lOMoARcPSD|26582732
MED SURG HESI VERSION VERSION A+
GRADE QUESTIONS AND ANSWERS
VERIFIED AND E GUARANTEED 2025
Small bowel obstruction is a condition characterized by which finding?
Severe fluid and electrolyte imbalances.
Metabolic acidosis.
Ribbon-like stools.
Intermittent lower abdominal cramping.
Rationale
Among the findings characteristic of a small bowel obstruction is the presence of
severe fluid and electrolyte imbalances.
How should the nurse position the electrodes for modified chest lead one (MCL I)
telemetry monitoring?
Positive polarity right shoulder, negative polarity left shoulder, ground left chest nipple
line.
Positive polarity left shoulder, negative polarity right chest nipple line, ground left chest
nipple line.
Positive polarity right chest nipple line, negative polarity left chest nipple line, ground left
shoulder.
Negative polarity left shoulder, positive polarity right chest nipple line, ground left chest
nipple line. Rationale
In MCL I monitoring, the positive electrode is placed on the client's mid-chest to
the right of the sternum, and the negative electrode is placed on the upper left
part of the chest. The ground may be placed anywhere, but is usually placed on
the lower left portion of the chest.
Which description of symptoms is characteristic of a client diagnosed with
trigeminal neuralgia (tic douloureux)?
Tinnitus, vertigo, and hearing difficulties.
Sudden, stabbing, severe pain over the lip and chin.
Facial weakness and paralysis.
Difficulty in chewing, talking, and swallowing.
Rationale
Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric
shock, in the area innervated by one or more branches of the trigeminal nerve (5 th
cranial). Women are more often afflicted with this condition and generally occurs
in clients over the age of 50 years old.
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A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg.
Which action should the nurse implement?
Position the head of the bed (HOB) flat.
Withhold intravenous fluids.
Administer a bolus of IV fluids.
Give an antihypertensive medication.
Rationale
Most ischemic strokes occur during sleep when baseline blood pressure declines
or blood viscosity increases due to minimal fluid intake. Completed strokes
usually produce neurologic deficits within an hour, and the client's current
elevated blood pressure requires antihypertensive medication.
The nurse is assessing a client who has a history of Parkinson's disease for the
past 5 years. What symptoms would this client most likely exhibit?
Loss of short-term memory, facial tics and grimaces, and constant writhing movements.
Shuffling gait, masklike facial expression, and tremors of the head.
Extreme muscular weakness, easy fatigability, and ptosis.
Numbness of the extremities, loss of balance, and visual disturbances.
Rationale
Parkinson's Disease is one of the most common neurologic progressive disorder
of the older client. Shuffling gait, masklike facial expression, and tremors of the
head and hands are common clinical features of Parkinsonism.
Healthcare workers must protect themselves against becoming infected with HIV.
The Center for Disease Control has issued guidelines for healthcare workers in
relation to protection from HIV. These guidelines include which recommendation?
Place HIV positive clients in strict isolation and limit visitors.
Wear gloves when coming in contact with the blood or body fluids of any client.
Conduct mandatory HIV testing of those who work with AIDS clients.
Freeze HIV blood specimens at -70 F to kill the virus.
Rationale
The CDC guidelines recommend that healthcare workers use gloves when coming
in contact with blood or body fluids from any client since HIV is infectious before
the client becomes aware of their exposure and/or symptomatic.
The nurse is assisting a client out of bed for the first time after surgery. What
action should the nurse do first?
Place a chair at a right angle to the bedside.
Encourage deep breathing prior to standing.
Help the client to sit and dangle legs on the side of the bed.
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.
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What is the correct procedure for performing an opthalmoscopic examination on
a client's right retina?
Instruct the client to look at examiner's nose and not move his/her eyes during the
exam.
Set ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's right
eye.
From a distance of 12 to 15 inches and slightly to the side, shine the light into the
client's pupil.
For optimum visualization, keep the ophthalmoscope at least 3 inches from the client's
eye. 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.
The nurse knows that lab values sometimes vary for the older client. Which data
would the nurse expect to find when reviewing laboratory values of an 80-yearold
male?
Increased WBC, decreased RBC.
Increased serum bilirubin, slightly increased liver enzymes.
Increased protein in the urine, slightly increased serum glucose levels.
Decreased serum sodium, an increased urine specific gravity.
Rationale
As older adults aged, the protein found in urine slightly rises as a result of kidney
changes and the serum glucose increases slightly, also due to changes in the
kidney. The specific gravity declines by age 80 from 1.032 to 1.024.
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?
Lower left quadrant pain and a low-grade fever.
Severe pain at mcburney's point and nausea.
Abdominal pain and intermittent tenesmus.
Exacerbations of severe diarrhea.
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.
During an interview with a client planning elective surgery, the client asks the
nurse, "What is the advantage of having a preferred provider organization
insurance plan?" Which response is best for the nurse to provide?
Neither plan allows selections of healthcare providers or hospitals.
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There are fewer healthcare providers to choose from than in an HMO plan.
An individual may select healthcare providers from outside of the PPO network.
An individual can become a member of a PPO without belonging to a group.
Rationale
The financial implication of selecting a provider from outside of the network is the
feature most relevant to the average consumer. The nurse must have knowledge
about ppos, which provides the option for the consumer to select a Healthcare
Provider (HPO) from within the PPO network (in-network) at a reduced cost
versus higher cost for selecting an out-of-network HCP.
The nurse is teaching a female client who uses a contraceptive diaphragm about
reducing the risk for toxic shock syndrome (TSS). Which information should the
nurse include? (Select all that apply.)
Select all that apply
Some correct answers were not selected
Remove the diaphragm immediately after intercourse.
Wash the diaphragm with an alcohol solution.
Use the diaphragm to prevent conception during the menstrual cycle.
Do not leave the diaphragm in place longer than 8 hours after intercourse.
Replace the old diaphragm every 3 months.
Rationale
The diaphragm needs to remain against the cervix for 6 to 8 hours to prevent
pregnancy but should not remain for longer than 8 hours to avoid the risk of TSS.
The diaphragm should be replaced every 3 months to maintain integrity.
When providing discharge teaching for a client with osteoporosis, the nurse
should reinforce which home care activity?
A diet low in phosphates.
Skin inspection for bruising.
Exercise regimen, including swimming.
Elimination of hazards to home safety.
Rationale
Discussion about fall prevention strategies is imperative for the discharged client
with osteoporosis so that advice about safety measures in the home should be
done such as the elimination of throw rugs and proper lighting to minimize trip
hazards and falls.
In preparing a discharge plan for a 22-year-old male client diagnosed with
Buerger's disease (thromboangiitis obliterans), which referral is most important?
Genetic counseling.
Twelve-step recovery program.
Clinical nutritionist.
Smoking cessation program.
Rationale
Buerger's disease is strongly related to smoking or the use of some other form of
tobacco which affects the circulation in the arms and legs leading to infection
and gangrene and sometimes amputation of the affected area. The most effective
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MED SURG HESI VERSION VERSION A+
GRADE QUESTIONS AND ANSWERS
VERIFIED AND E GUARANTEED 2025
Small bowel obstruction is a condition characterized by which finding?
Severe fluid and electrolyte imbalances.
Metabolic acidosis.
Ribbon-like stools.
Intermittent lower abdominal cramping.
Rationale
Among the findings characteristic of a small bowel obstruction is the presence of
severe fluid and electrolyte imbalances.
How should the nurse position the electrodes for modified chest lead one (MCL I)
telemetry monitoring?
Positive polarity right shoulder, negative polarity left shoulder, ground left chest nipple
line.
Positive polarity left shoulder, negative polarity right chest nipple line, ground left chest
nipple line.
Positive polarity right chest nipple line, negative polarity left chest nipple line, ground left
shoulder.
Negative polarity left shoulder, positive polarity right chest nipple line, ground left chest
nipple line. Rationale
In MCL I monitoring, the positive electrode is placed on the client's mid-chest to
the right of the sternum, and the negative electrode is placed on the upper left
part of the chest. The ground may be placed anywhere, but is usually placed on
the lower left portion of the chest.
Which description of symptoms is characteristic of a client diagnosed with
trigeminal neuralgia (tic douloureux)?
Tinnitus, vertigo, and hearing difficulties.
Sudden, stabbing, severe pain over the lip and chin.
Facial weakness and paralysis.
Difficulty in chewing, talking, and swallowing.
Rationale
Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric
shock, in the area innervated by one or more branches of the trigeminal nerve (5 th
cranial). Women are more often afflicted with this condition and generally occurs
in clients over the age of 50 years old.
Downloaded by NELSON KIIRU ()
, lOMoARcPSD|26582732
A client with a completed ischemic stroke has a blood pressure of 180/90 mm Hg.
Which action should the nurse implement?
Position the head of the bed (HOB) flat.
Withhold intravenous fluids.
Administer a bolus of IV fluids.
Give an antihypertensive medication.
Rationale
Most ischemic strokes occur during sleep when baseline blood pressure declines
or blood viscosity increases due to minimal fluid intake. Completed strokes
usually produce neurologic deficits within an hour, and the client's current
elevated blood pressure requires antihypertensive medication.
The nurse is assessing a client who has a history of Parkinson's disease for the
past 5 years. What symptoms would this client most likely exhibit?
Loss of short-term memory, facial tics and grimaces, and constant writhing movements.
Shuffling gait, masklike facial expression, and tremors of the head.
Extreme muscular weakness, easy fatigability, and ptosis.
Numbness of the extremities, loss of balance, and visual disturbances.
Rationale
Parkinson's Disease is one of the most common neurologic progressive disorder
of the older client. Shuffling gait, masklike facial expression, and tremors of the
head and hands are common clinical features of Parkinsonism.
Healthcare workers must protect themselves against becoming infected with HIV.
The Center for Disease Control has issued guidelines for healthcare workers in
relation to protection from HIV. These guidelines include which recommendation?
Place HIV positive clients in strict isolation and limit visitors.
Wear gloves when coming in contact with the blood or body fluids of any client.
Conduct mandatory HIV testing of those who work with AIDS clients.
Freeze HIV blood specimens at -70 F to kill the virus.
Rationale
The CDC guidelines recommend that healthcare workers use gloves when coming
in contact with blood or body fluids from any client since HIV is infectious before
the client becomes aware of their exposure and/or symptomatic.
The nurse is assisting a client out of bed for the first time after surgery. What
action should the nurse do first?
Place a chair at a right angle to the bedside.
Encourage deep breathing prior to standing.
Help the client to sit and dangle legs on the side of the bed.
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.
Downloaded by NELSON KIIRU ()
, lOMoARcPSD|26582732
What is the correct procedure for performing an opthalmoscopic examination on
a client's right retina?
Instruct the client to look at examiner's nose and not move his/her eyes during the
exam.
Set ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's right
eye.
From a distance of 12 to 15 inches and slightly to the side, shine the light into the
client's pupil.
For optimum visualization, keep the ophthalmoscope at least 3 inches from the client's
eye. 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.
The nurse knows that lab values sometimes vary for the older client. Which data
would the nurse expect to find when reviewing laboratory values of an 80-yearold
male?
Increased WBC, decreased RBC.
Increased serum bilirubin, slightly increased liver enzymes.
Increased protein in the urine, slightly increased serum glucose levels.
Decreased serum sodium, an increased urine specific gravity.
Rationale
As older adults aged, the protein found in urine slightly rises as a result of kidney
changes and the serum glucose increases slightly, also due to changes in the
kidney. The specific gravity declines by age 80 from 1.032 to 1.024.
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?
Lower left quadrant pain and a low-grade fever.
Severe pain at mcburney's point and nausea.
Abdominal pain and intermittent tenesmus.
Exacerbations of severe diarrhea.
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.
During an interview with a client planning elective surgery, the client asks the
nurse, "What is the advantage of having a preferred provider organization
insurance plan?" Which response is best for the nurse to provide?
Neither plan allows selections of healthcare providers or hospitals.
Downloaded by NELSON KIIRU ()
, lOMoARcPSD|26582732
There are fewer healthcare providers to choose from than in an HMO plan.
An individual may select healthcare providers from outside of the PPO network.
An individual can become a member of a PPO without belonging to a group.
Rationale
The financial implication of selecting a provider from outside of the network is the
feature most relevant to the average consumer. The nurse must have knowledge
about ppos, which provides the option for the consumer to select a Healthcare
Provider (HPO) from within the PPO network (in-network) at a reduced cost
versus higher cost for selecting an out-of-network HCP.
The nurse is teaching a female client who uses a contraceptive diaphragm about
reducing the risk for toxic shock syndrome (TSS). Which information should the
nurse include? (Select all that apply.)
Select all that apply
Some correct answers were not selected
Remove the diaphragm immediately after intercourse.
Wash the diaphragm with an alcohol solution.
Use the diaphragm to prevent conception during the menstrual cycle.
Do not leave the diaphragm in place longer than 8 hours after intercourse.
Replace the old diaphragm every 3 months.
Rationale
The diaphragm needs to remain against the cervix for 6 to 8 hours to prevent
pregnancy but should not remain for longer than 8 hours to avoid the risk of TSS.
The diaphragm should be replaced every 3 months to maintain integrity.
When providing discharge teaching for a client with osteoporosis, the nurse
should reinforce which home care activity?
A diet low in phosphates.
Skin inspection for bruising.
Exercise regimen, including swimming.
Elimination of hazards to home safety.
Rationale
Discussion about fall prevention strategies is imperative for the discharged client
with osteoporosis so that advice about safety measures in the home should be
done such as the elimination of throw rugs and proper lighting to minimize trip
hazards and falls.
In preparing a discharge plan for a 22-year-old male client diagnosed with
Buerger's disease (thromboangiitis obliterans), which referral is most important?
Genetic counseling.
Twelve-step recovery program.
Clinical nutritionist.
Smoking cessation program.
Rationale
Buerger's disease is strongly related to smoking or the use of some other form of
tobacco which affects the circulation in the arms and legs leading to infection
and gangrene and sometimes amputation of the affected area. The most effective
Downloaded by NELSON KIIRU ()
