Med-Surg II HESI Exam - set one
A 34-year-old female is diagnosed with hypothyroidism. The nurse should assess the client
for which of the following? (Select all that apply.)
1. rapid pulse
2. decreased energy and fatigue
3. weight gain of 10 lbs (4.5 kg)
4. fine, thin hair with hair loss
5. constipation
6. menorrhagia. - ANS-2. decreased energy and fatigue, 3. weight gain of 10 lbs (4.5 kg), 5.
constipation, 6. menorrhagia
Clients with hypothyroidism exhibit symptoms indicating a lack of thyroid hormone.
Bradycardia, decreased energy and lethargy, memory problems, weight gain, coarse hair,
constipation, and menorrhagia are common signs and
symptoms of hypothyroidism.
CN: Physiological adaptation; CL: Analyze
\A 60-year-old female is diagnosed with hypothyroidism. The nurse should
assess the client for which of the following?
1. Tachycardia.
2. Weight gain.
3. Diarrhea.
4. Nausea. - ANS-Weight gain
\A client diagnosed with a deep vein thrombosis has heparin sodium infusing at 1,500
units/h. The concentration of heparin is 25,000 units/500 mL. If the infusion remains at the
same rate for a full 12-hour shift, how many milliliters of fluid will infuse?
__________________________-mL. - ANS-360 mL
\A client diagnosed with primary (essential) hypertension is taking
chlorothiazide (Diuril). The nurse determines teaching about this medication is effective
when the client makes the following statement. "I will (Select all that apply.)
1. take my weight daily at the same time each day."
2. not drink alcoholic beverages while on this medication."
3. reduce salt intake in my diet."
4. reduce my dosage if I have severe dizziness."
5. use sunscreen if I have prolonged exposure to sunlight."
6. take the drug late in the evening." - ANS-1. take my weight daily at the same time each
day."
2. not drink alcoholic beverages while on this medication."
3. reduce salt intake in my diet."
5. use sunscreen if I have prolonged exposure to sunlight."
,\A client has a nasogastric (NG) tube following a subtotal gastrectomy. The
nurse should:
1. Irrigate the tube with 30 mL of sterile water every hour, if needed.
2. Reposition the tube if it is not draining well.
3. Monitor the client for nausea, vomiting, and abdominal distention.
4. Turn the machine to high suction if the drainage is sluggish on low suction. - ANS-3.
Monitor the client for nausea, vomiting, and abdominal distention.
\A client has an emergency embolectomy for an embolus in the femoral artery. After the
client returns from the recovery room, in what order, from first to last, should the nurse
provide care?
1. Administer pain medication.
2. Draw blood for laboratory studies.
3. Regulate the IV infusion.
4. Monitor the pulses.
5. Inspect the dressing. - ANS-4. Monitor the pulses.
5. Inspect the dressing.
3. Regulate the IV infusion.
1. Administer pain medication.
2. Draw blood for laboratory studies.
The nurse should first monitor the popliteal and the pedal pulses in the affected extremity
after arterial embolectomy. Monitoring peripheral pulses below the site of
occlusion checks the arterial circulation in the involved extremity. The nurse should next
inspect the dressing to be sure that the client is not bleeding at the surgical site. The
nurse should next regulate the IV infusion to prevent fluid overload. Then the nurse should
assess pain and administer pain medications as prescribed. Last, the nurse can obtain blood
for laboratory studies.
\A client has been diagnosed with adenocarcinoma of the stomach and is
scheduled to undergo a subtotal gastrectomy (Billroth II procedure). During preoperative
teaching, the nurse is reinforcing information about the surgical procedure. Which of the
following explanations is most accurate?
1. The procedure will result in enlargement of the pyloric sphincter.
2. The procedure will result in anastomosis of the gastric stump to the jejunum.
3. The procedure will result in removal of the duodenum.
4. The procedure will result in repositioning of the vagus nerve. - ANS-2. The procedure will
result in anastomosis of the gastric stump to the jejunum.
\A client has been on long-term prednisone therapy. The nurse should instruct the client to
consume a diet high in which of the following? Select all that apply.
1. Carbohydrate.
2. Protein.
3. Trans fat.
4. Potassium.
5. Calcium.
6. Vitamin D. - ANS-2. Protein.
, 4. Potassium.
5. Calcium.
6. Vitamin D.
\A client has been taking aluminum hydroxide 30 mL six times per day at home to treat a
peptic ulcer. The client has been unable to have a bowel movement for 3 days. Based on
this information, the nurse would determine that which of the following is the most likely
cause of the client's constipation?
1. The client has not been including enough fiber in the diet.
2. The client needs to increase the daily exercise.
3. The client is experiencing an adverse effect of the aluminum hydroxide.
4. The client has developed a gastrointestinal obstruction. - ANS-3. The client is
experiencing an adverse effect of the aluminum hydroxide.
\A client is admitted with a 6.5-cm thoracic aneurysm. The nurse records findings from the
initial assessment in the client's chart, as shown below.
At 10:30 AM, the client has sharp mid-chest pain after having a bowel movement. What
should the nurse do first?
1. Assess the client's vital signs.
2. Administer a bolus of lactated Ringer's solution.
3. Assess the client's neurologic status.
4. Contact the physician. - ANS-1. Assess the client's vital signs.
\A client is admitted with a diagnosis of thrombophlebitis and deep vein
thrombosis of the right leg. A loading dose of heparin has been given in the emergency
room, and IV heparin will be continued for the next several days. The nurse should develop
a plan of care for this client that will involve:
1. Administering aspirin as prescribed.
2. Encouraging green leafy vegetables in the diet.
3. Monitoring the client's prothrombin time (PT).
4. Monitoring the client's activated partial thromboplastin time (aPTT) and
International Normalized Ratio (INR). - ANS-4. Monitoring the client's activated partial
thromboplastin time (aPTT) and International Normalized Ratio (INR).
\A client is admitted with an acute onset of shortness of breath. A diagnosis of pulmonary
embolism is made. One common cause of pulmonary embolism is:
1. Arteriosclerosis.
2. Aneurysm formation.
3. Deep vein thrombosis (DVT).
4. Varicose veins. - ANS-3. Deep vein thrombosis (DVT).
\A client is on complete bed rest. The nurse should assess the client for risk for developing
which of the following complications?
1. Air embolus.
2. Fat embolus.
3. Stress fractures.
4. Thrombophlebitis. - ANS-4. Thrombophlebitis.
\A client is receiving an IV infusion of 5% dextrose in water (D5W). The skin
A 34-year-old female is diagnosed with hypothyroidism. The nurse should assess the client
for which of the following? (Select all that apply.)
1. rapid pulse
2. decreased energy and fatigue
3. weight gain of 10 lbs (4.5 kg)
4. fine, thin hair with hair loss
5. constipation
6. menorrhagia. - ANS-2. decreased energy and fatigue, 3. weight gain of 10 lbs (4.5 kg), 5.
constipation, 6. menorrhagia
Clients with hypothyroidism exhibit symptoms indicating a lack of thyroid hormone.
Bradycardia, decreased energy and lethargy, memory problems, weight gain, coarse hair,
constipation, and menorrhagia are common signs and
symptoms of hypothyroidism.
CN: Physiological adaptation; CL: Analyze
\A 60-year-old female is diagnosed with hypothyroidism. The nurse should
assess the client for which of the following?
1. Tachycardia.
2. Weight gain.
3. Diarrhea.
4. Nausea. - ANS-Weight gain
\A client diagnosed with a deep vein thrombosis has heparin sodium infusing at 1,500
units/h. The concentration of heparin is 25,000 units/500 mL. If the infusion remains at the
same rate for a full 12-hour shift, how many milliliters of fluid will infuse?
__________________________-mL. - ANS-360 mL
\A client diagnosed with primary (essential) hypertension is taking
chlorothiazide (Diuril). The nurse determines teaching about this medication is effective
when the client makes the following statement. "I will (Select all that apply.)
1. take my weight daily at the same time each day."
2. not drink alcoholic beverages while on this medication."
3. reduce salt intake in my diet."
4. reduce my dosage if I have severe dizziness."
5. use sunscreen if I have prolonged exposure to sunlight."
6. take the drug late in the evening." - ANS-1. take my weight daily at the same time each
day."
2. not drink alcoholic beverages while on this medication."
3. reduce salt intake in my diet."
5. use sunscreen if I have prolonged exposure to sunlight."
,\A client has a nasogastric (NG) tube following a subtotal gastrectomy. The
nurse should:
1. Irrigate the tube with 30 mL of sterile water every hour, if needed.
2. Reposition the tube if it is not draining well.
3. Monitor the client for nausea, vomiting, and abdominal distention.
4. Turn the machine to high suction if the drainage is sluggish on low suction. - ANS-3.
Monitor the client for nausea, vomiting, and abdominal distention.
\A client has an emergency embolectomy for an embolus in the femoral artery. After the
client returns from the recovery room, in what order, from first to last, should the nurse
provide care?
1. Administer pain medication.
2. Draw blood for laboratory studies.
3. Regulate the IV infusion.
4. Monitor the pulses.
5. Inspect the dressing. - ANS-4. Monitor the pulses.
5. Inspect the dressing.
3. Regulate the IV infusion.
1. Administer pain medication.
2. Draw blood for laboratory studies.
The nurse should first monitor the popliteal and the pedal pulses in the affected extremity
after arterial embolectomy. Monitoring peripheral pulses below the site of
occlusion checks the arterial circulation in the involved extremity. The nurse should next
inspect the dressing to be sure that the client is not bleeding at the surgical site. The
nurse should next regulate the IV infusion to prevent fluid overload. Then the nurse should
assess pain and administer pain medications as prescribed. Last, the nurse can obtain blood
for laboratory studies.
\A client has been diagnosed with adenocarcinoma of the stomach and is
scheduled to undergo a subtotal gastrectomy (Billroth II procedure). During preoperative
teaching, the nurse is reinforcing information about the surgical procedure. Which of the
following explanations is most accurate?
1. The procedure will result in enlargement of the pyloric sphincter.
2. The procedure will result in anastomosis of the gastric stump to the jejunum.
3. The procedure will result in removal of the duodenum.
4. The procedure will result in repositioning of the vagus nerve. - ANS-2. The procedure will
result in anastomosis of the gastric stump to the jejunum.
\A client has been on long-term prednisone therapy. The nurse should instruct the client to
consume a diet high in which of the following? Select all that apply.
1. Carbohydrate.
2. Protein.
3. Trans fat.
4. Potassium.
5. Calcium.
6. Vitamin D. - ANS-2. Protein.
, 4. Potassium.
5. Calcium.
6. Vitamin D.
\A client has been taking aluminum hydroxide 30 mL six times per day at home to treat a
peptic ulcer. The client has been unable to have a bowel movement for 3 days. Based on
this information, the nurse would determine that which of the following is the most likely
cause of the client's constipation?
1. The client has not been including enough fiber in the diet.
2. The client needs to increase the daily exercise.
3. The client is experiencing an adverse effect of the aluminum hydroxide.
4. The client has developed a gastrointestinal obstruction. - ANS-3. The client is
experiencing an adverse effect of the aluminum hydroxide.
\A client is admitted with a 6.5-cm thoracic aneurysm. The nurse records findings from the
initial assessment in the client's chart, as shown below.
At 10:30 AM, the client has sharp mid-chest pain after having a bowel movement. What
should the nurse do first?
1. Assess the client's vital signs.
2. Administer a bolus of lactated Ringer's solution.
3. Assess the client's neurologic status.
4. Contact the physician. - ANS-1. Assess the client's vital signs.
\A client is admitted with a diagnosis of thrombophlebitis and deep vein
thrombosis of the right leg. A loading dose of heparin has been given in the emergency
room, and IV heparin will be continued for the next several days. The nurse should develop
a plan of care for this client that will involve:
1. Administering aspirin as prescribed.
2. Encouraging green leafy vegetables in the diet.
3. Monitoring the client's prothrombin time (PT).
4. Monitoring the client's activated partial thromboplastin time (aPTT) and
International Normalized Ratio (INR). - ANS-4. Monitoring the client's activated partial
thromboplastin time (aPTT) and International Normalized Ratio (INR).
\A client is admitted with an acute onset of shortness of breath. A diagnosis of pulmonary
embolism is made. One common cause of pulmonary embolism is:
1. Arteriosclerosis.
2. Aneurysm formation.
3. Deep vein thrombosis (DVT).
4. Varicose veins. - ANS-3. Deep vein thrombosis (DVT).
\A client is on complete bed rest. The nurse should assess the client for risk for developing
which of the following complications?
1. Air embolus.
2. Fat embolus.
3. Stress fractures.
4. Thrombophlebitis. - ANS-4. Thrombophlebitis.
\A client is receiving an IV infusion of 5% dextrose in water (D5W). The skin
