MED SURG RN HESI EXIT VERSION 5 2023-
2024 ACTUAL EXAM COMPLETE QUESTIONS
AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS )
A client with a productive cough has obtained a sputum specimen for culture as instructed. What is
the best initial nursing action? - ANSWERS,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? - ANSWERS,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? -
ANSWERS,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? - ANSWERS,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? - ANSWERS,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? - ANSWERS,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
1
,should the nurse provide? - ANSWERS,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.) - ANSWERS,0.6 ml
What information should the nurse include in the teaching plan of a client diagnosed with
gastroesophageal reflux disease (GERD)? - ANSWERS,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? - ANSWERS,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. - ANSWERS,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? - ANSWERS,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? -
ANSWERS,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? - ANSWERS,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? -
ANSWERS,Fluid volume excess
2
, A female client enters the clinic and insists on being seen. She is weak, nervous, and reports a racing
heart beat and recent weight loss of 15 pounds. After ruling out substance withdrawal, the
healthcare provider suspects hyperthyroidism and admits her for further testing. Which action
should the nurse implement? - ANSWERS,Space the client's care to provide periods of rest
The nurse is teaching a client with glomerulonephritis about self-care. Which dietary
recommendations should the nurse encourage the client to follow? - ANSWERS,Restrict protein
intake by limiting meats and other high-protein foods
An overweight, young adult made who was recently diagnosed with type 2 diabetes mellitus is
admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions
should the nurse implement? (Select all that apply.) - ANSWERS,Check his fingerstick glucose level.
Assess his skin temperature and moisture.
Measure his pulse and blood pressure.
A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which
assessment finding warrants immediate intervention by the nurse? - ANSWERS,Irregular apical
pulse
An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her
fingers. After warming her hands, the fingers turn red and the client reports a burning sensation.
What action should the nurse take? - ANSWERS,Continue to monitor the fingers until color returns
to normal
A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His
right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath
sounds. Vital signs are temperature 101F, heart rate 128 beats/minute, respirations 28
breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to
implement first? - ANSWERS,Administer PRN oral antipyretic
The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic
cholecystectomy under general anesthesia. Which finding warrants notification of the healthcare
provider prior to proceeding with the scheduled procedure? - ANSWERS,The client's blood pressure
reading is 184/88 mm Hg
3
2024 ACTUAL EXAM COMPLETE QUESTIONS
AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS )
A client with a productive cough has obtained a sputum specimen for culture as instructed. What is
the best initial nursing action? - ANSWERS,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? - ANSWERS,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? -
ANSWERS,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? - ANSWERS,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? - ANSWERS,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? - ANSWERS,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
1
,should the nurse provide? - ANSWERS,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.) - ANSWERS,0.6 ml
What information should the nurse include in the teaching plan of a client diagnosed with
gastroesophageal reflux disease (GERD)? - ANSWERS,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? - ANSWERS,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. - ANSWERS,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? - ANSWERS,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? -
ANSWERS,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? - ANSWERS,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? -
ANSWERS,Fluid volume excess
2
, A female client enters the clinic and insists on being seen. She is weak, nervous, and reports a racing
heart beat and recent weight loss of 15 pounds. After ruling out substance withdrawal, the
healthcare provider suspects hyperthyroidism and admits her for further testing. Which action
should the nurse implement? - ANSWERS,Space the client's care to provide periods of rest
The nurse is teaching a client with glomerulonephritis about self-care. Which dietary
recommendations should the nurse encourage the client to follow? - ANSWERS,Restrict protein
intake by limiting meats and other high-protein foods
An overweight, young adult made who was recently diagnosed with type 2 diabetes mellitus is
admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions
should the nurse implement? (Select all that apply.) - ANSWERS,Check his fingerstick glucose level.
Assess his skin temperature and moisture.
Measure his pulse and blood pressure.
A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which
assessment finding warrants immediate intervention by the nurse? - ANSWERS,Irregular apical
pulse
An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her
fingers. After warming her hands, the fingers turn red and the client reports a burning sensation.
What action should the nurse take? - ANSWERS,Continue to monitor the fingers until color returns
to normal
A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His
right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath
sounds. Vital signs are temperature 101F, heart rate 128 beats/minute, respirations 28
breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to
implement first? - ANSWERS,Administer PRN oral antipyretic
The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic
cholecystectomy under general anesthesia. Which finding warrants notification of the healthcare
provider prior to proceeding with the scheduled procedure? - ANSWERS,The client's blood pressure
reading is 184/88 mm Hg
3
