WGU Med Surg HESI [2026/2027] Updated Version
| Verified Questions & Detailed
Rationales\LATEST UPDATE
A client has been hospitalized with a femur fracture and is being treated with
traction. Which action by the nurse is the priority when caring for this client?
Assess neurovascular status. Correct
Change the client's position.
Inspect the traction equipment.
Review pain medication orders.
The use of traction for long bone fractures reduces the potential for damage to
the surrounding tissues. Reports of increased pain may indicate circulatory
compromise or tissue damage (compartment syndrome). Assessing the client's
neurovascular status is the nurse's highest priority.
,A client is placed on a mechanical ventilator following a cerebral hemorrhage,
and vecuronium bromide 0.04 mg/kg q12 hours IV is prescribed. Which is the
priority nursing diagnosis for this client?
Impaired communication related to paralysis of skeletal muscles. Correct
High risk for infection related to increased intracranial pressure.
Potential for injury related to impaired lung expansion.
Social isolation related to inability to communicate.
To increase the client's tolerance of endotracheal intubation and/or mechanical
ventilation, a skeletal-muscle relaxant, such as vecuronium, is usually prescribed.
Impaired communication is a serious outcome because the client cannot
communicate his/her needs due to intubation and diaphragmatic paralysis
caused by the drug.
An elderly client is admitted with a diagnosis of bacterial pneumonia. When
observing the client for the first signs of decreasing oxygenation, the nurse
should assess for which clinical cues?
Abominal distention.
Undue fatigue.
Cyanosis of the lips.
Confusion and tachycardia. Correct
The onset of pneumonia in the elderly may be signaled by general deterioration,
confusion, increased heart rate or increased respiratory rate due to the
decreased oxygen- carbon dioxide exchange at the alveoli, known as the V-Q
mismatch. Cyanosis is a very late sign.
,The nurse is interviewing a male client with hypertension. Which additional
medical diagnosis in the client's history presents the greatest risk for
developing a cerebral vascular accident (CVA)?
Diabetes mellitus. Correct
Hypothyroidism.
Parkinson's disease.
Recurring pneumonia.
According to the National Stroke Association (2013), history of diabetes mellitus
poses the greatest risk for developing a CVA, 2-4Xs more than those who do not
have diabetes mellitus. The reason for this occurrence is related to the excess
glucose circulating throughout the body not being utilized by the cells, leading
to increased fatty deposits or clots inside the blood vessels in the brain or neck,
eventually causing a stroke.
A client with heart disease is on a continuous telemetry monitor and has
developed sinus bradycardia. In determining the possible cause of the
bradycardia, the nurse assesses the client's medication record. Which
medication is most likely the cause of the bradycardia?
Propanolol. Correct
Captopril.
Furosemide.
Dobutamine.
Propanolol is a beta adrenergic blocking agent, which causes decreased heart
rate and decreased contractility.
, Which symptoms should the nurse expect a client to exhibit who is diagnosed
with a pheochromocytoma?
Numbness, tingling, and cramps in the extremities.
Headache, diaphoresis, and palpitations. Correct
Cyanosis, fever, and classic signs of shock.
Nausea, vomiting, and muscular weakness.
Pheochromocytoma is a catecholamine secreting non-cancerous tumor of the
adrenal medulla, and a headache, profuse sweating and palpitations is the
typical triad of symptoms depending upon the relative proportions of
epinephrine and norepinephrine secretion. Surgical removal of the tumor is the
only treatment.
| Verified Questions & Detailed
Rationales\LATEST UPDATE
A client has been hospitalized with a femur fracture and is being treated with
traction. Which action by the nurse is the priority when caring for this client?
Assess neurovascular status. Correct
Change the client's position.
Inspect the traction equipment.
Review pain medication orders.
The use of traction for long bone fractures reduces the potential for damage to
the surrounding tissues. Reports of increased pain may indicate circulatory
compromise or tissue damage (compartment syndrome). Assessing the client's
neurovascular status is the nurse's highest priority.
,A client is placed on a mechanical ventilator following a cerebral hemorrhage,
and vecuronium bromide 0.04 mg/kg q12 hours IV is prescribed. Which is the
priority nursing diagnosis for this client?
Impaired communication related to paralysis of skeletal muscles. Correct
High risk for infection related to increased intracranial pressure.
Potential for injury related to impaired lung expansion.
Social isolation related to inability to communicate.
To increase the client's tolerance of endotracheal intubation and/or mechanical
ventilation, a skeletal-muscle relaxant, such as vecuronium, is usually prescribed.
Impaired communication is a serious outcome because the client cannot
communicate his/her needs due to intubation and diaphragmatic paralysis
caused by the drug.
An elderly client is admitted with a diagnosis of bacterial pneumonia. When
observing the client for the first signs of decreasing oxygenation, the nurse
should assess for which clinical cues?
Abominal distention.
Undue fatigue.
Cyanosis of the lips.
Confusion and tachycardia. Correct
The onset of pneumonia in the elderly may be signaled by general deterioration,
confusion, increased heart rate or increased respiratory rate due to the
decreased oxygen- carbon dioxide exchange at the alveoli, known as the V-Q
mismatch. Cyanosis is a very late sign.
,The nurse is interviewing a male client with hypertension. Which additional
medical diagnosis in the client's history presents the greatest risk for
developing a cerebral vascular accident (CVA)?
Diabetes mellitus. Correct
Hypothyroidism.
Parkinson's disease.
Recurring pneumonia.
According to the National Stroke Association (2013), history of diabetes mellitus
poses the greatest risk for developing a CVA, 2-4Xs more than those who do not
have diabetes mellitus. The reason for this occurrence is related to the excess
glucose circulating throughout the body not being utilized by the cells, leading
to increased fatty deposits or clots inside the blood vessels in the brain or neck,
eventually causing a stroke.
A client with heart disease is on a continuous telemetry monitor and has
developed sinus bradycardia. In determining the possible cause of the
bradycardia, the nurse assesses the client's medication record. Which
medication is most likely the cause of the bradycardia?
Propanolol. Correct
Captopril.
Furosemide.
Dobutamine.
Propanolol is a beta adrenergic blocking agent, which causes decreased heart
rate and decreased contractility.
, Which symptoms should the nurse expect a client to exhibit who is diagnosed
with a pheochromocytoma?
Numbness, tingling, and cramps in the extremities.
Headache, diaphoresis, and palpitations. Correct
Cyanosis, fever, and classic signs of shock.
Nausea, vomiting, and muscular weakness.
Pheochromocytoma is a catecholamine secreting non-cancerous tumor of the
adrenal medulla, and a headache, profuse sweating and palpitations is the
typical triad of symptoms depending upon the relative proportions of
epinephrine and norepinephrine secretion. Surgical removal of the tumor is the
only treatment.
