Med Surg Final HESI TEST BANK WITH
VERIFIED ANSWERS GRADED A+
A client with a productive cough has obtained a sputum specimen for
culture as instructed. What is the best initial nursing action?
A. Administer the first dose of antibiotic therapy
B. Observe the color, consistency, and amount of sputum
C. Encourage the client to consume plenty of warm liquids
D. Send the specimen to the lab for analysis - B. Observe the color,
consistency, and amount of sputum
A client is brought to the ED by ambulance in cardiac arrest with
cardiopulmonary resuscitation (CPR) in progress. The client is intubated
and is receiving 100% oxygen per self-inflating (ambu) bag. The nurse
determines that the client is cyanotic, cold, and diaphoretic. Which
assessment is most important for the nurse to obtain?
A. Breath sounds over bilateral lung fields.
B. Carotid pulsation during compressions
C. Deep tendon reflexes
D. Core body temperature - A. Breath sounds over bilateral lung fields.
After a hospitalization for Syndrome of Inappropriate Antidiuretic
Hormone (SIADH), a client develops pontine myselinolysis. Which
intervention should the nurse implement first?
A. Reorient client to his room
B. Place a patch on one eye
C. Evaluate client's ability to swallow
D. Perform range of motion exercises - A. Reorient client to his room
A male client with heart failure (HF) calls the clinic and reports that he
cannot put his shoes on because they are too tight. Which additional
information should the nurse obtain?
,A. What time did he take his last medications?
B. Has his weight changed in the last several days?
C. Is he still able to tighten his belt buckle?
D. How many hours did he sleep last night? - B. Has his weight changed in
the last several days?
An older adult woman with a long history of chronic obstructive
pulmonary disease (COPD) is admitted with progressive shortness of
breath and a persistent cough. She is anxious and is complaining of a dry
mouth. Which intervention should the nurse implement?
A. Administer a prescribed sedative
B. Encourage client to drink water
C. Apply a high-flow venturi mask
D. Assist her to an upright position - D. Assist her to an upright position
A client with a history of asthma and bronchitis arrives at the clinic with
shortness of breath, productive cough with thickened tenacious mucous,
and the inability to walk up a flight of stairs without experiencing
breathlessness. Which action is most important for the nurse to instruct
the client about self-care?
A. Increase the daily intake of oral fluids to liquefy secretions
B. Avoid crowded enclosed areas to reduce pathogen exposure
C. Call the clinic if undesirable side effects of mediations occur
D. Teach anxiety reduction methods for feelings of suffocation - A.
Increase the daily intake of oral fluids to liquefy secretions
A cardiac catherterization of a client with heart disease indicates the
following blockages: 95% proximal left anterior descending (LAD), 99%
proximal circumflex, and ? % proximal right coronary artery (RCA). The
client later asks the nurse "what does all this mean for me?" What
information should the nurse provide?
A. Blood supply to the heart is diminished by artherosclerotic lesions,
which necessitate lifestyle changes.
,B. Blood vessels supplying the pumping chamber have blockages
indicating a past heart attack.
C. Three main arteries have major blockages, with only 1 to 5% of blood
flow getting through to the heart muscle.
D. The heart is not receiving enough blood, so there is a risk of heart
failure and fluid retention. - C. Three main arteries have major blockages,
with only 1 to 5% of blood flow getting through to the heart muscle.
A client who weighs 175 pounds is receiving IV bolus dose of heparin 80
units/kg. The heparin is available in a 2 ml vial, labeled 10,000 units/ml.
How many ml should the nurse administer? (Enter numeric value only. If
rounding is required, round to the nearest tenth.) - 0.6 ml
What information should the nurse include in the teaching plan of a client
diagnosed with gastroesophageal reflux disease (GERD)?
A. Sleep without pillows at night to maintain neck alignment.
B. Adjust food intake to three full meals per day and no snacks.
C. Minimize symptoms by wearing loose, comfortable clothing
D. Avoid participation in any aerobic exercise programs - C. Minimize
symptoms by wearing loose, comfortable clothing
The nurse is caring for a client with a lower left lobe pulmonary abscess.
Which position should the nurse instruct the client to maintain?
A. left lateral
B. Supine, knees flexed
C. Dorsal recumbent
D. Knee-chest - A. left lateral
A client with cholelithiasis has a gallstone lodged in the common bile duct
and is unable to eat or drink without becoming nauseated and vomiting.
Which finding should the nurse report to the healthcare provider.
A. Belching
B. Amber urine
C. Yellow sclera
D. Flatulence - C. Yellow sclera
, While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the
nurse performs a neurological assessment every four hours. Which
assessment finding warrants immediate intervention by the nurse?
A. Inappropriate laughter
B. Increasing anxiety
C. Weakened cough effort
D. Asymmetrical weakness - C. Weakened cough effort
The nurse is providing preoperative education for a Jewish client
scheduled to receive a xenograft graft to promote burn healing. Which
information should the nurse provide this client?
A. Grafting increases the risk for bacterial infections
B. The xenograft is taken from nonhuman sources
C. Grafts are later removed by a debriding procedure
D. As the burn heals, the graft permanently attaches - B. The xenograft is
taken from nonhuman sources
A male client who had colon surgery 3 days ago is anxious and requesting
assistance to reposition. While the nurse is turning him, the wound
dehiscences and eviscerates. The nurse moistens an available sterile
dressing and places it over the wound. What intervention should the nurse
implement next?
A. Bring additional sterile dressing supplies to the room
B. Prepare the client to return to the operating room
C. Obtain a sample of the drainage to send to the lab
D. Auscultate the abdomen for bowel sound activity - B. Prepare the client
to return to the operating room
A client with carcinoma of the lung is complaining of weakness and has a
serum sodium level of 117 mEq/L. Which nursing problem should the nurse
include in this client's plan of care?
A. Altered urinary elimination
B. Impaired gas exchange
VERIFIED ANSWERS GRADED A+
A client with a productive cough has obtained a sputum specimen for
culture as instructed. What is the best initial nursing action?
A. Administer the first dose of antibiotic therapy
B. Observe the color, consistency, and amount of sputum
C. Encourage the client to consume plenty of warm liquids
D. Send the specimen to the lab for analysis - B. Observe the color,
consistency, and amount of sputum
A client is brought to the ED by ambulance in cardiac arrest with
cardiopulmonary resuscitation (CPR) in progress. The client is intubated
and is receiving 100% oxygen per self-inflating (ambu) bag. The nurse
determines that the client is cyanotic, cold, and diaphoretic. Which
assessment is most important for the nurse to obtain?
A. Breath sounds over bilateral lung fields.
B. Carotid pulsation during compressions
C. Deep tendon reflexes
D. Core body temperature - A. Breath sounds over bilateral lung fields.
After a hospitalization for Syndrome of Inappropriate Antidiuretic
Hormone (SIADH), a client develops pontine myselinolysis. Which
intervention should the nurse implement first?
A. Reorient client to his room
B. Place a patch on one eye
C. Evaluate client's ability to swallow
D. Perform range of motion exercises - A. Reorient client to his room
A male client with heart failure (HF) calls the clinic and reports that he
cannot put his shoes on because they are too tight. Which additional
information should the nurse obtain?
,A. What time did he take his last medications?
B. Has his weight changed in the last several days?
C. Is he still able to tighten his belt buckle?
D. How many hours did he sleep last night? - B. Has his weight changed in
the last several days?
An older adult woman with a long history of chronic obstructive
pulmonary disease (COPD) is admitted with progressive shortness of
breath and a persistent cough. She is anxious and is complaining of a dry
mouth. Which intervention should the nurse implement?
A. Administer a prescribed sedative
B. Encourage client to drink water
C. Apply a high-flow venturi mask
D. Assist her to an upright position - D. Assist her to an upright position
A client with a history of asthma and bronchitis arrives at the clinic with
shortness of breath, productive cough with thickened tenacious mucous,
and the inability to walk up a flight of stairs without experiencing
breathlessness. Which action is most important for the nurse to instruct
the client about self-care?
A. Increase the daily intake of oral fluids to liquefy secretions
B. Avoid crowded enclosed areas to reduce pathogen exposure
C. Call the clinic if undesirable side effects of mediations occur
D. Teach anxiety reduction methods for feelings of suffocation - A.
Increase the daily intake of oral fluids to liquefy secretions
A cardiac catherterization of a client with heart disease indicates the
following blockages: 95% proximal left anterior descending (LAD), 99%
proximal circumflex, and ? % proximal right coronary artery (RCA). The
client later asks the nurse "what does all this mean for me?" What
information should the nurse provide?
A. Blood supply to the heart is diminished by artherosclerotic lesions,
which necessitate lifestyle changes.
,B. Blood vessels supplying the pumping chamber have blockages
indicating a past heart attack.
C. Three main arteries have major blockages, with only 1 to 5% of blood
flow getting through to the heart muscle.
D. The heart is not receiving enough blood, so there is a risk of heart
failure and fluid retention. - C. Three main arteries have major blockages,
with only 1 to 5% of blood flow getting through to the heart muscle.
A client who weighs 175 pounds is receiving IV bolus dose of heparin 80
units/kg. The heparin is available in a 2 ml vial, labeled 10,000 units/ml.
How many ml should the nurse administer? (Enter numeric value only. If
rounding is required, round to the nearest tenth.) - 0.6 ml
What information should the nurse include in the teaching plan of a client
diagnosed with gastroesophageal reflux disease (GERD)?
A. Sleep without pillows at night to maintain neck alignment.
B. Adjust food intake to three full meals per day and no snacks.
C. Minimize symptoms by wearing loose, comfortable clothing
D. Avoid participation in any aerobic exercise programs - C. Minimize
symptoms by wearing loose, comfortable clothing
The nurse is caring for a client with a lower left lobe pulmonary abscess.
Which position should the nurse instruct the client to maintain?
A. left lateral
B. Supine, knees flexed
C. Dorsal recumbent
D. Knee-chest - A. left lateral
A client with cholelithiasis has a gallstone lodged in the common bile duct
and is unable to eat or drink without becoming nauseated and vomiting.
Which finding should the nurse report to the healthcare provider.
A. Belching
B. Amber urine
C. Yellow sclera
D. Flatulence - C. Yellow sclera
, While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the
nurse performs a neurological assessment every four hours. Which
assessment finding warrants immediate intervention by the nurse?
A. Inappropriate laughter
B. Increasing anxiety
C. Weakened cough effort
D. Asymmetrical weakness - C. Weakened cough effort
The nurse is providing preoperative education for a Jewish client
scheduled to receive a xenograft graft to promote burn healing. Which
information should the nurse provide this client?
A. Grafting increases the risk for bacterial infections
B. The xenograft is taken from nonhuman sources
C. Grafts are later removed by a debriding procedure
D. As the burn heals, the graft permanently attaches - B. The xenograft is
taken from nonhuman sources
A male client who had colon surgery 3 days ago is anxious and requesting
assistance to reposition. While the nurse is turning him, the wound
dehiscences and eviscerates. The nurse moistens an available sterile
dressing and places it over the wound. What intervention should the nurse
implement next?
A. Bring additional sterile dressing supplies to the room
B. Prepare the client to return to the operating room
C. Obtain a sample of the drainage to send to the lab
D. Auscultate the abdomen for bowel sound activity - B. Prepare the client
to return to the operating room
A client with carcinoma of the lung is complaining of weakness and has a
serum sodium level of 117 mEq/L. Which nursing problem should the nurse
include in this client's plan of care?
A. Altered urinary elimination
B. Impaired gas exchange
