Med Surg HESI Exam Questions with Detailed
Answers | Medical-Surgical Nursing Study
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Which statement made by a client with chronic pancreatitis indicates
that further education is needed?
I will cut back on smoking cigarettes daily. Correct
I will avoid drinking caffeinated beverages.
I will rest frequently and avoid vigorous exercise. Incorrect
I will eat a bland, low-fat, high-protein diet.
To prevent exacerbations of chronic pancreatitis, clients should be
instructed to avoid nicotine entirely. Additional teaching includes
avoiding caffeinated beverages, resting frequently as needed, and
eating a bland diet low fat and high in protein.
How should the nurse position the electrodes for modified chest lead
one (MCL I) telemetry monitoring?
Negative polarity left shoulder, positive polarity right chest nipple
line, ground left chest nipple line. Correct
In MCL I monitoring, the positive electrode is placed on the client's
mid-chest to the right of the sternum, and the negative electrode is
placed on the upper left part of the chest. The ground may be placed
anywhere, but is usually placed on the lower left portion of the chest.
,In preparing to administer intravenous albumin to a client following
surgery, which are the priority nursing interventions? (Select all that
apply.)
Set the infusion pump to infuse the albumin within four
hours. Correct
Compare the client's blood type with the label on the albumin.
Assign a UAP to monitor blood pressure q15 minutes.
Administer through a large gauge catheter. Correct
Monitor hemoglobin and hematocrit levels. Correct
Assess for increased bleeding after administration. Correct
Albumin should be infused within four hours because it does not
contain any preservatives. Any fluid remaining after four hours
should be discarded. A large gauge catheter allows for fast infusion
rate, which may be necessary. Hemodilution may decrease
hemoglobin (HgB) and hematocrit (HCT) levels, so the HgB and HCT
levels should be monitored while monitoring for bleeding because of
the increased blood volume and blood pressure.
A client who has heart failure is admitted with a serum potassium
level of 2.9 mEq/L (2.9 mmol/L). Which action is most important for
the nurse to implement?
Give 20 mEq of potassium chloride.
Initiate continuous cardiac monitoring. Correct
Arrange a consultation with the dietician.
Teach about the side effects of diuretics.
Hypokalemia (normal 3.5 to 5 mEq/L [3.5 to 5 mmol/L]) causes
changes in myocardial irritability and ECG waveform, so it is most
important for the nurse to initiate continuous cardiac monitoring to
identify ventricular ectopy or other life-threatening dysrhythmias.
After cardiac monitoring is initiated, then the potassium chloride
,should be given so that the effects of potassium replacement on the
cardiac rhythm can be monitored.
After checking the urinary drainage system for kinks in the tubing,
the nurse determines that a client who has returned from the post-
anesthesia care has a dark, concentrated urinary output of 54 mL for
the last 2 hours. Which priority nursing action should be
implemented?
Report the findings to the surgeon. Correct
Irrigate the indwelling urinary catheter.
Apply manual pressure to the bladder.
Increase the IV flow rate for 15 minutes. Incorrect
After surgery, an adult who weighs 132 pounds (60 kg) should
produce about 60 mL of urine hourly (1 mL/kg/hour). Dark,
concentrated, and low volume of urine output should be reported to
the surgeon.
Two days postoperative, a male client reports aching pain in his left
leg. The nurse assesses redness and warmth on the lower left calf.
Which intervention would be most helpful to this client?
Apply sequential compression devices (SCDs) bilaterally.
Assess for a positive Homan's sign in each leg. Incorrect
Pad all bony prominences on the affected leg.
Advise the client to remain in bed with the leg elevated. Correct
For a client exhibiting symptoms of deep vein thrombosis (DVT), a
complication of immobility, the initial care includes bedrest and
elevation of the extremity.
Which description of pain is consistent with a diagnosis
of rheumatoid arthritis?
, Joint pain is worse in the morning and involves symmetric
joints. Correct
Joint pain is better in the morning and worsens throughout the day.
Joint pain is consistent throughout the day and is relieved by pain
medication. Incorrect
Joint pain is worse during the day and involves unilateral joints.
Rheumatoid arthritis (RA) is an autoimmune disease that causes joint
pain and swelling. RA is characterized by pain that is worse when
arising and involves symmetric joints.
A client’s susceptibility to ulcerative colitis is most likely due to
which aspect in the client’s history?
Jewish European ancestry. Correct
H. pylori bowel infection.
Family history of irritable bowel syndrome.
Age between 25 and 55 years.
Ulcerative colitis is 4 to 5 times more common among individuals of
Jewish European or Ashkenazi ancestry.
While working in the emergency room, the nurse is exposed to a
client with active tuberculosis. When should the nurse plan to obtain
a tuberculin skin test?
Immediately after the exposure.
Within one week of the exposure.
Four to six weeks after the exposure. Correct
Three months after the exposure.
A tuberculin skin test is effective 4 to 6 weeks after an exposure, so
the individual with a known exposure should wait 4 to 6 weeks before
having a tuberculin skin test.
Answers | Medical-Surgical Nursing Study
Guide|100% Guarantee Pass| Well Verified and
Updated| Newest Exam |Latest Exam and Brand
new Version!!!!
Which statement made by a client with chronic pancreatitis indicates
that further education is needed?
I will cut back on smoking cigarettes daily. Correct
I will avoid drinking caffeinated beverages.
I will rest frequently and avoid vigorous exercise. Incorrect
I will eat a bland, low-fat, high-protein diet.
To prevent exacerbations of chronic pancreatitis, clients should be
instructed to avoid nicotine entirely. Additional teaching includes
avoiding caffeinated beverages, resting frequently as needed, and
eating a bland diet low fat and high in protein.
How should the nurse position the electrodes for modified chest lead
one (MCL I) telemetry monitoring?
Negative polarity left shoulder, positive polarity right chest nipple
line, ground left chest nipple line. Correct
In MCL I monitoring, the positive electrode is placed on the client's
mid-chest to the right of the sternum, and the negative electrode is
placed on the upper left part of the chest. The ground may be placed
anywhere, but is usually placed on the lower left portion of the chest.
,In preparing to administer intravenous albumin to a client following
surgery, which are the priority nursing interventions? (Select all that
apply.)
Set the infusion pump to infuse the albumin within four
hours. Correct
Compare the client's blood type with the label on the albumin.
Assign a UAP to monitor blood pressure q15 minutes.
Administer through a large gauge catheter. Correct
Monitor hemoglobin and hematocrit levels. Correct
Assess for increased bleeding after administration. Correct
Albumin should be infused within four hours because it does not
contain any preservatives. Any fluid remaining after four hours
should be discarded. A large gauge catheter allows for fast infusion
rate, which may be necessary. Hemodilution may decrease
hemoglobin (HgB) and hematocrit (HCT) levels, so the HgB and HCT
levels should be monitored while monitoring for bleeding because of
the increased blood volume and blood pressure.
A client who has heart failure is admitted with a serum potassium
level of 2.9 mEq/L (2.9 mmol/L). Which action is most important for
the nurse to implement?
Give 20 mEq of potassium chloride.
Initiate continuous cardiac monitoring. Correct
Arrange a consultation with the dietician.
Teach about the side effects of diuretics.
Hypokalemia (normal 3.5 to 5 mEq/L [3.5 to 5 mmol/L]) causes
changes in myocardial irritability and ECG waveform, so it is most
important for the nurse to initiate continuous cardiac monitoring to
identify ventricular ectopy or other life-threatening dysrhythmias.
After cardiac monitoring is initiated, then the potassium chloride
,should be given so that the effects of potassium replacement on the
cardiac rhythm can be monitored.
After checking the urinary drainage system for kinks in the tubing,
the nurse determines that a client who has returned from the post-
anesthesia care has a dark, concentrated urinary output of 54 mL for
the last 2 hours. Which priority nursing action should be
implemented?
Report the findings to the surgeon. Correct
Irrigate the indwelling urinary catheter.
Apply manual pressure to the bladder.
Increase the IV flow rate for 15 minutes. Incorrect
After surgery, an adult who weighs 132 pounds (60 kg) should
produce about 60 mL of urine hourly (1 mL/kg/hour). Dark,
concentrated, and low volume of urine output should be reported to
the surgeon.
Two days postoperative, a male client reports aching pain in his left
leg. The nurse assesses redness and warmth on the lower left calf.
Which intervention would be most helpful to this client?
Apply sequential compression devices (SCDs) bilaterally.
Assess for a positive Homan's sign in each leg. Incorrect
Pad all bony prominences on the affected leg.
Advise the client to remain in bed with the leg elevated. Correct
For a client exhibiting symptoms of deep vein thrombosis (DVT), a
complication of immobility, the initial care includes bedrest and
elevation of the extremity.
Which description of pain is consistent with a diagnosis
of rheumatoid arthritis?
, Joint pain is worse in the morning and involves symmetric
joints. Correct
Joint pain is better in the morning and worsens throughout the day.
Joint pain is consistent throughout the day and is relieved by pain
medication. Incorrect
Joint pain is worse during the day and involves unilateral joints.
Rheumatoid arthritis (RA) is an autoimmune disease that causes joint
pain and swelling. RA is characterized by pain that is worse when
arising and involves symmetric joints.
A client’s susceptibility to ulcerative colitis is most likely due to
which aspect in the client’s history?
Jewish European ancestry. Correct
H. pylori bowel infection.
Family history of irritable bowel syndrome.
Age between 25 and 55 years.
Ulcerative colitis is 4 to 5 times more common among individuals of
Jewish European or Ashkenazi ancestry.
While working in the emergency room, the nurse is exposed to a
client with active tuberculosis. When should the nurse plan to obtain
a tuberculin skin test?
Immediately after the exposure.
Within one week of the exposure.
Four to six weeks after the exposure. Correct
Three months after the exposure.
A tuberculin skin test is effective 4 to 6 weeks after an exposure, so
the individual with a known exposure should wait 4 to 6 weeks before
having a tuberculin skin test.
