Med Surg 1 HESI Final T2 with Complete
Solutions
1. A nurse is visiting a client who is receiving home health care, focusing on
medication and dietary instructions and management of heart failure. The nurse
should reinforce which instruction?
A.) If you feel tired and short of breath, lie down flat and prop up your feet.
B.) Eating liver several times a week will help build up your strength.
C.) Your daily dose of furosemide should be taken first thing in the morning.
D.) The dose of enalapril will help prevent vasodilation from occurring.
Answer: C
2. A nurse planning care for a client who has undergone transurethral resection of
the prostate (TURP) remembers that the most common cause of postoperative
pain is which factor?
A.) Bladder spasms
B.) Bleeding within the bladder
C.) The location of the incision
D.) Tension on the Foley catheter
Answer: A
,3. A nurse assessing the skin of a client who is immobile notes this change in
appearance of the skin in the sacral area:
The nurse documents this finding in which way?
A.) Stage I pressure ulcer
B.) Stage II pressure ulcer
C.) Stage III pressure ulcer
D.) Stage IV pressure ulcer
Answer: A
4. A nurse reinforces teaching given to a client with gastroesophageal reflux
disease (GERD) about measures to manage the disease. What does the nurse
encourage the client to do to obtain relief of the symptoms?
A.) Limit intake of coffee and tea.
B.) Eat three large, well-balanced meals per day.
C.) Rest in a supine position for 30 minutes after each meal.
D.) Elevate the head of the bed at least 6 to 8 inches for sleep.
Answer: D
5. A nurse provides instructions to a client who is taking allopurinol for the
treatment of gout. Which statements by the client indicate an understanding of
the medication?
A.) "I need to take the medication 1 hour before I eat."
B.) "I need to drink at least 8 glasses of fluid every day."
, C. "I'll start taking a vitamin C supplement each morning."
D.) "I can use an antihistamine lotion if I get an itchy rash."
Answer: B
6. A client with phantom limb pain has decided to use transcutaneous electrical
nerve stimulation (TENS) as prescribed by the health care provider. The nurse
reinforces instructions regarding the use of the TENS unit. Which statements by
the client indicate a need for further instruction regarding this pain-relief measure?
A.) "I'm so glad this will help relieve the pain."
B.) "Now I won't need to take so many pain medications."
C.) "I need to put the electrodes on the areas that you marked."
D.) "I'm not sure I'm going to like having those electrodes attached to my skin."
Answer: C
7. A hospitalized client has just been found to have acute renal failure (ARF). The
laboratory calls the nursing unit and reports that the client has a serum potassium
level of 6.4 mEq/L. On the basis of this laboratory finding, the nurse should first
take which action?
A.) Call the health care provider
B.) Check the client's sodium level
C.) Encourage the client to increase fluid intake
D.) Have the client decrease intake of potassium-rich foods
Answer: A
Solutions
1. A nurse is visiting a client who is receiving home health care, focusing on
medication and dietary instructions and management of heart failure. The nurse
should reinforce which instruction?
A.) If you feel tired and short of breath, lie down flat and prop up your feet.
B.) Eating liver several times a week will help build up your strength.
C.) Your daily dose of furosemide should be taken first thing in the morning.
D.) The dose of enalapril will help prevent vasodilation from occurring.
Answer: C
2. A nurse planning care for a client who has undergone transurethral resection of
the prostate (TURP) remembers that the most common cause of postoperative
pain is which factor?
A.) Bladder spasms
B.) Bleeding within the bladder
C.) The location of the incision
D.) Tension on the Foley catheter
Answer: A
,3. A nurse assessing the skin of a client who is immobile notes this change in
appearance of the skin in the sacral area:
The nurse documents this finding in which way?
A.) Stage I pressure ulcer
B.) Stage II pressure ulcer
C.) Stage III pressure ulcer
D.) Stage IV pressure ulcer
Answer: A
4. A nurse reinforces teaching given to a client with gastroesophageal reflux
disease (GERD) about measures to manage the disease. What does the nurse
encourage the client to do to obtain relief of the symptoms?
A.) Limit intake of coffee and tea.
B.) Eat three large, well-balanced meals per day.
C.) Rest in a supine position for 30 minutes after each meal.
D.) Elevate the head of the bed at least 6 to 8 inches for sleep.
Answer: D
5. A nurse provides instructions to a client who is taking allopurinol for the
treatment of gout. Which statements by the client indicate an understanding of
the medication?
A.) "I need to take the medication 1 hour before I eat."
B.) "I need to drink at least 8 glasses of fluid every day."
, C. "I'll start taking a vitamin C supplement each morning."
D.) "I can use an antihistamine lotion if I get an itchy rash."
Answer: B
6. A client with phantom limb pain has decided to use transcutaneous electrical
nerve stimulation (TENS) as prescribed by the health care provider. The nurse
reinforces instructions regarding the use of the TENS unit. Which statements by
the client indicate a need for further instruction regarding this pain-relief measure?
A.) "I'm so glad this will help relieve the pain."
B.) "Now I won't need to take so many pain medications."
C.) "I need to put the electrodes on the areas that you marked."
D.) "I'm not sure I'm going to like having those electrodes attached to my skin."
Answer: C
7. A hospitalized client has just been found to have acute renal failure (ARF). The
laboratory calls the nursing unit and reports that the client has a serum potassium
level of 6.4 mEq/L. On the basis of this laboratory finding, the nurse should first
take which action?
A.) Call the health care provider
B.) Check the client's sodium level
C.) Encourage the client to increase fluid intake
D.) Have the client decrease intake of potassium-rich foods
Answer: A
