MED SURG HESI 2022,
HESI MED SURG 1 TEST
WITH CORRECT
RESOLUTIONS.
[Document subtitle]
,The nurse is preparing to assist a client with a cuffed tracheostomy tube to
eat. What intervention is the priority before the client is permitted to drink or
eat? - correct ans:Inflate the cuff
Rationale: If a client with a tracheostomy is allowed to eat and the
tracheostomy has a cuff, the nurse should inflate the cuff to prevent
aspiration of food or fluids. The cuff would not be deflated because of the risk
of aspiration.
The nurse has implemented a bowel maintenance program for an
unconscious client. The nurse would evaluate the plan as best meeting the
needs of the client if which method was successful in stimulating a bowel
movement? - correct ans:Glycerin suppository
Rationale: The least amount of invasiveness needed to produce a bowel
movement is best. Use of glycerin suppositories is the least invasive method
and usually stimulates bowel evacuation within a half-hour.
A client is readmitted to the hospital with dehydration after surgery for
creation of an ileostomy. The nurse assesses that the client has lost 3 lb of
weight, has poor skin turgor, and has concentrated urine. The nurse
interprets the client's clinical picture as correlating most closely with recent
intake of which medication, which is contraindicated for the ileostomy client?
- correct ans:Biscodyl
Rationale: The client with an ileostomy is prone to dehydration because of
the location of the ostomy in the gastrointestinal tract and should not take
laxatives
The client is complaining of skin irritation from the edges of a cast applied
the previous day. Which action should the nurse take? - correct ans:The
nurse petals the edges of the cast with tape
,Rationale: minimize skin irritation.
The nurse is taking a health history for a client with hyperparathyroidism.
Which question would elicit information about this client's condition? - correct
ans:"Are you experiencing pain in your joints?"
Rationale: Hyperparathyroidism is associated with over secretion of
parathyroid hormone (PTH), which
causes excessive osteoblast growth and activity within the bones. When
bone reabsorption is increased,
calcium is released from the bones into the blood, causing hypercalcemia.
The bones suffer demineralization as a result of calcium loss, leading to bone
and joint pain
A client with type 2 diabetes mellitus has a blood glucose level greater than
600 mg/dL (34.3 mmol/L) and is complaining of polydipsia, polyuria, weight
loss, and weakness. The nurse reviews the health care provider's
documentation and expects to note which diagnosis? - correct
ans:Hyperosmolar hyperglycemic syndrome (HHS)
Rationale: HHS is seen primarily in clients with type 2 diabetes mellitus, who
experience a relative deficiency of insulin. The onset of signs and symptoms
may be gradual.
Manifestations may include polyuria, polydipsia, dehydration, mental status
alterations, weight loss, and weakness.
The nurse is developing a plan of care for a client who will be admitted to the
hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The
nurse develops the plan, expecting that the health care provider (HCP) will
most likely prescribe which option? - correct ans:Maintain activity level as
prescribed.
, Rationale: Standard management for the client with DVT includes
maintaining the activity level
as prescribed by the health care provider; limb elevation; relief of discomfort
with warm, moist
heat; and analgesics as needed. Recent research is showing that ambulation,
as previously thought, does not cause pulmonary embolism and does not
cause the existing DVT to worsen.
Therefore, the nurse should maintain the prescribed activity level, which
could be bed rest or ambulation.
A client has had surgery to repair a fractured left hip. When repositioning the
client from side to side in the bed, what should the nurse plan to use as the
most important item for this maneuver? - correct ans:Abductor splint
Rationale: After surgery to repair a fractured hip, an abductor splint is used
to maintain the affected extremity in good alignment. A bed pillow and an
overhead trapeze also are used, but neither is the priority item to be used in
repositioning the client from side to side
The nurse is preparing to care for a client who had a supratentorial
craniotomy. The nurse should plan to place the client in which position ? -
correct ans:Semi Fowler's
Rationale: Supratentorial craniotomy means the exposure of any part of a
cerebral hemisphere over the basal line joining the nasion to the inion.
A client with an external arteriovenous shunt in place for hemodialysis is at
risk for bleeding. Which is the priority nursing intervention? - correct
ans:Ensure that small clamps are attached to the arteriovenous shunt
dressing.
HESI MED SURG 1 TEST
WITH CORRECT
RESOLUTIONS.
[Document subtitle]
,The nurse is preparing to assist a client with a cuffed tracheostomy tube to
eat. What intervention is the priority before the client is permitted to drink or
eat? - correct ans:Inflate the cuff
Rationale: If a client with a tracheostomy is allowed to eat and the
tracheostomy has a cuff, the nurse should inflate the cuff to prevent
aspiration of food or fluids. The cuff would not be deflated because of the risk
of aspiration.
The nurse has implemented a bowel maintenance program for an
unconscious client. The nurse would evaluate the plan as best meeting the
needs of the client if which method was successful in stimulating a bowel
movement? - correct ans:Glycerin suppository
Rationale: The least amount of invasiveness needed to produce a bowel
movement is best. Use of glycerin suppositories is the least invasive method
and usually stimulates bowel evacuation within a half-hour.
A client is readmitted to the hospital with dehydration after surgery for
creation of an ileostomy. The nurse assesses that the client has lost 3 lb of
weight, has poor skin turgor, and has concentrated urine. The nurse
interprets the client's clinical picture as correlating most closely with recent
intake of which medication, which is contraindicated for the ileostomy client?
- correct ans:Biscodyl
Rationale: The client with an ileostomy is prone to dehydration because of
the location of the ostomy in the gastrointestinal tract and should not take
laxatives
The client is complaining of skin irritation from the edges of a cast applied
the previous day. Which action should the nurse take? - correct ans:The
nurse petals the edges of the cast with tape
,Rationale: minimize skin irritation.
The nurse is taking a health history for a client with hyperparathyroidism.
Which question would elicit information about this client's condition? - correct
ans:"Are you experiencing pain in your joints?"
Rationale: Hyperparathyroidism is associated with over secretion of
parathyroid hormone (PTH), which
causes excessive osteoblast growth and activity within the bones. When
bone reabsorption is increased,
calcium is released from the bones into the blood, causing hypercalcemia.
The bones suffer demineralization as a result of calcium loss, leading to bone
and joint pain
A client with type 2 diabetes mellitus has a blood glucose level greater than
600 mg/dL (34.3 mmol/L) and is complaining of polydipsia, polyuria, weight
loss, and weakness. The nurse reviews the health care provider's
documentation and expects to note which diagnosis? - correct
ans:Hyperosmolar hyperglycemic syndrome (HHS)
Rationale: HHS is seen primarily in clients with type 2 diabetes mellitus, who
experience a relative deficiency of insulin. The onset of signs and symptoms
may be gradual.
Manifestations may include polyuria, polydipsia, dehydration, mental status
alterations, weight loss, and weakness.
The nurse is developing a plan of care for a client who will be admitted to the
hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The
nurse develops the plan, expecting that the health care provider (HCP) will
most likely prescribe which option? - correct ans:Maintain activity level as
prescribed.
, Rationale: Standard management for the client with DVT includes
maintaining the activity level
as prescribed by the health care provider; limb elevation; relief of discomfort
with warm, moist
heat; and analgesics as needed. Recent research is showing that ambulation,
as previously thought, does not cause pulmonary embolism and does not
cause the existing DVT to worsen.
Therefore, the nurse should maintain the prescribed activity level, which
could be bed rest or ambulation.
A client has had surgery to repair a fractured left hip. When repositioning the
client from side to side in the bed, what should the nurse plan to use as the
most important item for this maneuver? - correct ans:Abductor splint
Rationale: After surgery to repair a fractured hip, an abductor splint is used
to maintain the affected extremity in good alignment. A bed pillow and an
overhead trapeze also are used, but neither is the priority item to be used in
repositioning the client from side to side
The nurse is preparing to care for a client who had a supratentorial
craniotomy. The nurse should plan to place the client in which position ? -
correct ans:Semi Fowler's
Rationale: Supratentorial craniotomy means the exposure of any part of a
cerebral hemisphere over the basal line joining the nasion to the inion.
A client with an external arteriovenous shunt in place for hemodialysis is at
risk for bleeding. Which is the priority nursing intervention? - correct
ans:Ensure that small clamps are attached to the arteriovenous shunt
dressing.
