications on this customer, the nurse stresses that the purchaser take which
action?
A) Restrict fluid consumption.
B) Prevent ketosis.
C) Control hyperglycemia.
D) Prevent hypoglycemia. - ANS-C
Hyperglycemia is a essential component inside the pathogenesis of long-time period diabetic
complications. Maintaining tight glycemic manage will assist put off the onset of complications.
Preventing hypoglycemia and ketosis, although crucial, isn't as vital as preserving each day
glycemic manipulate. Restricting fluid consumption isn't a part of the treatment plan for clients
with diabetes.
A client has recently been placed on prednisone (Deltasone). What is the very best precedence
preparation the nurse will offer?
A) "Take the drug with meals or milk."
B) "Report any abdominal pain or darkish-coloured vomit."
C) "Expect to enjoy weight gain."
D) "Watch your weight loss plan at the same time as in this medicinal drug." - ANS-B
All of these guidelines are suitable to offer the customer; however, telling the customer to report
stomach pain and darkish-coloured vomit is most crucial because those ought to signal gastric
ulceration.
A customer is admitted with infection and a excessive fever. Which exams by way of the nurse
take priority? (Select all that apply.)
A) Skin turgor
B) Pulse exceptional
C) Blood stress
, D) Bowel sounds
E) Respiratory attempt
F) Mental fame - ANS-A, B, C, F
Dehydration can accompany fever, mainly if the patron is sweating profusely. Blood pressure,
pulse fine, and pores and skin turgor are tests of fluid repute. Mental repute adjustments can
accompany fluid losses, especially in older clients.
A purchaser is admitted with left lower lung pneumonia. Which assessment finding does the
nurse correlate with this condition?
A) Expiratory wheeze on the right side
B) Crackles heard on expiration bilaterally
C) Dullness to percussion at the lower left aspect
D) Crepitus of the pores and skin around the left lung - ANS-C
The client with pneumonia may have dullness to percussion on the affected aspect. The
different alternatives are all inconsistent with pneumonia.
A customer is being dealt with for dehydration. Which declaration made through the customer
indicates information of this condition?
A. I will use a salt substitute when making and ingesting my food.
B. I ought to drink a quart of water or other liquid every day.
C. I will now not drink liquids after 6 PM so I may not should arise at night time.
D. I will weigh myself every morning before I consume or drink. - ANS-D
Because 1 L of water weighs 1 kg, change in body weight is a great degree of extra fluid loss or
fluid retention. Weight loss greater than zero.5 lb each day is indicative of excessive fluid loss.
The different statements are not indicative of practices so one can prevent dehydration.
A patron is hospitalized with a urinary tract contamination (UTI). Which scientific manifestation
signals the nurse to the possibility of a complication from the UTI?
A) Hematuria
B) Fever and chills
C) Cloudy, dark urine
D) Burning on urination - ANS-B
Lower urinary tract infections are rarely related to systemic symptoms of fever and chills. A
patron with a UTI who develops fever and chills should be assessed for the improvement of
pyelonephritis. The other alternatives can be visible with UTI.
A consumer is receiving a chemotherapeutic agent intravenously thru a peripheral line. What is
the nurse's first motion when the consumer reviews burning on the web site?
