HESI Final - MedSurg (Red Book &Misc Evolve Resources)
Study online at https://quizlet.com/_957d9l
D
Rationale: Sedatives such as pentobar-
A client with alcohol-related liver disease bital are contraindicated for clients with
is admitted to the unit. Which prescrip- liver damage and can have danger-
tion should the nurse call the health care ous consequences. Option A is often
provider about for reverification for this prescribed because the normal clotting
client? mechanism is damaged. Option B is
A. Vitamin K1, 5 mg IM daily needed to help restore energy to the de-
B. High-calorie, low-sodium diet bilitated client. Sodium is often restricted
C. Fluid restriction to 1500 mL/day because of edema. Fluids are restricted
D. Nembutal sodium at bedtime for rest to decrease ascites, which often accom-
panies cirrhosis, particularly in the later
stages of the disease
When assigning clients on a med-
ical-surgical floor to an RN and a PN, it is
best for the charge nurse to assign which
client to the PN? B
A. A young adult with bacterial meningitis Rationale: The most stable client is op-
with recent seizures tion B. Options A, C, and D are all at high
B. An older adult client with pneumonia risk for increased intracranial pressure
and viral meningitis and require the expertise of the RN for
C. A female client in isolation with assessment and management of care.
meningococcal meningitis
D. A male client 1 day postoperative after
drainage of a brain abscess
A home health nurse knows that a
70-year-old male client who is conva- C
lescing at home following a hip replace- Rationale: Thin nonelastic skin is an im-
ment is at risk for developing pressure portant factor in pressure formation. The
ulcers. Which physical characteristic of proportion of body fat to lean mass in-
aging puts the client at risk? creases with age and might help de-
A. 16% increase in overall body fat crease ulcer tendency. Option B causes
B. Reduced melanin production gray hair. Option D can contribute to bro-
C. Thinning of the skin, with loss of elas- ken bones, but it is probably not a factor
ticity in pressure ulcer formation.
D. Calcium loss in the bones
The nurse receives the client's next
scheduled bag of TPN labeled with
, HESI Final - MedSurg (Red Book &Misc Evolve Resources)
Study online at https://quizlet.com/_957d9l
D
the additive NPH insulin. Which action
Rationale: Only regular insulin is admin-
should the nurse implement?
istered by the IV route, so the TPN so-
A. Hang the solution at the current rate.
lution containing NPH insulin should be
B. Refrigerate the solution until needed.
returned to the pharmacy. Options A, B,
C. Prepare the solution with new tubing.
and C are not indicated because the so-
D. Return the solution to the pharmacy.
lution should not be administered.
B
Rationale:The blood urea nitrogen
The nurse notes that a client who is (BUN) level indicates the effectiveness
scheduled for surgery the next morn- of the kidneys in filtering waste from
ing has an elevated blood urea nitrogen the blood. Dehydration, which could be
(BUN) level. Which condition is most like- caused by vomiting, would cause an in-
ly to have contributed to this finding? creased BUN level. Option A would affect
A. Myocardial infarction 2 months ago serum enzyme levels, not the BUN level.
B. Anorexia and vomiting for the past 2 Option C would primarily affect the blood
days glucose level; renal failure that could in-
C. Recently diagnosed type 2 diabetes crease the BUN level would be unlikely in
mellitus a client newly diagnosed with type 2 dia-
D. Skeletal traction for a right hip fracture betes. Effects of option D might affect the
complete blood count (CBC) but would
not directly increase the BUN level.
B
Rationale:Straining all urine is the most
important nursing action to take in this
case. Encouraging fluid intake is impor-
What is the most important nursing prior- tant for any client who may have a kidney
ity for a client who has been admitted for stone, but it is even more important to
a possible kidney stone? strain all urine. Straining urine will en-
A. Reducing dairy products in the diet able the nurse to determine when the
B. Straining all urine kidney stone has been passed and may
C. Measuring intake and output prevent the need for surgery. Option C
D. Increasing fluid intake is not the highest priority action. Option
A is usually not recommended until the
stone is obtained and the content of the
stone is determined. Even then, dietary
restrictions are controversial.
, HESI Final - MedSurg (Red Book &Misc Evolve Resources)
Study online at https://quizlet.com/_957d9l
C
Rationale:All four of these clients have
During the change of shift report, the
the potential to have significant com-
charge nurse reviews the infusions be-
plications. The client with the morphine
ing received by clients on the oncology
epidural infusion is at highest risk for
unit. The client receiving which infusion
respiratory depression and should be
should be assessed first?
assessed first. Option A can cause hy-
A. Continuous IV infusion of magnesium
potension. The client receiving option B
B. One-time infusion of albumin
is at lowest risk for serious complications.
C. Continuous epidural infusion of mor-
Although option D can cause nephrotoxi-
phine
city and phlebitis, these problems are not
D. Intermittent infusion of IV vancomycin
as immediately life threatening as option
C.
A hospitalized client is receiving naso-
gastric tube feedings via a small-bore
B
tube and a continuous pump infusion. He
Rationale:A productive cough may indi-
begins to cough and produces a moder-
cate that the feeding has been aspirated.
ate amount of white sputum. Which ac-
The nurse should first stop the feeding
tion should the nurse take first?
to prevent further aspiration. Options A,
A. Auscultate the client's breath sounds.
C, and D should all be performed before
B. Turn off the continuous feeding pump.
restarting the tube feeding if no evidence
C. Check placement of the nasogastric
of aspiration is present and the tube is in
tube.
place.
D. Measure the amount of residual feed-
ing.
D
Rationale:The loss of cardiac function in
Which statement reflects the highest pri-
aging decreases cardiac output, so dys-
ority nursing diagnosis for an older client
rhythmias, particularly tachycardias, are
recently admitted to the hospital for a
poorly tolerated. With onset of a tachy-
new-onset cardiac dysrhythmia?
cardic or bradycardic dysrhythmia, car-
A. Diarrhea related to medication side
diac output is compromised further, plac-
effects
ing the client at risk of syncope and
B. Anxiety related to fear of recurrent
falling, as well as confusion. Option A is
anginal episodes
of high priority but less so than maintain-
C. Altered nutrition related to high serum
ing client safety. Clients may experience
lipid levels
option B as a result of a newly diag-
nosed cardiac condition, but this nursing
, HESI Final - MedSurg (Red Book &Misc Evolve Resources)
Study online at https://quizlet.com/_957d9l
diagnosis does not have the priority of
D. Risk for injury related to syncope and
option D. Option C also does not have the
confusion
priority of option D.
D
Rationale:Treatment of flail chest is fo-
cused on preventing atelectasis and re-
Which nursing action is necessary for the lated complications of compromised ven-
client with a flail chest? tilation by encouraging coughing and
A. Withhold prescribed analgesic med- deep breathing. This condition is typi-
ications. cally diagnosed in clients with three or
B. Percuss the fractured rib area with more rib fractures, resulting in paradoxic
light taps. movement of a segment of the chest wall.
C. Avoid implementing pulmonary suc- Option C should not be avoided because
tioning. suctioning is necessary to maintain pul-
D. Encourage coughing and deep monary toilet in clients who require me-
breathing. chanical ventilation. Option A should not
be withheld. Option B should not be ap-
plied because the fractures are clearly
visible on the chest radiograph.
In assessing a client with an arteriove-
nous (AV) shunt who is scheduled for
dialysis today, the nurse notes the ab- C
sence of a thrill or bruit at the shunt site. Rationale:Absence of a thrill or bruit in-
What action should the nurse take? dicates that the shunt may be obstruct-
A. Advise the client that the shunt is in- ed. The nurse should notify the health
tact and ready for dialysis as scheduled. care provider so that intervention can be
B. Encourage the client to keep the initiated to restore function of the shunt.
shunt site elevated above the level of the Option A is incorrect. Option B will not
heart. resolve the obstruction. An AV shunt is
C. Notify the health care provider of the internal and cannot be flushed without
findings immediately. access using special needles.
D. Flush the site at least once with a
heparinized saline solution.
An older client is admitted with a diagno- D
sis of bacterial pneumonia. Which symp- Rationale:The onset of pneumonia in the
tom should the nurse report to the health older client may be signaled by general
care provider after assessing the client? deterioration, confusion, increased heart
A. Leukocytosis and febrile rate, and/or increased respiratory rate.
Study online at https://quizlet.com/_957d9l
D
Rationale: Sedatives such as pentobar-
A client with alcohol-related liver disease bital are contraindicated for clients with
is admitted to the unit. Which prescrip- liver damage and can have danger-
tion should the nurse call the health care ous consequences. Option A is often
provider about for reverification for this prescribed because the normal clotting
client? mechanism is damaged. Option B is
A. Vitamin K1, 5 mg IM daily needed to help restore energy to the de-
B. High-calorie, low-sodium diet bilitated client. Sodium is often restricted
C. Fluid restriction to 1500 mL/day because of edema. Fluids are restricted
D. Nembutal sodium at bedtime for rest to decrease ascites, which often accom-
panies cirrhosis, particularly in the later
stages of the disease
When assigning clients on a med-
ical-surgical floor to an RN and a PN, it is
best for the charge nurse to assign which
client to the PN? B
A. A young adult with bacterial meningitis Rationale: The most stable client is op-
with recent seizures tion B. Options A, C, and D are all at high
B. An older adult client with pneumonia risk for increased intracranial pressure
and viral meningitis and require the expertise of the RN for
C. A female client in isolation with assessment and management of care.
meningococcal meningitis
D. A male client 1 day postoperative after
drainage of a brain abscess
A home health nurse knows that a
70-year-old male client who is conva- C
lescing at home following a hip replace- Rationale: Thin nonelastic skin is an im-
ment is at risk for developing pressure portant factor in pressure formation. The
ulcers. Which physical characteristic of proportion of body fat to lean mass in-
aging puts the client at risk? creases with age and might help de-
A. 16% increase in overall body fat crease ulcer tendency. Option B causes
B. Reduced melanin production gray hair. Option D can contribute to bro-
C. Thinning of the skin, with loss of elas- ken bones, but it is probably not a factor
ticity in pressure ulcer formation.
D. Calcium loss in the bones
The nurse receives the client's next
scheduled bag of TPN labeled with
, HESI Final - MedSurg (Red Book &Misc Evolve Resources)
Study online at https://quizlet.com/_957d9l
D
the additive NPH insulin. Which action
Rationale: Only regular insulin is admin-
should the nurse implement?
istered by the IV route, so the TPN so-
A. Hang the solution at the current rate.
lution containing NPH insulin should be
B. Refrigerate the solution until needed.
returned to the pharmacy. Options A, B,
C. Prepare the solution with new tubing.
and C are not indicated because the so-
D. Return the solution to the pharmacy.
lution should not be administered.
B
Rationale:The blood urea nitrogen
The nurse notes that a client who is (BUN) level indicates the effectiveness
scheduled for surgery the next morn- of the kidneys in filtering waste from
ing has an elevated blood urea nitrogen the blood. Dehydration, which could be
(BUN) level. Which condition is most like- caused by vomiting, would cause an in-
ly to have contributed to this finding? creased BUN level. Option A would affect
A. Myocardial infarction 2 months ago serum enzyme levels, not the BUN level.
B. Anorexia and vomiting for the past 2 Option C would primarily affect the blood
days glucose level; renal failure that could in-
C. Recently diagnosed type 2 diabetes crease the BUN level would be unlikely in
mellitus a client newly diagnosed with type 2 dia-
D. Skeletal traction for a right hip fracture betes. Effects of option D might affect the
complete blood count (CBC) but would
not directly increase the BUN level.
B
Rationale:Straining all urine is the most
important nursing action to take in this
case. Encouraging fluid intake is impor-
What is the most important nursing prior- tant for any client who may have a kidney
ity for a client who has been admitted for stone, but it is even more important to
a possible kidney stone? strain all urine. Straining urine will en-
A. Reducing dairy products in the diet able the nurse to determine when the
B. Straining all urine kidney stone has been passed and may
C. Measuring intake and output prevent the need for surgery. Option C
D. Increasing fluid intake is not the highest priority action. Option
A is usually not recommended until the
stone is obtained and the content of the
stone is determined. Even then, dietary
restrictions are controversial.
, HESI Final - MedSurg (Red Book &Misc Evolve Resources)
Study online at https://quizlet.com/_957d9l
C
Rationale:All four of these clients have
During the change of shift report, the
the potential to have significant com-
charge nurse reviews the infusions be-
plications. The client with the morphine
ing received by clients on the oncology
epidural infusion is at highest risk for
unit. The client receiving which infusion
respiratory depression and should be
should be assessed first?
assessed first. Option A can cause hy-
A. Continuous IV infusion of magnesium
potension. The client receiving option B
B. One-time infusion of albumin
is at lowest risk for serious complications.
C. Continuous epidural infusion of mor-
Although option D can cause nephrotoxi-
phine
city and phlebitis, these problems are not
D. Intermittent infusion of IV vancomycin
as immediately life threatening as option
C.
A hospitalized client is receiving naso-
gastric tube feedings via a small-bore
B
tube and a continuous pump infusion. He
Rationale:A productive cough may indi-
begins to cough and produces a moder-
cate that the feeding has been aspirated.
ate amount of white sputum. Which ac-
The nurse should first stop the feeding
tion should the nurse take first?
to prevent further aspiration. Options A,
A. Auscultate the client's breath sounds.
C, and D should all be performed before
B. Turn off the continuous feeding pump.
restarting the tube feeding if no evidence
C. Check placement of the nasogastric
of aspiration is present and the tube is in
tube.
place.
D. Measure the amount of residual feed-
ing.
D
Rationale:The loss of cardiac function in
Which statement reflects the highest pri-
aging decreases cardiac output, so dys-
ority nursing diagnosis for an older client
rhythmias, particularly tachycardias, are
recently admitted to the hospital for a
poorly tolerated. With onset of a tachy-
new-onset cardiac dysrhythmia?
cardic or bradycardic dysrhythmia, car-
A. Diarrhea related to medication side
diac output is compromised further, plac-
effects
ing the client at risk of syncope and
B. Anxiety related to fear of recurrent
falling, as well as confusion. Option A is
anginal episodes
of high priority but less so than maintain-
C. Altered nutrition related to high serum
ing client safety. Clients may experience
lipid levels
option B as a result of a newly diag-
nosed cardiac condition, but this nursing
, HESI Final - MedSurg (Red Book &Misc Evolve Resources)
Study online at https://quizlet.com/_957d9l
diagnosis does not have the priority of
D. Risk for injury related to syncope and
option D. Option C also does not have the
confusion
priority of option D.
D
Rationale:Treatment of flail chest is fo-
cused on preventing atelectasis and re-
Which nursing action is necessary for the lated complications of compromised ven-
client with a flail chest? tilation by encouraging coughing and
A. Withhold prescribed analgesic med- deep breathing. This condition is typi-
ications. cally diagnosed in clients with three or
B. Percuss the fractured rib area with more rib fractures, resulting in paradoxic
light taps. movement of a segment of the chest wall.
C. Avoid implementing pulmonary suc- Option C should not be avoided because
tioning. suctioning is necessary to maintain pul-
D. Encourage coughing and deep monary toilet in clients who require me-
breathing. chanical ventilation. Option A should not
be withheld. Option B should not be ap-
plied because the fractures are clearly
visible on the chest radiograph.
In assessing a client with an arteriove-
nous (AV) shunt who is scheduled for
dialysis today, the nurse notes the ab- C
sence of a thrill or bruit at the shunt site. Rationale:Absence of a thrill or bruit in-
What action should the nurse take? dicates that the shunt may be obstruct-
A. Advise the client that the shunt is in- ed. The nurse should notify the health
tact and ready for dialysis as scheduled. care provider so that intervention can be
B. Encourage the client to keep the initiated to restore function of the shunt.
shunt site elevated above the level of the Option A is incorrect. Option B will not
heart. resolve the obstruction. An AV shunt is
C. Notify the health care provider of the internal and cannot be flushed without
findings immediately. access using special needles.
D. Flush the site at least once with a
heparinized saline solution.
An older client is admitted with a diagno- D
sis of bacterial pneumonia. Which symp- Rationale:The onset of pneumonia in the
tom should the nurse report to the health older client may be signaled by general
care provider after assessing the client? deterioration, confusion, increased heart
A. Leukocytosis and febrile rate, and/or increased respiratory rate.
