MED-SURG HESI QUESTIONS AND ANSWERS

MEDSURG HESI QUESTIONS AND ANSWERS • 1 Which milestone indicates to the nurse successful achievement of young adulthood? • Demonstrates a conceptualization of death and dying. • Completes education and becomes self-supporting. Correct • Creates a new definition of self and roles with others. • Develops a strong need for parental support and approval. • 2.ID: The nurse working on a telemetry unit finds a client unconscious and in pulseless ventricular tachycardia (VT). The client has an implanted automatic defibrillator. What action should the nurse implement? • Prepare the client for transcutaneous pacemaker. • Shock the client with 200 joules per hospital policy. Correct • Use a magnet to deactivate the implanted pacemaker. • Observe the monitor until the onset of ventricular fibrillation. • 3.ID: How should the nurse position the electrodes for modified chest lead one (MCL I) telemetry monitoring? • Positive polarity right shoulder, negative polarity left shoulder, ground left chest nipple line. • Positive polarity left shoulder, negative polarity right chest nipple line, ground left chest nipple line. • Positive polarity right chest nipple line, negative polarity left chest nipple line, ground left shoulder. • Negative polarity left shoulder, positive polarity right chest nipple line, ground left chest nipple line. Correct • 4.ID: Based on the analysis of the client's atrial fibrillation, the nurse should prepare the client for which treatment protocol? • Diuretic therapy. • Pacemaker implantation. • Anticoagulation therapy. Correct • Cardiac catheterization. • 5.ID: In preparing to administer intravenous albumin to a client following surgery, what is the priority nursing intervention? (Select all that apply.) • Set the infusion pump to infuse the albumin within four hours. Correct • Compare the client's blood type with the label on the albumin. • Assign a UAP to monitor blood pressure q15 minutes. • Administer through a large gauge catheter. Correct • Monitor hemoglobin and hematocrit levels. Correct • Assess for increased bleeding after administration. Correct • 6.ID: A client who has heart failure is admitted with a serum potassium level of 2.9 mEq/L. Which action is most important for the nurse to implement? • Give 20 mEq of potassium chloride. • Initiate continuous cardiac monitoring. Correct • Arrange a consultation with the dietician. • Teach about the side effects of diuretics. • 7.ID: The nurse is teaching a female client about the best time to plan sexual intercourse in order to conceive. Which information should the nurse provide? • Two weeks before menstruation. Correct • Vaginal mucous discharge is thick. • Low basal temperature. • First thing in the morning. • 8.ID: A 49-year-old female client arrives at the clinic for an annual exam and asks the nurse why she becomes excessively diaphoretic and feels warm during nighttime. What is the nurse’s best response? • Explain the effect of the follicle-stimulating and luteinizing hormones. • Discuss perimenopause and related comfort measures. Correct • Assess lung fields and for a cough productive of blood-tinged mucous. • Ask if a fever above 101º F has occurred in the last 24 hours. • 9.ID: Which client should the nurse recognize as most likely to experience sleep apnea? • Middle-aged female who takes a diuretic nightly. • Obese older male client with a short, thick neck. Correct • Adolescent female with a history of tonsillectomy. • School-aged male with a history of hyperactivity disorder. • 10.ID: The nurse is planning care for a client with newly diagnosed diabetes mellitus that requires insulin. Which assessment should the nurse identify before beginning the teaching session? • Present knowledge related to the skill of injection. • Intelligence and developmental level of the client. • Willingness of the client to learn the injection sites. Correct • Financial resources available for the equipment. • 11.ID: The nurse is assessing a client's laboratory values following administration of chemotherapy. Which lab value leads the nurse to suspect that the client is experiencing tumor lysis syndrome (TLS)? • Serum PTT of 10 seconds. • Serum calcium of 5 mg/dl. Correct • Oxygen saturation of 90%. • Hemoglobin of 10 g/dl. • 12.ID: During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. What action should the nurse take first? • Use a laryngoscope to check for a foreign body lodged in the esophagus. • Reposition the head to validate that the head is in the proper position to open the airway. Correct • Turn the client to the side and administer three back blows. • Perform a finger sweep of the mouth to remove any vomitus. • 13.ID: A client has undergone insertion of a permanent pacemaker. When developing a discharge teaching plan, the nurse writes a goal of, "The client will verbalize symptoms of pacemaker failure." Which symptoms are most important to teach the client? • Facial flushing. • Fever. • Pounding headache. • Feelings of dizziness. Correct • 14.ID: A client with heart disease is on a continuous telemetry monitor and has developed sinus bradycardia. In determining the possible cause of the bradycardia, the nurse assesses the client's medication record. Which medication is most likely the cause of the bradycardia? • Propanolol (Inderal). Correct • Captopril (Capoten). • Furosemide (Lasix). • Dobutamine (Dobutrex). • 15.ID: A middle-aged male client with diabetes continues to eat an abundance of foods that are high in sugar and fat. According to the Health Belief Model, which event is most likely to increase the client's willingness to become compliant with the prescribed diet? • He visits his diabetic brother who just had surgery to amputate an infected foot. Correct • He is provided with the most current information about the dangers of untreated diabetes. • He comments on the community service announcements about preventing complications associated with diabetes. • His wife expresses a sincere willingness to prepare meals that are within his prescribed diet. • 16.ID: A female client receiving IV vasopressin (Pitressin) for esophageal varice rupture reports to the nurse that she feels substernal tightness and pressure across her chest. Which PRN protocol should the nurse initiate? • Start an IV nitroglycerin infusion. Correct • Nasogastric lavage with cool saline. • Increase the vasopressin infusion. • Prepare for endotracheal intubation. • 17.ID: The nurse is interviewing a male client with hypertension. Which additional medical diagnosis in the client's history presents the greatest risk for developing a cerebral vascular accident (CVA)? • Diabetes mellitus. Correct • Hypothyroidism. • Parkinson's disease. • Recurring pneumonia. • 18.ID: The nurse is assessing a client with bacterial meningitis. Which assessment finding indicates the client may have developed septic emboli? • Cyanosis of the fingertips. Correct • Bradycardia and bradypnea. • Presence of S3 and S4 heart sounds. • 3+ pitting edema of the lower extremities. • 19.ID: A client with multiple sclerosis has experienced an exacerbation of symptoms, including paresthesias, diplopia, and nystagmus. Which instruction should the nurse provide? • Stay out of direct sunlight. • Restrict intake of high protein foods. • Schedule extra rest periods. Correct • Go to the emergency room immediately. • 20.ID: A client has been taking oral corticosteroids for the past five days because of seasonal allergies. Which assessment finding is of most concern to the nurse? • White blood count of 10,000 mm3. • Serum glucose of 115 mg/dl. • Purulent sputum. Correct • Excessive hunger. • 21.ID: The healthcare provider prescribes aluminum and magnesium hydroxide (Maalox), 1 tablet PO PRN, for a client with chronic renal failure who is complaining of indigestion. What intervention should the nurse implement? • Administer 30 minutes before eating. • Evaluate the effectiveness 1 hour after administration. • Instruct the client to swallow the tablet whole. • Question the healthcare provider's prescription. Correct • 22.ID: A female client taking oral contraceptives reports to the nurse that she is experiencing calf pain. What action should the nurse implement? • Determine if the client has also experienced breast tenderness and weight gain. • Encourage the client to begin a regular, daily program of walking and exercise. • Advise the client to notify the healthcare provider for immediate medical attention. Correct • Tell the client to stop taking the medication for a week to see if symptoms subside. • 23.ID: The nurse is preparing a teaching plan for a client who is newly diagnosed with Type 1 diabetes mellitus. Which signs and symptoms should the nurse describe when teaching the client about hypoglycemia? • Sweating, trembling, tachycardia. Correct • Polyuria, polydipsia, polyphagia. • Nausea, vomiting, anorexia. • Fruity breath, tachypnea, chest pain. • 24.ID: A client who is receiving chemotherapy asks the nurse, "Why is so much of my hair falling out each day?" Which response by the nurse best explains the reason for alopecia? • Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant. Correct • Alopecia is a common side effect you will experience during long-term steroid therapy. • Your hair will grow back completely after your course of chemotherapy is completed. • The chemotherapy causes permanent alterations in your hair follicles that lead to hair loss. • 25.ID: A client receiving cholestyramine (Questran) for hyperlipidemia should be evaluated for what vitamin deficiency? • K. Correct • B12. • B6. • C. • 26.ID: