HESI PN MED SURG ACTUAL EXAM 2025 GRADED A

These are all practice questions for the 2025 Med/Surg HESI. All the explanations listed are found in Lewis’s Medical-Surgical Nursing, Assessment and Management of Clinical Problems, Eleventh Edition by Harding, Kwong, Roberts, Hagler, and Reinisch. • A nurse is caring for a client w diabetes insipidus. Which data warrants the most immediate intervention by the nurse? ◦ Serum sodium of 185 ‣ Normal range of sodium is 135-145 • Textbook pg 1148 ◦ “Diabetes insipidus is caused by a deficiency of production or secretion of ADH or a decreased renal response to ADH. The decrease in ADH results in fluid and electrolyte imbalances” • A nurse is obtaining the admission history for a client w suspected peptic ulcer disease. Which subjective data reported by the client supports this medical diagnosis? ◦ Upper mid-abdominal pain described as gnawing and burning • Textbook pages 905-911 ◦ “Peptic ulcer disease is a condition characterized by erosion of the GI mucosa from the digestive action of HCL acid and pepsin.” ◦ “In gastric ulcers, the discomfort is generally high in the epigastrium and occurs about 1-2 hrs after meals. The pain is described as “burning” or “gaseous” • The nurse assesses a client who is newly diagnosed w hyperthyroidism and observes that the client’s eyeballs are protuberant, causing a wide-eyed appearance and eye discomfort. Based on this finding, which action should the nurse include in this client’s plan of care? ◦ Obtain a prescription for artificial tear drops • Textbook pg 1150 ◦ “A classic finding in Graves’ disease is exophthalmos, a protrusion of the eyeballs from the orbits that is usually bilateral…The increased pressure forces the eyeballs outward. The upper lids are usually retracted and elevated, with the sclera visible above the iris. When the eyelids do not close completely, the exposed corneal surfaces become dry and irritated.” • To reduce the risk for pulmonary complication for a client w Amyotropic Lateral Sclerosis, which interventions should the nurse implement? ◦ Perform chest physiotherapy ◦ Teach the client breathing exercises ◦ Encourage use of incentive spirometer ‣ These are the only options that have to do with the pulmonary system • Textbook pg 1379 lOMoAR cPSD| • A client is hospitalized w heart failure. Which intervention should the nurse implement to improve ventilation and reduce venous return? ◦ Place the client in high fowler’s position ‣ The only option that encourages BOTH ventilation and reduces venous return • Textbook pg 748 • A client who was involved in a motor vehicle collision is admitted w a fractured left femur which is immobilized using a fracture traction splint in prep for an open reduction internal fixation (ORIF). The nurse determines that the client’s distal pulses are diminished in the L foot. Which interventions should the nurse implement? ◦ Verify pedal pulses using a Doppler pulse device ◦ Evaluate the application of the splint to the left leg ◦ Monitor left leg for pain, pallor, parenthesis, paralysis, pressure ‣ Only options that involve the left leg • Textbook pg • “The neurovascular assessment consists of peripheral vascular assessment (color, temperature, cap refill, peripheral pulses, edema) and peripheral neurologic assessment (sensation, motor function, pain). • The healthcare provider prescribes diagnostic tests for a client whose chest X-ray indicates pneumonia. Which diagnostic test should the nurse review for implementation in the most therapeutic treatment of the pneumonia? ◦ Sputum culture and sensitivity • Textbook pg 506-507 ◦ “Ideally, a sputum specimen for culture and Gram stain to identify the organism is obtained before beginning antibiotic thereby…” • A client w a history of bronchitis arrives at the clinic w shortness of breath, productive cough w 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? ◦ Increase the daily intake of oral fluids to liquefy secretions • Textbook pg 503 ◦ “Treatment is supportive. It includes cough suppressants, encouraging oral fluid intake, and using a humidifier.” • The home health nurse provides teaching about insulin self injection to a client who was recently diagnosed w diabetes mellitus. When the client begins to perform a return demonstration of an insulin injection into the abdomen, which instruction should the nurse provide? ◦ Continue w the insulin injection • The nurse observes an increased number of blood clots in the drainage tubing of a client w continuous bladder irrigation following a trans urethral resectionof the prostate (TURP). What is lOMoAR cPSD| the best initial nursing action? ◦ Increase the flow of the bladder irrigation • Pg 1261 ◦ “With CBI, irrigation solution is continuously infused and drained from the bladder. The rate of infusion is based on the color of drainage. Ideally, the urine drainage should be light pink without clots.” • Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first? ◦ Assess pulses w a vascular Doppler • A client arrives to the Med/Surg unit 4 hours after a transurethral resection of the prostate. A triple-lumen Catheter for continuous bladder irrigation w normal saline is infusing and the nurse observes dark, pink-tinged outflow w blood clots in the tubing and collection bag. Which action should the nurse take? ◦ Monitor catheter drainage • Pg 1261 ◦ “With CBI, irrigation solution is continuously induced and drained from the bladder. The rate of infusion is based on the color of drainage…Continuously monitor the inflow and outflow of the irrigant” • The nurse is planning care for an older adult client who experienced a cerebrovascular accident several weeks ago. The client has expressive aphasia and often becomes flustered w the nursing staff. Which intervention should the nurse implement? ◦ Encourage client’s use of picture charts • Pg 1336 ◦ “Types of aphasia include…expressive aphasia (inability to produce language.” (Using picture charts will allow the client to answer questions right now, without having to do other training.) • After 3 days of persistent epigastric pain, a female client presents to the clinic. She has been taking oral antacids without relief. Her vital signs are HR 122, resp 16, O2 90%, and BP 116/70. The nurse obtains a 12-lead ECG. Which assessment finding is the most critical? ◦ ST elevation in three leads • Pg 718 ◦ “A STEMI, caused by an occlusive thrombus, results in ST- elevation in the ECG leads facing the area of infarction…A STEMI is an emergency. To limit the infarct size, the artery must be opened within 90 minutes of presentation to restore blood t and O12 to the heart muscle and limit infarct size.” • A client w acute renal injury (AKI) weight 50 kg and has potassium level of 6.7 is admitted to lOMoAR cPSD| the hospital. Which prescribed medication should the nurse administer first? ◦ Sodium polystyrene sulfonate 15 g by mouth • Pg 1063 table 46.5 ◦ “Sodium polystyrene/Kayexalate” ‣ Given by mouth or retention enema ‣ When resin is in the bowel, potassium is exchanged for sodium potassium-rich stool ‣ Produces osmotic diarrhea, allowing for evacuation of ‣ Removes 1 mEq of potassium per 1 g of drum ‣ Do not give to pt w paralytic lieu’s • A client w gouty arthritis reports tenderness and swelling of the right ankle and great toe. The nurse observes the area of inflammation extends above the ankle area. The client receives prescriptions for colchicine and indomethacin. Which instruction should th nurse include in the discharge teaching? ◦ Drink at least 8 cups of water per day • Pg ◦ “Excessive Uris acid excretion may lead to stone formation in the kidneys/urinary tract.” • A client w a history of peptic ulcer disease is admitted after vomiting bright red blood several times over the course of 2 hours. In reviewing the lab results, the nurse finds the client’s hemoglobin is 12 g/dL and the hemotocrit is 35%. Which action should the nurse prepare to take? ◦ Administer 1000 mL normal saline ‣ Helps treat nausea • An obese client w emphysema who smokes at least a pack of cigarettes daily is admitted after experiencing a sudden increase in dyspnea and activity intolerance. Oxygen therapy is initiated and it is determined that the client will be discharged w oxygen. Which info is most important for the nurse to emphasize in the discharge teaching plan? ◦ Guidelines for oxygen use • Which food is most important for the nurse to encourage a client w osteomalacia to include in a daily diet? ◦ Fortified milk and cereals • Pg ◦ “Encourage dietary intake of eggs, meat, and oily fish. Milk and breakfast cereals fortified w calcium and vitamin D should be part of the diet.” lOMoAR cPSD| • A client w herpes zoster on the thorax tells the nurse of having difficulty sleeping. Which is the probable etiology of this problem? ◦ ‣ Shingles of the thorax manifests as a rash on the abdominal area • The nurse is caring for a client who is postop for a femoral head fracture repair. Which interventions should the nurse plan to administer for deep vein thrombosis prophylaxis? ◦ Pneumatic compression devices ◦ Call-pump exercises ◦ Prescribed anticoagulant therapy • Pg 1456 • The nurse is obtaining a health history from a new client who has a history of kidney stones. Which statement by the client indicates an increased risk for renal calculi? ◦ Each a vegetarian diet with cheese 2-3 times/day • A client tells the clinic nurse about experiencing burning on urination, and assessment reveals that the client had sexual intercourse four days ago with a person who was casually met. Which action should the nurse implement? ◦ Obtain a specimen of urethral drainage for culture • Textbook Pg 1026 ◦ “Manifestations of a UTI range from painful urinatuion in uncomplicated urethritis or cystitis…After confirmation of bacteria and pyuria, a urine culture mat be done” • An adult client is admitted w flank pain and is diagnosed with acute pylonephritis. What is the priority nursing action? ◦ Administer IV antibiotics as prescribed • Pg 1029 Table 45.7 ◦ “Drug Therapy: Parenteral antibiotics” • A client w cholelithiasis is admitted w jaundice due to obstruction of the common bile duct. Which finding is most important for the nurse to report to the healthcare provider? ◦ Distended, hard, and rigid abdomen • Pg 999-1000 • A client w chronic kidney disease is started on hemodialysis. During the first dialysis treatment, the client’s BP drops from 150/90 to 80/30. Which action should the nurse take first? ◦ Stop the dialysis treatment • The nurse is collecting info from a client w chronic pancreatitis who reports persistent gnawing abdominal pain. to help the client manage the pain, which assessment data is most important for the nurse to obtain? lOMoAR cPSD| ◦ Eating patterns and dietary intake • Pg 996-998 ◦ “Diet, pancreatic enzyme replacement, and copntrol of diabetes are ways to control the pancreatic insufficiency. Small, bland, frequent meals that are low in fat content are recommended to decrease pancreatic stimulation.” • A client who had a C-5 spinal cord injury 2 years ago is admitted to the ED w the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit? ◦ Profuse diaphoresis and a severe, pounding headache • Pg ◦ “Manifestations (of autonomic dysreflexia) include hypertension, throbbing, headache, marked diaphoresis above the level of injury, bradycardia (30-40 bpm), piloerection from pilomotor spasm, flushing of the skin above the level of injury, blurred vision/spots in the visual fields, nasal congestion, anxiety, and nausea” • During spring break, a young adult presents to the urgent care clinic and reports a stiff neck, a fever for the past 6 hrs, and a headache. Which intervention is most important for the nurse to implement first? ◦ Implement isolation precautions ‣ These are symptoms indicating bacterial meningitis • Pg 1324 ◦ “Fever, severe headache, nausea, vomiting, and nuchal rigidity are key signs of meningitis.” ◦ From the internet: bacterial meningitis should immediately indicate droplet isolation precautions • The nurse assesses a client w petichae and ecchymosis scattered across the arms and legs. Which lab result should the nurse review? ◦ Platelet count • Pg 597 Table 29.6 ◦ “Petichae indicate decreased platelets our clotting factors resulting in hemorrhage into the skin” • An older adult client w a long history of chronic obstructive pulmonary disease (COPD) is admitted w progressive shortness of breath and a persistent cough. The client is anxious and is complaining of a dry mouth. Which intervention should the nurse implement? ◦ Assist client to an upright position ‣ Least invasive to most invasive—this is the least invasive option for COPD exacerbations lOMoAR cPSD| • The nurse is providing discharge instructions to a client who is receiving Prednisone 5 mg PO daily for a rash due to contact w poison ivy. Which symptoms should the nurse tell the client to report to the healthcare provider? ◦ rapid weight gain • When conducting discharge teaching for a client diagnosed w diverticulosis, which diet instruction should the nurse include? ◦ Eat a high-fiber diet and increase fluid intake • Pg 957-958 ◦ “Teach them the importance of following a high-fiber diet and encourage fluid intake of at least 2 L/day” • An adult who was recently diagnosed w glaucoma tells the nurse”It feels like I am driving through a tunnel.” The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide to this client? ◦ Maintain prescribed eye drop regimen • Pg 372 ◦ “Loss of vision because of glaucoma is a preventable problem. Teach the pt and caregiver about the risk for glaucoma and that it increases with age.” • Which client has the highest risk for developing skin cancer? ◦ A 65-yo fair skinned client who is a construction worker • Pg 411 ◦ “Risk factors for skin cancer include ‣ Having fair skin, blond or red hair w blue eye color ‣ History of outdoor sunbathing ‣ Living near the equator or at high altitudes ‣ Family/personal history of skin cancer ‣ Having an outdoor occupation ‣ Spending a lot of time in outdoor recreation activities ‣ Indoor tanning • A client w a history of type 1 diabetes mellitus and asthma is readmitted to the unit for the third time in two months with a current fasting blood sugar is 324 mg/do. The client describes to the nurse of not understanding why the blood glucose level continues to be out of control. Which interventions should the nurse implement? ◦ Have the client describe a typical day at work, home, and social activities ◦ Have the client demonstrate technique used to monitor blood glucose levels • The bourse assesses a client w cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients w cirrhosis?