HESI Exam: NUR201 Medical-Surgical Nursing
Questions and 100% Correct Verified Answers
A patient with inflammatory bowel disease has a nursing diagnosis
of imbalanced nutrition: less than body
requirements related to decreased nutritional intake and decreased
intestinal absorption. Which assessment data
support this nursing diagnosis?
a. Pallor and hair loss
b. Frequent diarrhea stools
c. Anorectal excoriation and pain
d. Hypotension and urine output below 30 mL/hr -Answer:-a.
Signs of malnutrition include pallor from anemia, hair loss, bleeding,
cracked gingivae, and muscle weakness, which support a nursing
diagnosis that identifies impaired nutrition. Diarrhea may
contribute to malnutrition but is not a defining characteristic.
Anorectal excoriation and pain
relate to problems with skin integrity. Hypotension relates to
problems with fluid deficit.
,A physician just told a patient that she has a volvulus. When the
patient asks the nurse what this is, what is the best
description for the nurse to give her?
a. Bowel folding on itself
b. Twisting of bowel on itself
c. Emboli of arterial supply to the bowel
d. Protrusion of bowel in weak or abnormal opening -Answer:-b.
Volvulus is the bowel twisting on itself. The bowel
folding on itself is intussusception. Emboli of arterial blood supply
to the bowel is vascular obstruction. Protrusion of bowel in a weak
or abnormal opening is a hernia
The patient comes to the emergency department with intermittent
crampy abdominal pain, nausea, projectile
vomiting, and dehydration. The nurse suspects a GI obstruction.
Based on the manifestations, what area of the bowel should the
nurse suspect is obstructed?
a. Large intestine
b. Esophageal sphincter
, c. Upper small intestine
d. Lower small intestine -Answer:-c.
Intermittent crampy abdominal pain, nausea, projectile vomiting,
and dehydration are characteristics of mechanical upper small
intestinal obstruction. With continued vomiting, metabolic alkalosis
may occur. Large bowel obstruction is characterized by
constipation, low-grade abdominal pain, and abdominal distention.
Fecal vomiting is seen with lower small intestinal obstruction.
An important nursing intervention for a patient with a small
intestinal obstruction who has an NG tube is to
a. offer ice chips to suck PRN.
b. provide mouth care every 1 to 2 hours.
c. irrigate the tube with normal saline every 8 hours.
d. keep the patient supine with the head of the bed elevated 30
degrees. -Answer:-b.
Mouth care should be done frequently for the patient with a small
intestinal obstruction who has an NG tube because of vomiting, fecal
taste and odor, and mouth breathing. No ice chips are allowed when
a patient is NPO because of a bowel obstruction. The NG tube should
Questions and 100% Correct Verified Answers
A patient with inflammatory bowel disease has a nursing diagnosis
of imbalanced nutrition: less than body
requirements related to decreased nutritional intake and decreased
intestinal absorption. Which assessment data
support this nursing diagnosis?
a. Pallor and hair loss
b. Frequent diarrhea stools
c. Anorectal excoriation and pain
d. Hypotension and urine output below 30 mL/hr -Answer:-a.
Signs of malnutrition include pallor from anemia, hair loss, bleeding,
cracked gingivae, and muscle weakness, which support a nursing
diagnosis that identifies impaired nutrition. Diarrhea may
contribute to malnutrition but is not a defining characteristic.
Anorectal excoriation and pain
relate to problems with skin integrity. Hypotension relates to
problems with fluid deficit.
,A physician just told a patient that she has a volvulus. When the
patient asks the nurse what this is, what is the best
description for the nurse to give her?
a. Bowel folding on itself
b. Twisting of bowel on itself
c. Emboli of arterial supply to the bowel
d. Protrusion of bowel in weak or abnormal opening -Answer:-b.
Volvulus is the bowel twisting on itself. The bowel
folding on itself is intussusception. Emboli of arterial blood supply
to the bowel is vascular obstruction. Protrusion of bowel in a weak
or abnormal opening is a hernia
The patient comes to the emergency department with intermittent
crampy abdominal pain, nausea, projectile
vomiting, and dehydration. The nurse suspects a GI obstruction.
Based on the manifestations, what area of the bowel should the
nurse suspect is obstructed?
a. Large intestine
b. Esophageal sphincter
, c. Upper small intestine
d. Lower small intestine -Answer:-c.
Intermittent crampy abdominal pain, nausea, projectile vomiting,
and dehydration are characteristics of mechanical upper small
intestinal obstruction. With continued vomiting, metabolic alkalosis
may occur. Large bowel obstruction is characterized by
constipation, low-grade abdominal pain, and abdominal distention.
Fecal vomiting is seen with lower small intestinal obstruction.
An important nursing intervention for a patient with a small
intestinal obstruction who has an NG tube is to
a. offer ice chips to suck PRN.
b. provide mouth care every 1 to 2 hours.
c. irrigate the tube with normal saline every 8 hours.
d. keep the patient supine with the head of the bed elevated 30
degrees. -Answer:-b.
Mouth care should be done frequently for the patient with a small
intestinal obstruction who has an NG tube because of vomiting, fecal
taste and odor, and mouth breathing. No ice chips are allowed when
a patient is NPO because of a bowel obstruction. The NG tube should
