MED SURG FINAL HESI SEMESTER 4
EXAMS WITH VERIFIED ANSWERS
1. A client with a productive cough has obtained a sputum specimen for
culture as instructed. What is the best initial nursing action?
A. Administer the first dose of antibiotic therapy
B. Observe the color, consistency, and amount of sputum
C. Encourage the client to consume plenty of warm liquids
D. Send the specimen to the lab for analysis - ANSWER-B.
Observe the color, consistency, and amount of sputum
2. A client is brought to the ED by ambulance in cardiac arrest with
cardiopulmonary resuscitation (CPR) in progress. The client is intubated
and is receiving 100% oxygen per self-inflating (ambu) bag. The nurse
determines that the client is cyanotic, cold, and diaphoretic. Which
assessment is most important for the nurse to obtain?
A. Breath sounds over bilateral lung fields.
B. Carotid pulsation during compressions
C. Deep tendon reflexes
D. Core body temperature - ANSWER-A. Breath sounds over
bilateral lung fields.
3. After a hospitalization for Syndrome of Inappropriate Antidiuretic
Hormone (SIADH), a client develops pontine myselinolysis. Which
intervention should the nurse implement first?
A. Reorient client to his room
B. Place a patch on one eye
C. Evaluate client's ability to swallow
D. Perform range of motion exercises - ANSWER-A. Reorient client
to his room
,4. A male client with heart failure (HF) calls the clinic and reports that he
cannot put his shoes on because they are too tight. Which additional
information should the nurse obtain?
A. What time did he take his last medications?
B. Has his weight changed in the last several days?
C. Is he still able to tighten his belt buckle?
D. How many hours did he sleep last night? - ANSWER-B. Has his
weight changed in the last several days?
5. An older adult woman with a long history of chronic obstructive
pulmonary disease (COPD) is admitted with progressive shortness of
breath and a persistent cough. She is anxious and is complaining of a
dry mouth. Which intervention should the nurse implement?
A. Administer a prescribed sedative
B. Encourage client to drink water
C. Apply a high-flow venturi mask
D. Assist her to an upright position - ANSWER-D. Assist her to an
upright position
6. A client with a history of asthma and bronchitis arrives at the clinic
with shortness of breath, productive cough with thickened tenacious
mucous, and the inability to walk up a flight of stairs without
experiencing breathlessness. Which action is most important for the
nurse to instruct the client about self-care?
A. Increase the daily intake of oral fluids to liquefy secretions
B. Avoid crowded enclosed areas to reduce pathogen exposure
C. Call the clinic if undesirable side effects of mediations occur
D. Teach anxiety reduction methods for feelings of suffocation -
ANSWER-A. Increase the daily intake of oral fluids to liquefy
secretions
,7. A cardiac catherterization of a client with heart disease indicates the
following blockages: 95% proximal left anterior descending (LAD), 99%
proximal circumflex, and ? % proximal right coronary artery (RCA). The
client later asks the nurse "what does all this mean for me?" What
information should the nurse provide?
A. Blood supply to the heart is diminished by artherosclerotic
lesions, which necessitate lifestyle changes.
B. Blood vessels supplying the pumping chamber have
blockages indicating a past heart attack.
C. Three main arteries have major blockages, with only 1 to 5%
of blood flow getting through to the heart muscle.
D. The heart is not receiving enough blood, so there is a risk of
heart failure and fluid retention. - ANSWER-C. Three main
arteries have major blockages, with only 1 to 5% of blood flow
getting through to the heart muscle.
8. A client who weighs 175 pounds is receiving IV bolus dose of heparin
80 units/kg. The heparin is available in a 2 ml vial, labeled 10,000
units/ml. How many ml should the nurse administer? (Enter numeric
value only. If rounding is required, round to the nearest tenth.) -
ANSWER-0.6 ml
9. 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 -
ANSWER-C. Minimize symptoms by wearing loose,
comfortable clothing
, 10. The nurse is caring for a client with a lower left lobe pulmonary
abscess. Which position should the nurse instruct the client to
maintain?
A. left lateral
B. Supine, knees flexed
C. Dorsal recumbent
D. Knee-chest - ANSWER-A. left lateral
11. A client with cholelithiasis has a gallstone lodged in the common
bile duct and is unable to eat or drink without becoming nauseated and
vomiting. Which finding should the nurse report to the healthcare
provider.
A. Belching
B. Amber urine
C. Yellow sclera
D. Flatulence - ANSWER-C. Yellow sclera
12. While caring for a client with Amyotrophic Lateral Sclerosis (ALS),
the nurse performs a neurological assessment every four hours. Which
assessment finding warrants immediate intervention by the nurse?
A. Inappropriate laughter
B. Increasing anxiety
C. Weakened cough effort
D. Asymmetrical weakness - ANSWER-C. Weakened cough effort
13. The nurse is providing preoperative education for a Jewish client
scheduled to receive a xenograft graft to promote burn healing. Which
information should the nurse provide this client?
A. Grafting increases the risk for bacterial infections
EXAMS WITH VERIFIED ANSWERS
1. A client with a productive cough has obtained a sputum specimen for
culture as instructed. What is the best initial nursing action?
A. Administer the first dose of antibiotic therapy
B. Observe the color, consistency, and amount of sputum
C. Encourage the client to consume plenty of warm liquids
D. Send the specimen to the lab for analysis - ANSWER-B.
Observe the color, consistency, and amount of sputum
2. A client is brought to the ED by ambulance in cardiac arrest with
cardiopulmonary resuscitation (CPR) in progress. The client is intubated
and is receiving 100% oxygen per self-inflating (ambu) bag. The nurse
determines that the client is cyanotic, cold, and diaphoretic. Which
assessment is most important for the nurse to obtain?
A. Breath sounds over bilateral lung fields.
B. Carotid pulsation during compressions
C. Deep tendon reflexes
D. Core body temperature - ANSWER-A. Breath sounds over
bilateral lung fields.
3. After a hospitalization for Syndrome of Inappropriate Antidiuretic
Hormone (SIADH), a client develops pontine myselinolysis. Which
intervention should the nurse implement first?
A. Reorient client to his room
B. Place a patch on one eye
C. Evaluate client's ability to swallow
D. Perform range of motion exercises - ANSWER-A. Reorient client
to his room
,4. A male client with heart failure (HF) calls the clinic and reports that he
cannot put his shoes on because they are too tight. Which additional
information should the nurse obtain?
A. What time did he take his last medications?
B. Has his weight changed in the last several days?
C. Is he still able to tighten his belt buckle?
D. How many hours did he sleep last night? - ANSWER-B. Has his
weight changed in the last several days?
5. An older adult woman with a long history of chronic obstructive
pulmonary disease (COPD) is admitted with progressive shortness of
breath and a persistent cough. She is anxious and is complaining of a
dry mouth. Which intervention should the nurse implement?
A. Administer a prescribed sedative
B. Encourage client to drink water
C. Apply a high-flow venturi mask
D. Assist her to an upright position - ANSWER-D. Assist her to an
upright position
6. A client with a history of asthma and bronchitis arrives at the clinic
with shortness of breath, productive cough with thickened tenacious
mucous, and the inability to walk up a flight of stairs without
experiencing breathlessness. Which action is most important for the
nurse to instruct the client about self-care?
A. Increase the daily intake of oral fluids to liquefy secretions
B. Avoid crowded enclosed areas to reduce pathogen exposure
C. Call the clinic if undesirable side effects of mediations occur
D. Teach anxiety reduction methods for feelings of suffocation -
ANSWER-A. Increase the daily intake of oral fluids to liquefy
secretions
,7. A cardiac catherterization of a client with heart disease indicates the
following blockages: 95% proximal left anterior descending (LAD), 99%
proximal circumflex, and ? % proximal right coronary artery (RCA). The
client later asks the nurse "what does all this mean for me?" What
information should the nurse provide?
A. Blood supply to the heart is diminished by artherosclerotic
lesions, which necessitate lifestyle changes.
B. Blood vessels supplying the pumping chamber have
blockages indicating a past heart attack.
C. Three main arteries have major blockages, with only 1 to 5%
of blood flow getting through to the heart muscle.
D. The heart is not receiving enough blood, so there is a risk of
heart failure and fluid retention. - ANSWER-C. Three main
arteries have major blockages, with only 1 to 5% of blood flow
getting through to the heart muscle.
8. A client who weighs 175 pounds is receiving IV bolus dose of heparin
80 units/kg. The heparin is available in a 2 ml vial, labeled 10,000
units/ml. How many ml should the nurse administer? (Enter numeric
value only. If rounding is required, round to the nearest tenth.) -
ANSWER-0.6 ml
9. 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 -
ANSWER-C. Minimize symptoms by wearing loose,
comfortable clothing
, 10. The nurse is caring for a client with a lower left lobe pulmonary
abscess. Which position should the nurse instruct the client to
maintain?
A. left lateral
B. Supine, knees flexed
C. Dorsal recumbent
D. Knee-chest - ANSWER-A. left lateral
11. A client with cholelithiasis has a gallstone lodged in the common
bile duct and is unable to eat or drink without becoming nauseated and
vomiting. Which finding should the nurse report to the healthcare
provider.
A. Belching
B. Amber urine
C. Yellow sclera
D. Flatulence - ANSWER-C. Yellow sclera
12. While caring for a client with Amyotrophic Lateral Sclerosis (ALS),
the nurse performs a neurological assessment every four hours. Which
assessment finding warrants immediate intervention by the nurse?
A. Inappropriate laughter
B. Increasing anxiety
C. Weakened cough effort
D. Asymmetrical weakness - ANSWER-C. Weakened cough effort
13. The nurse is providing preoperative education for a Jewish client
scheduled to receive a xenograft graft to promote burn healing. Which
information should the nurse provide this client?
A. Grafting increases the risk for bacterial infections
