Med Surg Test bank Real Red
HESI Test bank Med-Surg
2024 Updated |Fully solved|
100% Accurate All correct
Answers with Explanations &
Graded A+
A client with hypertension has been receiving ramipril (Altace), 5 mg PO, daily for 2 weeks and is scheduled to
receive a dose at 0900. At 0830, the client's blood pressure is 120/70 mm Hg. Which action should the nurse take?
A.Administer the prescribed dose at the scheduled time.
B.Hold the dose and contact the health care provider.
C.Hold the dose and recheck the blood pressure in 1 hour.
D.Check the health care provider's prescription to clarify the dose.
A. Administer the prescribed dose at the scheduled time
Rationale:
The client's blood pressure is within normal limits, indicating that the ramipril, an antihypertensive, is having the
desired effect and should be administered. Options B and C would be appropriate if the client's blood pressure was
excessively low (<100 mm Hg systolic) or if the client were exhibiting signs of hypotension such as dizziness. This
prescribed dose is within the normal dosage range, as defined by the manufacturer; therefore, option D is not
necessary.
Which consideration is most important when the nurse is assigning a room for a client being admitted with
progressive systemic sclerosis (scleroderma)?
A.Provide a room that can be kept warm.
B.Make sure that the room can be kept dark.
C.Keep the client close to the nursing unit.
D.Select a room that is visible from the nurses' desk.
,Med Surg Test bank Real Red
HESI Test bank Med-Surg
2024 Updated |Fully solved|
100% Accurate All correct
Answers with Explanations &
Graded A+
A.Provide a room that can be kept warm.
Rationale:
Abnormal blood flow in response to cold (Raynaud phenomenon) is precipitated in clients with scleroderma. Option B
is not a significant factor. Stress can also precipitate the severe pain of Raynaud phenomenon, so a quiet
environment is preferred to option C, which is often very noisy. Option D is not necessary.
.
A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place. When initiating bolus
tube feedings postoperatively, when should the nurse inflate the cuff?
A.Immediately after feeding
B.Just prior to tube feeding
C.Continuous inflation is required
D.Inflation is not required
B. Just prior to tube feeding
Rationale:
The cuff should be inflated before the feeding to block the trachea and prevent food from entering if oral feedings are
started while a cuffed tracheostomy tube is in place. It should remain inflated throughout the feeding to prevent
aspiration of food into the respiratory system. Options A and D place the client at risk for aspiration. Option C places
the client at risk for tracheal wall necrosis.
,Med Surg Test bank Real Red
HESI Test bank Med-Surg
2024 Updated |Fully solved|
100% Accurate All correct
Answers with Explanations &
Graded A+
A 55-year-old male client has been admitted to the hospital with a medical diagnosis of chronic obstructive pulmonary
disease (COPD). Which risk factor is the most significant in the development of this client's COPD?
A.The client's father was diagnosed with COPD in his 50s.
B.A close family member contracted tuberculosis last year.
C.The client smokes one to two packs of cigarettes per day.
D.The client has been 40 pounds overweight for 15 years.
C. The client smokes one to two packs of cigarettes per day.
Rationale:
Smoking, considered to be a modifiable risk factor, is the most significant risk factor for the development of COPD.
The exact mechanism of genetic and hereditary implications for the development of COPD is still under investigation,
although exposure to similar predisposing factors (e.g., smoking or inhaling secondhand smoke) may increase the
likelihood of COPD incidence among family members. Options B and D do not exceed the risks associated with
cigarette smoking in the development of COPD.
A family member was taught to suction a client's tracheostomy prior to the client's discharge from the hospital. Which
observation by the nurse indicates that the family member is capable of correctly performing the suctioning
technique?
A.Turns on the continuous wall suction to 190 mm Hg.
B.Inserts the catheter until resistance or coughing occurs.
C.Withdraws the catheter while maintaining suctioning.
D.Reclears the tracheostomy after suctioning the mouth.
B. Inserts the catheter until resistance or coughing occurs.
Rationale:
, Med Surg Test bank Real Red
HESI Test bank Med-Surg
2024 Updated |Fully solved|
100% Accurate All correct
Answers with Explanations &
Graded A+
Option B indicates correct technique for performing suctioning. Suction pressure should be between 80 and 120 mm
Hg, not 190 mm Hg. The catheter should be withdrawn 1 to 2 cm at a time with intermittent, not continuous, suction.
Option D introduces pathogens unnecessarily into the tracheobronchial tree.
A 74-year-old male client is admitted to the intensive care unit (ICU) with a diagnosis of respiratory failure secondary
to pneumonia. Currently, he is ventilator-dependent, with settings of tidal volume (VT) of 750 mL and an intermittent
mandatory ventilation (IMV) rate of 10 breaths/min. Arterial blood gas (ABG) results are as follows: pH, 7.48; PaCO2,
30 mm Hg; PaO2, 64 mm Hg; HCO3, 25 mEq/L; and FiO2, 0.80. Which intervention should the nurse implement
first?
A.Increase the ventilator VT to 850 mL.
B.Decrease the ventilator IMV to a rate of 8 breaths/min.
C. Reduce the FiO2 to 0.70 and redraw ABGs.
D.Add 5 cm positive end-expiratory pressure (PEEP).
D. Add 5 cm positive end-expiratory pressure (PEEP).
Rationale:
Adding PEEP helps improve oxygenation while reducing FiO2 to a less toxic level. Options A, B, and C will not result
in improved oxygenation and could cause further complications for this client, who is experiencing respiratory failure.
The nurse is administering a nystatin suspension for stomatitis. Which instruction will the nurse provide to the client
when administering this medication?
A."Hold the medication in your mouth for a few minutes before swallowing it."
HESI Test bank Med-Surg
2024 Updated |Fully solved|
100% Accurate All correct
Answers with Explanations &
Graded A+
A client with hypertension has been receiving ramipril (Altace), 5 mg PO, daily for 2 weeks and is scheduled to
receive a dose at 0900. At 0830, the client's blood pressure is 120/70 mm Hg. Which action should the nurse take?
A.Administer the prescribed dose at the scheduled time.
B.Hold the dose and contact the health care provider.
C.Hold the dose and recheck the blood pressure in 1 hour.
D.Check the health care provider's prescription to clarify the dose.
A. Administer the prescribed dose at the scheduled time
Rationale:
The client's blood pressure is within normal limits, indicating that the ramipril, an antihypertensive, is having the
desired effect and should be administered. Options B and C would be appropriate if the client's blood pressure was
excessively low (<100 mm Hg systolic) or if the client were exhibiting signs of hypotension such as dizziness. This
prescribed dose is within the normal dosage range, as defined by the manufacturer; therefore, option D is not
necessary.
Which consideration is most important when the nurse is assigning a room for a client being admitted with
progressive systemic sclerosis (scleroderma)?
A.Provide a room that can be kept warm.
B.Make sure that the room can be kept dark.
C.Keep the client close to the nursing unit.
D.Select a room that is visible from the nurses' desk.
,Med Surg Test bank Real Red
HESI Test bank Med-Surg
2024 Updated |Fully solved|
100% Accurate All correct
Answers with Explanations &
Graded A+
A.Provide a room that can be kept warm.
Rationale:
Abnormal blood flow in response to cold (Raynaud phenomenon) is precipitated in clients with scleroderma. Option B
is not a significant factor. Stress can also precipitate the severe pain of Raynaud phenomenon, so a quiet
environment is preferred to option C, which is often very noisy. Option D is not necessary.
.
A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place. When initiating bolus
tube feedings postoperatively, when should the nurse inflate the cuff?
A.Immediately after feeding
B.Just prior to tube feeding
C.Continuous inflation is required
D.Inflation is not required
B. Just prior to tube feeding
Rationale:
The cuff should be inflated before the feeding to block the trachea and prevent food from entering if oral feedings are
started while a cuffed tracheostomy tube is in place. It should remain inflated throughout the feeding to prevent
aspiration of food into the respiratory system. Options A and D place the client at risk for aspiration. Option C places
the client at risk for tracheal wall necrosis.
,Med Surg Test bank Real Red
HESI Test bank Med-Surg
2024 Updated |Fully solved|
100% Accurate All correct
Answers with Explanations &
Graded A+
A 55-year-old male client has been admitted to the hospital with a medical diagnosis of chronic obstructive pulmonary
disease (COPD). Which risk factor is the most significant in the development of this client's COPD?
A.The client's father was diagnosed with COPD in his 50s.
B.A close family member contracted tuberculosis last year.
C.The client smokes one to two packs of cigarettes per day.
D.The client has been 40 pounds overweight for 15 years.
C. The client smokes one to two packs of cigarettes per day.
Rationale:
Smoking, considered to be a modifiable risk factor, is the most significant risk factor for the development of COPD.
The exact mechanism of genetic and hereditary implications for the development of COPD is still under investigation,
although exposure to similar predisposing factors (e.g., smoking or inhaling secondhand smoke) may increase the
likelihood of COPD incidence among family members. Options B and D do not exceed the risks associated with
cigarette smoking in the development of COPD.
A family member was taught to suction a client's tracheostomy prior to the client's discharge from the hospital. Which
observation by the nurse indicates that the family member is capable of correctly performing the suctioning
technique?
A.Turns on the continuous wall suction to 190 mm Hg.
B.Inserts the catheter until resistance or coughing occurs.
C.Withdraws the catheter while maintaining suctioning.
D.Reclears the tracheostomy after suctioning the mouth.
B. Inserts the catheter until resistance or coughing occurs.
Rationale:
, Med Surg Test bank Real Red
HESI Test bank Med-Surg
2024 Updated |Fully solved|
100% Accurate All correct
Answers with Explanations &
Graded A+
Option B indicates correct technique for performing suctioning. Suction pressure should be between 80 and 120 mm
Hg, not 190 mm Hg. The catheter should be withdrawn 1 to 2 cm at a time with intermittent, not continuous, suction.
Option D introduces pathogens unnecessarily into the tracheobronchial tree.
A 74-year-old male client is admitted to the intensive care unit (ICU) with a diagnosis of respiratory failure secondary
to pneumonia. Currently, he is ventilator-dependent, with settings of tidal volume (VT) of 750 mL and an intermittent
mandatory ventilation (IMV) rate of 10 breaths/min. Arterial blood gas (ABG) results are as follows: pH, 7.48; PaCO2,
30 mm Hg; PaO2, 64 mm Hg; HCO3, 25 mEq/L; and FiO2, 0.80. Which intervention should the nurse implement
first?
A.Increase the ventilator VT to 850 mL.
B.Decrease the ventilator IMV to a rate of 8 breaths/min.
C. Reduce the FiO2 to 0.70 and redraw ABGs.
D.Add 5 cm positive end-expiratory pressure (PEEP).
D. Add 5 cm positive end-expiratory pressure (PEEP).
Rationale:
Adding PEEP helps improve oxygenation while reducing FiO2 to a less toxic level. Options A, B, and C will not result
in improved oxygenation and could cause further complications for this client, who is experiencing respiratory failure.
The nurse is administering a nystatin suspension for stomatitis. Which instruction will the nurse provide to the client
when administering this medication?
A."Hold the medication in your mouth for a few minutes before swallowing it."
