MED SURG HESI 2025
A client has had surgery to repair a fractured left hip. When repositioning the client from side
to side in the bed, what should the nurse plan to use as the most important item for this
maneuver? - ANS-Abductor splint
Rationale: After surgery to repair a fractured hip, an abductor splint is used to maintain the
affected extremity in good alignment. A bed pillow and an overhead trapeze also are used,
but neither is the priority item to be used in repositioning the client from side to side
\A client is admitted to the hospital emergency department after receiving a burn injury in a
house fire. The skin on the client's trunk is tan, dry, and hard. It is edematous but not very
painful. The nurse determines that this client's burn should be classified as which type? -
ANS-Full-thickness
Rationale: Full-thickness burns involve the epidermis, the full dermis, and some of the
subcutaneous fat layer. The burn appears to be a tan or fawn color, with skin that is hard,
dry, and inelastic. Edema is severe, and the accumulated fluid compresses tissue
underneath because of eschar formation. Some nerve endings have been damaged, and the
area may be insensitive to touch, with little or no pain.
\A client is admitted with suspected diabetic ketoacidosis (DKA). Which clinical
manifestations best support a diagnosis of DKA? - ANS-Blood glucose 350 mg/dL (19.4
mmol/L); arterial blood gases: pH 7.28, PaCo2 30, HCO3- 14.
Rationale: DKA is caused by a profound deficiency of insulin and is characterized by
hyperglycemia
(blood glucose level greater than or equal to 250 mg/dL [13.9 mmol/L]), ketosis (ketones in
urine or
serum), metabolic acidosis, and dehydration. The correct option is 4, as it represents an
elevated blood
glucose and the arterial blood gases (ABGs) indicate metabolic acidosis.
\A client is readmitted to the hospital with dehydration after surgery for creation of an
ileostomy. The nurse assesses that the client has lost 3 lb of weight, has poor skin turgor,
and has concentrated urine. The nurse interprets the client's clinical picture as correlating
most closely with recent intake of which medication, which is contraindicated for the
ileostomy client? - ANS-Biscodyl
Rationale: The client with an ileostomy is prone to dehydration because of the location of the
ostomy in the gastrointestinal tract and should not take laxatives
\A client is scheduled for surgical creation of an internal arteriovenous (AV) fistula on the
following day. The client says to the nurse, "I'll be so happy when the fistula is made
tomorrow. This means I can have that other hemodialysis catheter pulled right out." Which
interpretation should the nurse make based on the client's statement? - ANS-The client does
not understand that the site needs to mature or develop for 1 to 2 weeks before use.
, Rationale: An AV fistula is the internal creation of an arterial-to-venous anastomosis. This
causes
engorgement of the vein, allowing both the artery and the vein to be easily cannulated for
hemodialysis.
Fistulas take 1 to 2 weeks to mature (engorgement) or develop before they can be used for
dialysis, so
the current method of access must remain in place to be used during that period
\A client uses triamcinolone (kenalog), a corticosteroid ointment, to manage pruritis caused
by a chronic skin rash. The client calls the clinic nurse to report increased erythema with
purulent exudate at the site. What action should the nurse implement? - ANS-Schedule an
appointment for the client to the healthcare provider.
\A client who has undergone gastric surgery has a nasogastric (NG) tube connected to low
intermittent suction that is not draining properly. Which action should the nurse take initially?
A. call the surgeon to report the problem.
B. Reposition the NG tube to the proper location.
C. Check the suction device to make sure it is working.
D. Irrigate the NG tube with saline to remove the obstruction. - ANS-C. Check the suction
device to make sure it is working.
Rationale:
After gastric surgery, the client will have an NG tube in place until bowel function returns. It is
important
for the NG tube to drain properly to prevent abdominal distention and vomiting. The nurse
must ensure that the NG tube is attached to suction at the level prescribed and that the
suction device is working
correctly. The tip of the NG tube may be placed near the suture line. Because of this
possibility, the nurse
should never reposition the NG tube or irrigate it. If the NG tube needs to be repositioned,
the nurse
should call the surgeon, who would do this repositioning under fluoroscopy
\A client with a history of ear problems is going on vacation by aircraft. The nurse advises
the client to include which activities to prevent barotrauma during ascent and descent of the
airplane? Select all that apply: - ANS-- Yawning
- Swallowing
- Chewing gum
- Sucking on a hard candy
Rationale:
Clients who are prone to barotrauma should perform any of a variety of mouth movements to
equalize pressure between the ear and the atmosphere, particularly during ascent and
descent of an aircraft. These can include yawning, swallowing, drinking, chewing, and
sucking on hard candy. Valsalva maneuver also may be helpful. The client should avoid
sitting with the mouth motionless during this time because the resulting lack of pressure
change in the ear will contribute to pressure buildup behind the tympanic membrane.
\A client with acute ulcerative colitis requests a snack. Which is the most appropriate snack
for this client?
A. Carrots and ranch dip
A client has had surgery to repair a fractured left hip. When repositioning the client from side
to side in the bed, what should the nurse plan to use as the most important item for this
maneuver? - ANS-Abductor splint
Rationale: After surgery to repair a fractured hip, an abductor splint is used to maintain the
affected extremity in good alignment. A bed pillow and an overhead trapeze also are used,
but neither is the priority item to be used in repositioning the client from side to side
\A client is admitted to the hospital emergency department after receiving a burn injury in a
house fire. The skin on the client's trunk is tan, dry, and hard. It is edematous but not very
painful. The nurse determines that this client's burn should be classified as which type? -
ANS-Full-thickness
Rationale: Full-thickness burns involve the epidermis, the full dermis, and some of the
subcutaneous fat layer. The burn appears to be a tan or fawn color, with skin that is hard,
dry, and inelastic. Edema is severe, and the accumulated fluid compresses tissue
underneath because of eschar formation. Some nerve endings have been damaged, and the
area may be insensitive to touch, with little or no pain.
\A client is admitted with suspected diabetic ketoacidosis (DKA). Which clinical
manifestations best support a diagnosis of DKA? - ANS-Blood glucose 350 mg/dL (19.4
mmol/L); arterial blood gases: pH 7.28, PaCo2 30, HCO3- 14.
Rationale: DKA is caused by a profound deficiency of insulin and is characterized by
hyperglycemia
(blood glucose level greater than or equal to 250 mg/dL [13.9 mmol/L]), ketosis (ketones in
urine or
serum), metabolic acidosis, and dehydration. The correct option is 4, as it represents an
elevated blood
glucose and the arterial blood gases (ABGs) indicate metabolic acidosis.
\A client is readmitted to the hospital with dehydration after surgery for creation of an
ileostomy. The nurse assesses that the client has lost 3 lb of weight, has poor skin turgor,
and has concentrated urine. The nurse interprets the client's clinical picture as correlating
most closely with recent intake of which medication, which is contraindicated for the
ileostomy client? - ANS-Biscodyl
Rationale: The client with an ileostomy is prone to dehydration because of the location of the
ostomy in the gastrointestinal tract and should not take laxatives
\A client is scheduled for surgical creation of an internal arteriovenous (AV) fistula on the
following day. The client says to the nurse, "I'll be so happy when the fistula is made
tomorrow. This means I can have that other hemodialysis catheter pulled right out." Which
interpretation should the nurse make based on the client's statement? - ANS-The client does
not understand that the site needs to mature or develop for 1 to 2 weeks before use.
, Rationale: An AV fistula is the internal creation of an arterial-to-venous anastomosis. This
causes
engorgement of the vein, allowing both the artery and the vein to be easily cannulated for
hemodialysis.
Fistulas take 1 to 2 weeks to mature (engorgement) or develop before they can be used for
dialysis, so
the current method of access must remain in place to be used during that period
\A client uses triamcinolone (kenalog), a corticosteroid ointment, to manage pruritis caused
by a chronic skin rash. The client calls the clinic nurse to report increased erythema with
purulent exudate at the site. What action should the nurse implement? - ANS-Schedule an
appointment for the client to the healthcare provider.
\A client who has undergone gastric surgery has a nasogastric (NG) tube connected to low
intermittent suction that is not draining properly. Which action should the nurse take initially?
A. call the surgeon to report the problem.
B. Reposition the NG tube to the proper location.
C. Check the suction device to make sure it is working.
D. Irrigate the NG tube with saline to remove the obstruction. - ANS-C. Check the suction
device to make sure it is working.
Rationale:
After gastric surgery, the client will have an NG tube in place until bowel function returns. It is
important
for the NG tube to drain properly to prevent abdominal distention and vomiting. The nurse
must ensure that the NG tube is attached to suction at the level prescribed and that the
suction device is working
correctly. The tip of the NG tube may be placed near the suture line. Because of this
possibility, the nurse
should never reposition the NG tube or irrigate it. If the NG tube needs to be repositioned,
the nurse
should call the surgeon, who would do this repositioning under fluoroscopy
\A client with a history of ear problems is going on vacation by aircraft. The nurse advises
the client to include which activities to prevent barotrauma during ascent and descent of the
airplane? Select all that apply: - ANS-- Yawning
- Swallowing
- Chewing gum
- Sucking on a hard candy
Rationale:
Clients who are prone to barotrauma should perform any of a variety of mouth movements to
equalize pressure between the ear and the atmosphere, particularly during ascent and
descent of an aircraft. These can include yawning, swallowing, drinking, chewing, and
sucking on hard candy. Valsalva maneuver also may be helpful. The client should avoid
sitting with the mouth motionless during this time because the resulting lack of pressure
change in the ear will contribute to pressure buildup behind the tympanic membrane.
\A client with acute ulcerative colitis requests a snack. Which is the most appropriate snack
for this client?
A. Carrots and ranch dip
