HESI RN MED SURG V1 to V4 EXAM QUESTIONS AND ANSWERS

HESI MED SURG V1 to V4 EXAM QUESTIONS AND ANSWERS 1. Nurse in ED caring for a client who is having an acute asthma attack. How can she tell the client in in respiratory distress (Select all) A. 95% O2 B. Wheezing C. Retraction of sternal muscles D. Pink mucous membranes E. Premature ventricular complexes (PVCs) 2. Newly admitted patient w/diagnosis of ascites. What order would the nurse question? (select all) a. High sodium b. Spironolactone c. Paracentesis d. Administration of salt-poor albumin e. Assisted ambulation 3. A client is administered to the emergency department with several large kidney stones. What is the nursing priority of this patient? a. Administer a Foley catheter b. Have the patient transferred to the ER to have the stones surgically removed c. Administer hydrochlorothiazide d. Administer acetaminophen 4. A student nurse is completing a pain assessment. The patient states that the pain is located in his abdomen, and relieved by defecation. After reviewing his chart she noticed the consistency of his stools also changed. What would the student suspect his diagnosis to be? a. Appendicitis b. Irritable bowel syndrome c. Irregular diet d. Abdominal hernia 5. The nurse obtains a diet history from a pregnant 16 yr old girl. The girl tells the nurse her typical daily diet includes cereal and milk for breakfast, pizza and soda for lunch, and a cheeseburger, milkshake, fries and a salad for dinner. Which of the following is the MOST accurate nursing diagnosis based on the data? a. Altered nutrition: more than body requirements related to high-fat diet b. Knowledge deficit: nutrition in pregnancy c. Altered nutrition: less that body requirements related to increased nutritional demands of pregnancy d. Risk for injury: fetal malnutrition related to poor maternal diet 6. A boy was riding his bike to school when he hit the curb. He fell and hurt his leg. The school nurse was called and found him alert and conscious, but in severe pain with a possible fracture to the right femur. Which of the following is the FIRST action the nurse should take a. check the pedal pulse and blanching sign in both legs b. immobilize the affected limb with a splint and ask him not to move c. make a thorough assessment of the circumstances surrounding the accident d. put him in semi-fowler’s position for comfort 7. A 65 year old patient with pneumonia is receiving gentamicin. It would be most important for a nurse to monitor which of the following lab values in this patient a. Hemoglobin and Hematocrit b. BUN and creatinine: cleared by kidneys, gentamicin is nephrotoxic c. Platelet count and clotting time d. Sodium and potassium 8. To enhance the percutaneous absorption of nitroglycerin ointment, it would be MOST important for the nurse to select a site that is a. Muscular, non-hairy, near the heart. Nitro placement on anterior chest wall; want to keep up with it, need it to attach and be seen. Non-hairy is the most important so that it can be seen 9. The nurse care for a client diagnosed with a right-sided cerebrovascular accident (CVA) with dysphagia. Which of the following actions by the nurse reflects appropriate care for the client (SELECT ALL THAT APPLY). a. The nurse assesses the client’s ability to swallow b. the nurse offers the client scrambled eggs (make sure they are more whole) c. the nurse positions the client at a 45 degree angle-should be 90 degrees d. the nurse instructs the client to place food on the left side of the mouth-stroke affects the left side of the mouth, can’t chew on this side e. the nurse turns off the tv 10. You are teaching a patient with a sigmoid colostomy about colostomy care. Which statement made by the patient shows the patient has an understanding? a. I should clean my stoma with hydrogen peroxide b. I will have watery stools now-ileostomy c. I should make sure my stoma is dry d. My stools will be formed-location 11. A 30 year old patient had a subtotal thyroidectomy in the morning. During the evening, the nurse records his vital signs and has a temp of 105 F, tachycardia, and appears restless. What is most likely the cause of these signs? a. Hyperglycemia b. Thyroid crisis c. DKA d. Tetany 12. A patient with B-folic deficiency should eat these foods for supplement a. Nuts b. Leafy greans c. Meats, cheese, and eggs d. Citrus juices 13. A client admitted to the hospital with a subarachnoid hemorrhage complains of a headache, vomiting and nuchal rigidity. The nurse knows a lumbar puncture would be contraindicated in the client in which of the following circumstances a. ICP increased b. Blood pressure decreases c. Vomiting continues d. dyspnea 14. A 35 year old patient with liver cirrhosis has developed ascites and now requires a paracentesis. Before her procedure you instruct the patient the patient to: a. Remain NPO for 4 hours b. Clean their bowels with an enema c. Empty their bladder-patient safety to prevent puncture, full bladder can displace and become punctured d. Take ordered pain medicine 15. A nurse was monitoring a patient who is 72 hours post-op from surgery. Which finding requires intervention? a. A pain rating of 2 on a scale of 1-10 b. Blood pressure of 130/90 c. Temperature of 100.8-cutoff temperature is 100.4 d. The patient is thirsty 16. A patient who is post-op from an abdominal surgery calls his nurse and asks her to come immediately. Upon arrival, you see that some of his internal organs are protruding through his incision. What is nursing intervention would you do FIRST? a. notify the provider