Med Surg Exam 2023 (2) - HESI Questions And Answers Graded A

1. A client is admitted to the hospital with symptoms consistent with right hemisphere stroke. With Neurovascular assessment requires immediate intervention by the nurse? A. Pupillary changes to ipsilateral dilation B. Orientation to person and place only. C. Left Sided Facial dropping and dysphagia D. Unequal bilateral hand grip strengths 2. Achieve maximum mobility and independence for a client multiple sclerosis (MS). Which intervention is most important for the nurse to implement? A. Provide a walker for ambulation B. Frequently assist client to the bathroom C. Apply alternating patches over the eyes 3. The Nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendations should the nurse recommend the client to follow? A. Limit oral Fluid intake to 500 mL per day C. Increase intake of potassium-rich foods such as bananas or cantaloupe D. Increase intake of high fiber foods, such as bran cereal. 4. The nurse Is caring for a client with herpes zoster who reports painful blisters that align from the back along the chest curvature to the anterior chest. Which intervention is the highest priority for the nurse? B. Administer antiviral medication C. Place wet compresses to ruptured vesicles D. Administer narcotic analgesics 5. A young adult who suffered a severe brain injury in an automobile collision has been mechanically ventilated for the past three days and has no spontaneous respiratory effort. After serial electroencephalograms (EEG) reveal no brain activity, the healthcare provider discusses end-of-life options with family who agree to discontinue life support. Which intervention should the nurse implement? A. Ask the family if they wish would remain at bedside during withdrawal B. Request a living will be placed in the client's medical record D. Turn off the mechanical ventilator and note the time of death 1 6. Following a transurethral resection of the prostate (TURP), a client is discharged from the hospital with an indwelling urinary catheter. Which instruction is most important for the nurse to include in the discharge teaching plan? A. Eliminate all the spicy food from your diet C. Clamp the catheter when taking a shower D. Avoid driving a car for 2 weeks 7. On the first postoperative day, the nurse finds an older male client disoriented and trying to climb over the bed railing. Previously he was oriented to person, place, and time on admission. Which intervention should the nurse implement first? A. Apply wrist restraints B. Determine the clients blood pressure C. Administer a mild sedative 8. Acute soft-tissue injuries (I.e. sprains, strains) provide the nurse with a variety of teaching opportunities. Which instruction should the nurse provide to a client with a soft-tissue injury? A. Watch for shortness of breath which may indicate a fat embolus B. Begin range of motion exercises within the first 24 hours D. After edema subsides, apply heat continuously 9. A male client is admitted to the rehabilitation unit following a cerebrovascular (CVA), which resulted in paralysis of his right arm. When the nurse enters the room, he is struggling to put on a shirt, and he curses at the nurse. What is the best response from the nurse? A. “We will give you a class on dressing tomorrow” B. This unit has a policy against staff harassment D. “It is important to dress the right arm first” 10. A client returns to unit following a craniotomy for removal of brain tumor and is obtunded but arouses to painful stimuli. Which assessment is most important for the nurse to obtain? A. Drainage on dressing C. Body temperature D. Serial blood pressure and pulse 11. An older client who is agitated, dyspneic, orthopneic, and using accessory muscle to breathe is admitted for further treatment. Initial assessment indicates beats/minute and irregular, respirations 36 2 breaths/minute, blood pressure 168/100 mmHg. Wheezes and crackles in all lung fields. An hour after the administered mg IV, which assessment should the nurse obtain to determine the client's response to treatment? (Select all that apply) A. Skin B. Pain scale D. Urinary output 12. The nurse is caring for an older male client with impaired skin integrity to sheering forces and pressure that is manifested as a draining stage 3 sacral ulcer. Which intervention is most important for the nurse to implement? A. Teach the family how to perform wound care C. Ensure that IV fluids are administered as prescribed D. Daily Range of motion exercise 13. While planning care for a client with carpal tunnel syndrome. The nurse identifies a collaborative problem of pain. What is the etiology of this problem? B. Diminished blood flow C. Ischemic tissue changes D. Irritation of nerve endings 14. A young adult female visits the clinic for primary dysmenorrhea and tells the nurse that she started taking a calcium supplement to reduce her menstrual cramps. But I quit taking calcium because it caused constipation. The client to know what she does to relive her menstrual cramps. Which action should the nurse implement first to address the client's concern? A. Encourage client to increase her dietary intake fiber B. Question the client about her use of birth control pills D. Determine if she takes any over-the-counter analgesics 15. A client with a medical diagnosis of a ruptured cerebral aneurysm exhibits these symptoms no eye opening, no sound vocalized, and flexion to pain (decorticate posturing). When calculating the Glasgow Coma Scale score, Which value should the nurse document for this client? A. 13 B. 9 3 C. 3 16. A client with acute myelogenic leukemia (AML) is admitted to chemotherapy (CT) using cytarabine and the antitumor daunorubion . Which measures are most important for the nurse to implement during the induction stage of chemotherapy? A. Assessment for graft versus host disease C. Administration of whole blood product D. Scheduling of outpatient maintenance therapy 17. To reduce pulmonary complications for a client with Amyotrophic Lateral sclerosis (ALS). Which intervention should the nurse implement? (Select all that apply) A. Perform chest physiotherapy B. Establish a regular bladder routine 18. A client with polycystic Kidney is admitted because of an abrupt onset of massive polyuria. The client is pale, tachycardia and female. Which serum laboratory finding requires immediate intervention by the nurse? B. Glucose 110 mg/dL C. Calcium 9 mg/dL D. HCO3 25 mEq/L 19. A client tells the nurse, “I just received good news about my tumor, I have a neoplasm, but it is benign.”. How should the nurse respond? A. Inform the healthcare provider that the client does not understand the test results C. Reinforce the clients joy and clarify the typical use of the team “neoplasm” D. Explain to the client the seriousness of having neoplastic disease.