MEDSURG-HESI EXAM
QUESTIONS AND VERIFIED
ANSWERS LATEST UPDATE
During the assessment of a client who is 24 hours post-hemicolectomy with a
temporary colostomy, the nurse determines that the client's stoma is dry and
dark red in color. What action should the nurse implement?
A) Notify the surgeon.
B) Document the assessment.
C) Secure a colostomy pouch over the stoma.
D) Place petrolatum gauze dressing over the stoma. - A) Notify the surgeon.
* The stoma should appear reddish pink and moist, which indicates circulatory
perfusion to the surgical diversion of the intestine. If the stoma becomes dry,
,firm, flaccid, or is dark red or purple, the stoma is ischemic, and the surgeon
should be notified immediately (A). Although (B, C, and D) may be
implemented, the findings require immediate medical attention.
The nurse is assessing a client with a chest tube that is attached to suction and a
closed drainage system. Which finding is most important for the nurse to further
assess?
A) Upper chest subcutaneous emphysema.
B) Tidaling (fluctuation) of fluid in the water-seal chamber.
C) Constant air bubbling in the suction-control chamber.
D) Pain rated 8 (0-10) at the insertion site. - Correct Answer(s): A
* Subcutaneous emphysema (A) is a complication and indicates air is leaking
beneath the skin. Tidaling in the water-seal chamber and constant bubbling with
suction in the suction-control chamber (B and C) are expected findings that
indicate the closed drainage system is working. Pain at the insertion site is an
expected finding (D) and the prescribed analgesia should be given to assist the
client to breathe deeply and facilitate lung expansion.
What assessment finding should the nurse identify that indicates a client with an
acute asthma exacerbation is beginning to improve after treatment?
,A) Wheezing becomes louder.
B) Cough remains unproductive.
C) Vesicular breath sounds decrease.
D) Bronchodilators stimulate coughing. - A) Wheezing becomes louder.
* In an acute asthma attack, air flow may be so significantly restricted that
wheezing is diminished. If the client is successfully responding to
bronchodilators and respiratory treatments, wheezing becomes louder (A) as air
flow increases in the airways. As the airways open and mucous is mobilized in
response to treatment, the cough becomes more productive, not (B). Vesicular
sounds are soft, low-pitched, gentle, rustling sounds heard over lung fields (C)
and is not an indicator of improvement during asthma treatment.
Bronchodilators do not stimulate coughing (D).
A client is admitted to the emergency department after being lost for four days
while hiking in a national forest. Upon review of the laboratory results, the
nurse determines the client's serum level for thyroid-stimulating hormone (TSH)
is elevated. Which additional assessment should the nurse make?
A) Body mass index.
B) Skin elasticity and turgor.
C) Thought processes and speech.
D) Exposure to cold environmental temperatures. - D) Exposure to cold
environmental temperatures.
* TSH influences the amount of thyroxine secretion which increases the rate of
metabolism to maintain body temperature near normal. Prolonged exposure to
cold environmental temperatures (D) stimulates the hypothalamus to secrete
thyrotropin-releasing hormone, which increases anterior pituitary serum release
, of TSH. (A) may reflect weight loss from lack of food. Tenting of the skin (B)
is indicative of dehydration. Slow or confused thought processes (C) or speech
patterns may be related to sleep deprivation.
Which method elicits the most accurate information during a physical
assessment of an older client?
A) Ask the client to recount one's health history.
B) Obtain the client's information from a caregiver.
C) Review the past medical record for medications.
D) Use reliable assessment tools for older adults. - D) Use reliable assessment
tools for older adults.
* Specific assessment tools (D) for an older adult, such as Older Adult Resource
Services Center Instrument (OARS), mini-mental assessment, fall risk,
depression (Geriatric Depression Scale), or skin breakdown risk (Braden Scale),
consider age-related physiologic and psychosocial changes related to aging and
provide the most accurate and complete information. (A and B) are subjective
and may vary in reliability based on the client's memory and caregiver's current
involvement. Although (C) is a good resource to identify polypharmacy, a
written record may not be available or currently accurate.
The nurse obtains a client's history that includes right mastectomy and radiation
therapy for cancer of the breast 10 years ago. Which current health problem
should the nurse consider is a consequence of the radiation therapy?
A) Asthma.
B) Myocardial infarction.
C) Chronic esophagitis with gastroesophageal reflux.
QUESTIONS AND VERIFIED
ANSWERS LATEST UPDATE
During the assessment of a client who is 24 hours post-hemicolectomy with a
temporary colostomy, the nurse determines that the client's stoma is dry and
dark red in color. What action should the nurse implement?
A) Notify the surgeon.
B) Document the assessment.
C) Secure a colostomy pouch over the stoma.
D) Place petrolatum gauze dressing over the stoma. - A) Notify the surgeon.
* The stoma should appear reddish pink and moist, which indicates circulatory
perfusion to the surgical diversion of the intestine. If the stoma becomes dry,
,firm, flaccid, or is dark red or purple, the stoma is ischemic, and the surgeon
should be notified immediately (A). Although (B, C, and D) may be
implemented, the findings require immediate medical attention.
The nurse is assessing a client with a chest tube that is attached to suction and a
closed drainage system. Which finding is most important for the nurse to further
assess?
A) Upper chest subcutaneous emphysema.
B) Tidaling (fluctuation) of fluid in the water-seal chamber.
C) Constant air bubbling in the suction-control chamber.
D) Pain rated 8 (0-10) at the insertion site. - Correct Answer(s): A
* Subcutaneous emphysema (A) is a complication and indicates air is leaking
beneath the skin. Tidaling in the water-seal chamber and constant bubbling with
suction in the suction-control chamber (B and C) are expected findings that
indicate the closed drainage system is working. Pain at the insertion site is an
expected finding (D) and the prescribed analgesia should be given to assist the
client to breathe deeply and facilitate lung expansion.
What assessment finding should the nurse identify that indicates a client with an
acute asthma exacerbation is beginning to improve after treatment?
,A) Wheezing becomes louder.
B) Cough remains unproductive.
C) Vesicular breath sounds decrease.
D) Bronchodilators stimulate coughing. - A) Wheezing becomes louder.
* In an acute asthma attack, air flow may be so significantly restricted that
wheezing is diminished. If the client is successfully responding to
bronchodilators and respiratory treatments, wheezing becomes louder (A) as air
flow increases in the airways. As the airways open and mucous is mobilized in
response to treatment, the cough becomes more productive, not (B). Vesicular
sounds are soft, low-pitched, gentle, rustling sounds heard over lung fields (C)
and is not an indicator of improvement during asthma treatment.
Bronchodilators do not stimulate coughing (D).
A client is admitted to the emergency department after being lost for four days
while hiking in a national forest. Upon review of the laboratory results, the
nurse determines the client's serum level for thyroid-stimulating hormone (TSH)
is elevated. Which additional assessment should the nurse make?
A) Body mass index.
B) Skin elasticity and turgor.
C) Thought processes and speech.
D) Exposure to cold environmental temperatures. - D) Exposure to cold
environmental temperatures.
* TSH influences the amount of thyroxine secretion which increases the rate of
metabolism to maintain body temperature near normal. Prolonged exposure to
cold environmental temperatures (D) stimulates the hypothalamus to secrete
thyrotropin-releasing hormone, which increases anterior pituitary serum release
, of TSH. (A) may reflect weight loss from lack of food. Tenting of the skin (B)
is indicative of dehydration. Slow or confused thought processes (C) or speech
patterns may be related to sleep deprivation.
Which method elicits the most accurate information during a physical
assessment of an older client?
A) Ask the client to recount one's health history.
B) Obtain the client's information from a caregiver.
C) Review the past medical record for medications.
D) Use reliable assessment tools for older adults. - D) Use reliable assessment
tools for older adults.
* Specific assessment tools (D) for an older adult, such as Older Adult Resource
Services Center Instrument (OARS), mini-mental assessment, fall risk,
depression (Geriatric Depression Scale), or skin breakdown risk (Braden Scale),
consider age-related physiologic and psychosocial changes related to aging and
provide the most accurate and complete information. (A and B) are subjective
and may vary in reliability based on the client's memory and caregiver's current
involvement. Although (C) is a good resource to identify polypharmacy, a
written record may not be available or currently accurate.
The nurse obtains a client's history that includes right mastectomy and radiation
therapy for cancer of the breast 10 years ago. Which current health problem
should the nurse consider is a consequence of the radiation therapy?
A) Asthma.
B) Myocardial infarction.
C) Chronic esophagitis with gastroesophageal reflux.
