MED SURG HESI V2 EXAM 2025

What information should the nurse include in the teaching plan of a client diagnosed with GERD? A. Sleep without pillows B. Adjust food intake to three full meals per day with no snacks C. Minimize symptoms by wearing loose comfortable clothing D. Avoid participation in any aerobic exercise program - -Minimize symptoms by wearing loose comfortable clothing After hospitalization for SIADH, a client develops pontine myelinolysis. Which intervention should the nurse implement first? A. Reorient client to room B. Place a patch on one eye C. Evaluate clients ability to swallow D. Perform range of motion exercises - -Reorient client to room A male client with heart failure calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain? A. What time did he take his medication? B. Has his weight changed in the last several days? C. Is he still able to tighten his belt buckle? D. How many hours did he sleep last night? - -Has his weight changed in the last several days? An older adult woman with a long history of COPD is admitted with progressive shortness of breath and a persistent cough, is anxious, and is complaining of dry mouth. which intervention should the nurse implement? A. Administer a prescribed sedative B. Encourage client to drink water C. Apply a high flow Venturi mask D. Assist her to an upright position - -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 thickening 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? A. Increase the daily intake of oral fluids to liquify secretions B. Avoid crowded enclosed areas to reduce pathogens exposure C. Call the clinic if undesirable side effects or medications - -Increase the daily intake of oral fluids to liquify secretions MED SURG MED SURG A cardiac catherization of a client with heart disease indicates the following blockages: 95% proximal left anterior descending (LAD), 99% proximal circumflex, and 95% proximal right coronary artery (RCA) the client later asks the nurse "What does all of that mean for me?" What information should the nurse provide. B. Three main arteries have major blockages, with only 1-5% of the blood flow getting through to the heart muscles - -Three main arteries have major blockages, with only 1 5% of the blood flow getting through to the heart muscles The nurse is caring for a client with a lower left lobe pulmonary abscess. what position should the nurse instruct the client to maintain? A. Left lateral B. Supine, knees flexed. C. Dorsal recumbent D. Knee-chest - -Left lateral A client with Cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseous and vomiting. Which finding should the nurse report to the healthcare provider? A. Belching B. Amber urine C. Yellow sclera D. Flatulence - -Yellow sclera While caring for a client with Amyotrophic lateral sclerosis (ALS) a nurse performs a neurological assessment every 4 hours. Which assessment finding warrants immediate intervention by the nurse? A. Inappropriate laughter B. Increasing anxiety C. Weakened cough effort D. Asymmetrical weakness - -Asymmetrical weakness The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft to promote burn healing. Which information should the provider this client? A. Grafting increase the risk for bacterial infections B. The xenograft is taken from a non-human source. C. Grafts are later removed by a debriding procedure D. As the burns heals, the graft permanently - -The xenograft is taken from a non human source 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 ulcerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next. A. Bring additional sterile dressing supplies to the room. MED SURG MED SURG B. Prepare the client to return to the OR C. Obtain a sample of the drainage to send to the lab D. ausculate the abdomen for bowel sounds - -Bring additional sterile dressing supplies to the room A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117/meq. Which nursing problem should the nurse include in the clients plan of care. A. Altered urinary elimination B. Impaired gas exchange C. Fluid volume excess D. Decreased cardiac output - -Fluid volume excess 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 MD suspects hyperthyroidisms and admits her for testing. which action should the nurse do? A. Begin preparing the client for thyroidectomy procedure B. Space the clients care to provide periods of rest C. Assess the client for hyperactive bowel sounds D. Provide warm blanket to prevent heat loss - -Assess the client for hyperactive bowel sounds The nurse is teaching a client with glomerulonephritis about self care. Which dietary recommendations should the nurse encourage the client to follow. A. increase intake of high-fiber foods, such as bran cereal. B. Restrict protein intake by limiting meals and other high-protein foods C. limit oral fluid intake of 500/ml/day D. Increase intake of potassium rich foods such as bananas and cantaloupe - -Restrict protein intake by limiting meals and other high-protein foods An overweight young adult male who was recently diagnosed with type 2 DM 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. A.Check his fingerstick glucose B. Assess his skin temperature and moisture C. Measure his pulse and BP D. Document anxiety on the surgical checklist E. Administer a PRN dose of regular insulin - -Check his fingerstick glucose, assess his skin temperature and moisture, measure his pulse and BP A client with Cushing Syndrome is recovering from an elective laparoscopic procedure. which assessment finding warrants immediate intervention by the nurse? A. Irregular apical pulse B. Purple marks on skin of the abdomen C. Quarter sized blood spot on the dressing MED SURG MED SURG D. Pitting ankle edema - -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? A. Apply a cool compress to the affected fingers for 20 minutes B. Secure a pulse oximeter to monitor the client's oxygen saturation C. Report the finding to the healthcare provider as soon as possible D. Continue to monitor the fingers until color returns to normal - -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. lung are coarse with diminished bibasilar breath sounds. Vital signs are T: 101 degrees, HR: 128, RR: 28, B/P: 122/82. Which interventions is most important for the nurse to implement first? A. Obtain oxygen saturation level. B. Encourage incentivize spirometry C. Assess lower extremity circulation D. Administer oral PRN antipyretic - -Administer oral PRN 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 HCP prior to proceeding with the scheduled procedure? A. light yellow coloring of the clients skin and eyes. B. The clients blood pressure reading 184/88mm C. The client vomits 20 mL of clear yellowish fluid D. the IV insertion site is red, swollen, and leaking IV fluid - -The clients blood pressure reading 184/88 A client who has a history of hyperthyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse? A. Facial puffiness and periorbital edema B. Hematocrit of 30% C. cold and dry skin D. Further decline in LOC - -Further decline in LOC Following surgical repair of the bladder, a female client is being discharged from the hospital to home with an indwelling urinary catheter. Which instruction is most important for the nurse to provide to this client? A. Avoid coiling the tubing and keep if free of kinks B. Cleanse the perineal area with soap and water twice daily C. Keep the drainage bag lower than the level of the bladder D. Drink 1,000 ml of fluids daily to irrigate catheter - -Keep the drainage back lower than the level of the bladder MED SURG MED SURG Which client has the highest risk for developing skin cancer? A. A 16 year old dark skinned female who tans in tanning bed once a week. B. A 65 year old fair skinned male who is a construction worker C. A 25 year old dark skinned male who mother had skin cancer. D. A 70 year old fair skinned female who works as a se