HESI Med Surg :Practice Exam: HESI Med Surg:NCLEX (HESI Med Surg Exam:HESI
Med Surg V1 ,HESI Med Surg V2 Exam:HESI MED-SURG Exam Test Bank:HESI
Med Surg Practice Exam
The nurse is assisting a client out of bed for the first time after surgery. What action should the nurse do
first? - ANSWER:Allow the client to sit with the bed in a high Fowler's position.
Rationale
The first step is to raise the head of the bed to a high Fowler's position, which allow venous return to
compensate from lying flat and the vasodilation effects of perioperative drugs. This helps prevent the
client from becoming light-headed and decreases the chance of a client fall.
After the fourth dose of gentamicin sulfate (Garamycin) IV, the nurse plans to draw blood samples to
determine peak and trough levels. When are the best times to draw these samples? - ANSWER:5
minutes before and 30 minutes after the next dose.
Rationale
Peak drug serum levels are achieved 30 minutes after the completion of the IV infusion of gentamicin
sulfate. The best time to draw a trough is the closest time to the next administration.
In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the laboratory test
results to indicate an increased serum level of which substance? - ANSWER:Sodium.
Rationale
Clients with primary aldosteronism exhibit an increase in serum sodium levels (hypernatremia) and have
profound decline in the serum levels of potassium (hypokalemia)--hypertension is the most prominent
and universal sign. Antidiuretic hormone is decreased with diabetes insipidus. Glucose is not affected by
primary aldosteronism.
Which milestone indicates to the nurse successful achievement of young adulthood? -
ANSWER:Completes education and becomes self-supporting.
Rationale
,Transitioning through young adulthood is characterized by establishing independence as an adult, and
includes developmental tasks such as completing education, beginning a career, and becoming self-
supporting (B). (A and C) are characteristic of adolescence. Although strong bonds with parents are an
expected finding for this age group, the need for support and approval (D) indicates dependency, which
is a developmental delay.
The nurse is assessing a client who smokes cigarettes and has been diagnosed with emphysema. Which
finding would the nurse expect this client to exhibit? - ANSWER:Normal skin coloring.
Rationale
The differentiation between the "pink puffer" and the "blue bloater" is a well-known method of
differentiating clients exhibiting symptoms of emphysema (normal color but puffing respirations) from
those exhibiting symptoms of chronic bronchitis (edematous, cyanotic, shallow respirations).
A male client who smokes two packs of cigarettes a day states he understands that smoking cigarettes is
contributing to the difficulty that he and his wife are having in getting pregnant and wants to know if
other factors could be contributing to their difficulty. What information is best for the nurse to provide?
(Select all that apply.) - ANSWER:Alcohol consumption can cause erectile dysfunction.
Low testosterone levels affect sperm production.
Cessation of smoking improves general health and fertility.
Rationale
Use of tobacco, alcohol, and marijuana may affect sperm counts. Sperm count is also negatively affected
by low testerone levels and obesity.
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? -
ANSWER:Shock the client with 200 joules per hospital policy.
Rationale
The client must be externally shocked 200 joules per hospital policy to restore an effective cardiac
rhythm. The automatic defibrillator is obviously malfunctioning.
What is the correct procedure for performing an opthalmoscopic examination on a client's right retina? -
ANSWER:From a distance of 12 to 15 inches and slightly to the side, shine the light into the client's pupil.
,Rationale
The client should focus on a distant object behind the examiner who should stand at 12-15 inches away
and to the side of his/her line of vision. The examiner should hold the ophthalmoscope firmly against
his/her face and then direct it at the client's pupil.
During lung assessment, the nurse places a stethoscope on a client's chest and instructs him/her to say
"99" each time the chest is touched with the stethoscope. What would be the correct interpretation if
the nurse hears the spoken words "99" very clearly through the stethoscope? - ANSWER:May indicate
pneumonia.
Rationale
This test (whispered pectoriloquy) demonstrates hyperresonance and helps determine the clarity with
which spoken words are heard upon auscultation. Normally, the spoken word is not well transmitted
through lung tissue, and is heard as a muffled or unclear transmission of the spoken word. Increased
clarity of a spoken word is indicative of some sort of consolidation process (e. g., tumor, pneumonia),
and is not a normal finding.
In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the laboratory test
results to indicate a decreased serum level of which substance? - ANSWER:Potassium.
Rationale
Clients with primary hyperaldosteronism exhibit a profound decline in the serum levels of potassium
(hypokalemia). Hypertension, along with the hypokalemia are the most prominent and universal signs
for this condition. If both of these findings are present, there is 50% likelihood the client to be diagnosed
with hyperaldosteronism.
When teaching diaphragmatic breathing to a client with chronic obstructive pulmonary disease (COPD),
which information should the nurse provide? - ANSWER:Place a small book or magazine on the abdomen
and make it rise while inhaling deeply.
Rationale
Diaphragmatic or abdominal breathing uses the diaphragm instead of accessory muscles to achieve
maximum inhalation and to slow the respiratory rate. The client should protrude the abdomen on
, inhalation and contract it with exhalation, so placing a book or magazine, helps the client visualize the
rise and fall of the abdomen.
A female client taking oral contraceptives reports to the nurse that she is experiencing calf pain. What
action should the nurse implement? - ANSWER:Advise the client to notify the healthcare provider for
immediate medical attention.
Rationale
Calf pain is indicative of thrombophlebitis, a serious, life-threatening complication associated with the
use of oral contraceptives which requires further assessment and possibly immediate medical
intervention.
The nurse is providing dietary instructions to a 68-year-old client who is at high risk for development of
coronary heart disease (CHD). Which information should the nurse include? - ANSWER:Increase intake of
soluble fiber to 10 to 25 grams per day.
Rationale
To reduce risk factors associated with coronary heart disease, the daily intake of soluble fiber should be
increased to between 10 and 25 gm. According to the American Heart Association, soluble fibers helps
reduce the LDL cholesterol levels.
A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which assessment
finding should the nurse expect this client to exhibit? - ANSWER:Lower left quadrant pain and a low-
grade fever.
Rationale
Left lower quadrant pain occurs with diverticulitis because the sigmoid colon is the most common area
for diverticula, and the inflammation of diverticula causes a low-grade fever.
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? -
ANSWER:Willingness of the client to learn the injection sites.
Rationale
Med Surg V1 ,HESI Med Surg V2 Exam:HESI MED-SURG Exam Test Bank:HESI
Med Surg Practice Exam
The nurse is assisting a client out of bed for the first time after surgery. What action should the nurse do
first? - ANSWER:Allow the client to sit with the bed in a high Fowler's position.
Rationale
The first step is to raise the head of the bed to a high Fowler's position, which allow venous return to
compensate from lying flat and the vasodilation effects of perioperative drugs. This helps prevent the
client from becoming light-headed and decreases the chance of a client fall.
After the fourth dose of gentamicin sulfate (Garamycin) IV, the nurse plans to draw blood samples to
determine peak and trough levels. When are the best times to draw these samples? - ANSWER:5
minutes before and 30 minutes after the next dose.
Rationale
Peak drug serum levels are achieved 30 minutes after the completion of the IV infusion of gentamicin
sulfate. The best time to draw a trough is the closest time to the next administration.
In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the laboratory test
results to indicate an increased serum level of which substance? - ANSWER:Sodium.
Rationale
Clients with primary aldosteronism exhibit an increase in serum sodium levels (hypernatremia) and have
profound decline in the serum levels of potassium (hypokalemia)--hypertension is the most prominent
and universal sign. Antidiuretic hormone is decreased with diabetes insipidus. Glucose is not affected by
primary aldosteronism.
Which milestone indicates to the nurse successful achievement of young adulthood? -
ANSWER:Completes education and becomes self-supporting.
Rationale
,Transitioning through young adulthood is characterized by establishing independence as an adult, and
includes developmental tasks such as completing education, beginning a career, and becoming self-
supporting (B). (A and C) are characteristic of adolescence. Although strong bonds with parents are an
expected finding for this age group, the need for support and approval (D) indicates dependency, which
is a developmental delay.
The nurse is assessing a client who smokes cigarettes and has been diagnosed with emphysema. Which
finding would the nurse expect this client to exhibit? - ANSWER:Normal skin coloring.
Rationale
The differentiation between the "pink puffer" and the "blue bloater" is a well-known method of
differentiating clients exhibiting symptoms of emphysema (normal color but puffing respirations) from
those exhibiting symptoms of chronic bronchitis (edematous, cyanotic, shallow respirations).
A male client who smokes two packs of cigarettes a day states he understands that smoking cigarettes is
contributing to the difficulty that he and his wife are having in getting pregnant and wants to know if
other factors could be contributing to their difficulty. What information is best for the nurse to provide?
(Select all that apply.) - ANSWER:Alcohol consumption can cause erectile dysfunction.
Low testosterone levels affect sperm production.
Cessation of smoking improves general health and fertility.
Rationale
Use of tobacco, alcohol, and marijuana may affect sperm counts. Sperm count is also negatively affected
by low testerone levels and obesity.
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? -
ANSWER:Shock the client with 200 joules per hospital policy.
Rationale
The client must be externally shocked 200 joules per hospital policy to restore an effective cardiac
rhythm. The automatic defibrillator is obviously malfunctioning.
What is the correct procedure for performing an opthalmoscopic examination on a client's right retina? -
ANSWER:From a distance of 12 to 15 inches and slightly to the side, shine the light into the client's pupil.
,Rationale
The client should focus on a distant object behind the examiner who should stand at 12-15 inches away
and to the side of his/her line of vision. The examiner should hold the ophthalmoscope firmly against
his/her face and then direct it at the client's pupil.
During lung assessment, the nurse places a stethoscope on a client's chest and instructs him/her to say
"99" each time the chest is touched with the stethoscope. What would be the correct interpretation if
the nurse hears the spoken words "99" very clearly through the stethoscope? - ANSWER:May indicate
pneumonia.
Rationale
This test (whispered pectoriloquy) demonstrates hyperresonance and helps determine the clarity with
which spoken words are heard upon auscultation. Normally, the spoken word is not well transmitted
through lung tissue, and is heard as a muffled or unclear transmission of the spoken word. Increased
clarity of a spoken word is indicative of some sort of consolidation process (e. g., tumor, pneumonia),
and is not a normal finding.
In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the laboratory test
results to indicate a decreased serum level of which substance? - ANSWER:Potassium.
Rationale
Clients with primary hyperaldosteronism exhibit a profound decline in the serum levels of potassium
(hypokalemia). Hypertension, along with the hypokalemia are the most prominent and universal signs
for this condition. If both of these findings are present, there is 50% likelihood the client to be diagnosed
with hyperaldosteronism.
When teaching diaphragmatic breathing to a client with chronic obstructive pulmonary disease (COPD),
which information should the nurse provide? - ANSWER:Place a small book or magazine on the abdomen
and make it rise while inhaling deeply.
Rationale
Diaphragmatic or abdominal breathing uses the diaphragm instead of accessory muscles to achieve
maximum inhalation and to slow the respiratory rate. The client should protrude the abdomen on
, inhalation and contract it with exhalation, so placing a book or magazine, helps the client visualize the
rise and fall of the abdomen.
A female client taking oral contraceptives reports to the nurse that she is experiencing calf pain. What
action should the nurse implement? - ANSWER:Advise the client to notify the healthcare provider for
immediate medical attention.
Rationale
Calf pain is indicative of thrombophlebitis, a serious, life-threatening complication associated with the
use of oral contraceptives which requires further assessment and possibly immediate medical
intervention.
The nurse is providing dietary instructions to a 68-year-old client who is at high risk for development of
coronary heart disease (CHD). Which information should the nurse include? - ANSWER:Increase intake of
soluble fiber to 10 to 25 grams per day.
Rationale
To reduce risk factors associated with coronary heart disease, the daily intake of soluble fiber should be
increased to between 10 and 25 gm. According to the American Heart Association, soluble fibers helps
reduce the LDL cholesterol levels.
A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which assessment
finding should the nurse expect this client to exhibit? - ANSWER:Lower left quadrant pain and a low-
grade fever.
Rationale
Left lower quadrant pain occurs with diverticulitis because the sigmoid colon is the most common area
for diverticula, and the inflammation of diverticula causes a low-grade fever.
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? -
ANSWER:Willingness of the client to learn the injection sites.
Rationale
