HESI MED SURG V1 2022 Questions and Answers
1. 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✔✔ 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.
2. The nurse has implemented a bowel maintenance program for an un-
conscious 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✔✔ 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.
3. 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 re-
,cent intake of which medication, which is contraindicated for the
ileostomy client✔✔ 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
4. The client is complaining of skin irritation from the edges of a cast
applied the previous day. Which action should the nurse take✔✔ The
nurse petals the edges of the cast with tape
Rationale: minimize skin irritation.
5. The nurse is taking a health history for a client with
hyperparathyroidism. Which question would elicit information about this
client's condition✔✔ "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
6. 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✔✔ Hyperosmolar
hyper- glycemic 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 alter- ations, weight loss, and weakness.
7. 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✔✔ 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
1. 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✔✔ 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.
2. The nurse has implemented a bowel maintenance program for an un-
conscious 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✔✔ 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.
3. 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 re-
,cent intake of which medication, which is contraindicated for the
ileostomy client✔✔ 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
4. The client is complaining of skin irritation from the edges of a cast
applied the previous day. Which action should the nurse take✔✔ The
nurse petals the edges of the cast with tape
Rationale: minimize skin irritation.
5. The nurse is taking a health history for a client with
hyperparathyroidism. Which question would elicit information about this
client's condition✔✔ "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
6. 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✔✔ Hyperosmolar
hyper- glycemic 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 alter- ations, weight loss, and weakness.
7. 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✔✔ 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
