MED SURG 2 HESI TEST BANK REAL EXAM 100+
QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES|AGRADE
1. A client with Cushing's syndrome is recovering from an elective laparoscopic procedure.
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Which assessment finding warrant's immediate intervention by the nurse?
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a. Purple marks on skin of the abdomen
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b. Irregular apical pulse
xz xz xz
c. Quarter size blood spot on dressing
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d. Pitting ankle edema - ans-b. Irregular apical pulse
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2. A client with lung cancer who wears a subcutaneous morphine sulfate patch for pain is sh
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ort of breath and is difficult to arouse. When performing a head to toe assessment, the nurs
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
e discovers four analgesic patches on the clients body. Which intervention should the nurse
xz xz xz xz xz xz xz xz xz xz xz xz xz
implement first?
xz xz
a. Remove all of the morphine patches
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b. Administer a narcotic antagonist
xz xz xz xz
c. Apply oxygen per face mask
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d. Measure the client's blood pressure - ans-b. Administer a narcotic antagonist
xz xz xz xz xz xz xz xz xz xz xz
3. A client receives prescriptions for a multidrug regimen for the treatment of tuberculosis.
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Which information should the nurse prioritize?
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a. Adherence to the regimen is imperative
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b. Medications should be taken with food
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c. Serum liver panels are collected regularly
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d. Enhanced sun protection measures will be needed - ans-
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a. Adherence to the regimen is imperative
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4. The nurse is preparing a client for surgery who was admitted to the emergency center foll
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owing a motor vehicle collision. The client has an open fracture of the femur and is bleeding
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
moderately from the bone protrusion site. During the prescriptive assessment, the nurse de
xz xz xz xz xz xz xz xz xz xz xz xz
termines that the client currently receives heparin sodium 5,000 units subcutaneously daily
xz xz xz xz xz xz xz xz xz xz xz
. What is the priority nursing action?
xz xz xz xz xz xz
a. Notify the healthcare provider of the client's medication history
xz xz xz xz xz xz xz xz xz
b. Observe the heparin injections sites for signs of bruising
xz xz xz xz xz xz xz xz xz
c. Have the client sign the surgical and transfusion permits
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,d. Ensure that the potential for bleeding is explained to the client - ans-
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a. Notify the healthcare provider of the client's medication history
xz xz xz xz xz xz xz xz xz
5. A client with orthopnea expresses concern about the ability to "get enough air" during a s
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
cheduled thoracentesis. On which information should the nurse's response be based?
xz xz xz xz xz xz xz xz xz xz
a. A thoracentesis is a brief process that has minimal discomfort
xz xz xz xz xz xz xz xz xz xz
b. Orthopnea is frequently caused by a client's uncontrolled anxiety
xz xz xz xz xz xz xz xz xz
c. The procedure is performed with the client in an upright position
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d. Extra pillows can be used if needed to elevate the client's head - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
c. The procedure is performed with the client in an upright position
xz xz xz xz xz xz xz xz xz xz xz
6. What information should the nurse include in the teaching plan of a client diagnosed with
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
gastroesophageal reflux disease (GERD)? xz xz xz
a. Sleep without pillows at night to maintain neck alignment
xz xz xz xz xz xz xz xz xz
b. Adjust food intake to three full meals per day and no snacks
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c. Minimize symptoms by wearing loose, comfortable clothing
xz xz xz xz xz xz xz
d. Avoid participation in any aerobic exercise programs - ans-
xz xz xz xz xz xz xz xz xz
c. Minimize symptoms by wearing loose, comfortable clothing
xz xz xz xz xz xz xz
7. The nurse is providing teaching to a client with Type 2 diabetes mellitus and peripheral ne
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
uropathy. Which information should the nurse provide?
xz xz xz xz xz xz
a. Family members can help with regular foot exams
xz xz xz xz xz xz xz xz
b. Heating pads are useful if on the low setting
xz xz xz xz xz xz xz xz xz
c. Aching feet may be soaked in lukewarm water for one hour or more
xz xz xz xz xz xz xz xz xz xz xz xz xz
d. Shoes should be worn outside the house, but it is fine to be barefoot inside - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
a. Family members can help with regular foot exams
xz xz xz xz xz xz xz xz
8. A client in the operating room received succinylcholine. The client is experiencing muscl
xz xz xz xz xz xz xz xz xz xz xz xz xz
e rigidity and has an extremely high temperature. What action should the nurse implement?
xz xz xz xz xz xz xz xz xz xz xz xz xz
a. Hold a prescription for dantrolene until fever is reduced
xz xz xz xz xz xz xz xz xz
b. Prepare ice packs for placement in the clients axillary area
xz xz xz xz xz xz xz xz xz xz
c. Call the PACU nurse to prepare for prolonged ventilator support
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d. Determine if prescribed antibiotics were administered preoperatively - ans-
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b. Prepare ice packs for placement in the clients axillary area
xz xz xz xz xz xz xz xz xz xz
9. The nurse is developing a plan of care for a client who reports blurred vision and who is n
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ewly diagnosed with cardiovascular disease. Which outcome should the nurse include in th
xz xz xz xz xz xz xz xz xz xz xz xz
e plan of care for this client?
xz xz xz xz xz xz
a. The nurse will encourage the client to walk thirty minutes every day
xz xz xz xz xz xz xz xz xz xz xz xz
b. The clients family will state signs and symptoms about the disease
xz xz xz xz xz xz xz xz xz xz xz
c. The clients daily blood pressure will be less than 140/80 this month
xz xz xz xz xz xz xz xz xz xz xz xz
,d. The client blood pressure readings will be less than 160/90 - ans-
xz xz xz xz xz xz xz xz xz xz xz xz
c. The clients daily blood pressure will be less than 140/80 this month
xz xz xz xz xz xz xz xz xz xz xz xz
10. The family suspects that acquired immune deficiency syndrome (AIDS) dementia is occ
xz xz xz xz xz xz xz xz xz xz xz xz
uring in their son who is human immunodeficiency virus (HIV) positive. Which symptoms co
xz xz xz xz xz xz xz xz xz xz xz xz xz
nfirm their suspicions? xz xz
a. He has begun to sleep 18 out of 24 hours
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b. A change has recently occurred in his handwriting
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c. He refuses to see any of his friends or to return their phone calls
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d. He exhibits angry outburst when the subject of dying is approached - ans-
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b. A change has recently occurred in his handwriting
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11. A hospitalized client with peripheral arterial disease (PAD) is instructed regarding leg a
xz xz xz xz xz xz xz xz xz xz xz xz xz
nd foot care. Which statement by the client indicates to the nurse that learning has occurred
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
?
a. "Whenever I am sitting in a chair I will keep my legs up to reduce swelling"
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b. "I can use a mirror to check the bottoms of my feet for any signs of breakdown"
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c. "I will try to keep moving if leg pain occurs to help promote good circulation"
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d. "I will use my swimming pool early in the day while the water is still very cool" - ans-
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b. "I can use a mirror to check the bottoms of my feet for any signs of breakdown"
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12. While completing a health assessment for a client with migraine headaches, the nurse a
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ssesses bilateral weakness in the client's hand grips. The client reports joint pain and troubl
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e twisting a door knob due to weakness. Which action should the nurse take in response to t
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hese findings? xz
a. Explain that relief of the migraine pain will reduce related symptoms
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b. Gather additional assessment data about the pain and weakness
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c. Implement fall precautions to reduce the client's risk for injury
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d. Consult with the occupational therapist for a functional assessment - ans-
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d. Consult with the occupational therapist for a functional assessment
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13. The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a
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thoracotomy two hours ago. The nurse observes the following vital signs: heart rate 140 bp
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m, respirations 26 breaths/
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minute and blood pressure 140/90. Which intervention is most important for the nurse to im
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plement?
a. Medicate for pain and monitor vital signs according to protocol
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b. Adminsted intravenous fluid bolus as prescribed by the HCP
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c. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter.
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d. Encourage the client to splint the incision with a pillow to cough and deep breathe - ans-
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a. Medicate for pain and monitor vital signs
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, 14. An adult is diagnosed with restless leg syndrome and is referred to the sleep clinic. The
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HCP prescribed ferrous sulfate 325 PO daily. Which laboratory values should the nurse mo
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nitor ? xz
a. Platelet count and hematocrit
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b. Serum electrolytes
xz xz
c. Serum iron and ferritin
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d. Neutrophils and eosinophils - ans-c. Serum iron and ferritin
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15. While caring for a client with a full thickness burn covering 40% of the body, the nurse ob
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serves purulent drainage at the wound. Before reporting this finding to the HCP , the nurse s
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hould review which of the client's laboratory values?
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a. White blood cell count
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b. Platelet count
xz xz
c. Blood pH level
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d. Hematocrit - ans-a. White blood cell count
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16. A client with a history of type 1 diabetes mellitus (DM) and asthma is readmitted to the u
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nit for the third time in two months with a current fasting blood sugar of 325 mg/
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dl. The client describes to the nurse of not understanding why the blood glucose level contin
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ues to be out of control. Which interventions should the nurse implement?
xz xz xz xz xz xz xz xz xz xz xz
Select all that apply.
xz xz xz xz
a. Have the client describe a typical day at work, home, and social activities
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b. Determine if the client is using a new insulin needle each administration
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c. Evaluate the clients asthma medications that can elevate the blood glucose
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d. Ask the client if they want a different manufactures glucose monitoring device
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e. Have the client demonstrate techniques used to monitor blood glucose levels - ans-
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a. Have the client describe a typical day at work, home, and social activities
xz xz xz xz xz xz xz xz xz xz xz xz xz
e. Have the client demonstrate techniques used to monitor blood glucose levels
xz xz xz xz xz xz xz xz xz xz xz
17. The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and leg
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s, and massive ascites. Which mechanism contributes to edema and ascites in clients with
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cirrhosis?
a. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules
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b. Decreased portcaval pressure with greater collateral circulation
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c. Decreased renin-angiotensin response related to an increase in renal blood flow
xz xz xz xz xz xz xz xz xz xz xz
d. Hypoalbuminemia that results in a decreased colloid oncotic pressure - ans-
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d. Hypoalbuminemia that results in a decreased colloid oncotic pressure
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18. An older client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routi
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ne health assessment. Which assessments would the nurse complete if a patient with type
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2 diabetes mellitus (DM) is experiencing long term complications? Select all that apply.
xz xz xz xz xz xz xz xz xz xz xz xz
QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES|AGRADE
1. A client with Cushing's syndrome is recovering from an elective laparoscopic procedure.
xz xz xz xz xz xz xz xz xz xz xz xz xz
Which assessment finding warrant's immediate intervention by the nurse?
xz xz xz xz xz xz xz xz
a. Purple marks on skin of the abdomen
xz xz xz xz xz xz xz
b. Irregular apical pulse
xz xz xz
c. Quarter size blood spot on dressing
xz xz xz xz xz xz
d. Pitting ankle edema - ans-b. Irregular apical pulse
xz xz xz xz xz xz xz xz
2. A client with lung cancer who wears a subcutaneous morphine sulfate patch for pain is sh
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ort of breath and is difficult to arouse. When performing a head to toe assessment, the nurs
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
e discovers four analgesic patches on the clients body. Which intervention should the nurse
xz xz xz xz xz xz xz xz xz xz xz xz xz
implement first?
xz xz
a. Remove all of the morphine patches
xz xz xz xz xz xz
b. Administer a narcotic antagonist
xz xz xz xz
c. Apply oxygen per face mask
xz xz xz xz xz
d. Measure the client's blood pressure - ans-b. Administer a narcotic antagonist
xz xz xz xz xz xz xz xz xz xz xz
3. A client receives prescriptions for a multidrug regimen for the treatment of tuberculosis.
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
Which information should the nurse prioritize?
xz xz xz xz xz
a. Adherence to the regimen is imperative
xz xz xz xz xz xz
b. Medications should be taken with food
xz xz xz xz xz xz
c. Serum liver panels are collected regularly
xz xz xz xz xz xz
d. Enhanced sun protection measures will be needed - ans-
xz xz xz xz xz xz xz xz xz
a. Adherence to the regimen is imperative
xz xz xz xz xz xz
4. The nurse is preparing a client for surgery who was admitted to the emergency center foll
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
owing a motor vehicle collision. The client has an open fracture of the femur and is bleeding
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
moderately from the bone protrusion site. During the prescriptive assessment, the nurse de
xz xz xz xz xz xz xz xz xz xz xz xz
termines that the client currently receives heparin sodium 5,000 units subcutaneously daily
xz xz xz xz xz xz xz xz xz xz xz
. What is the priority nursing action?
xz xz xz xz xz xz
a. Notify the healthcare provider of the client's medication history
xz xz xz xz xz xz xz xz xz
b. Observe the heparin injections sites for signs of bruising
xz xz xz xz xz xz xz xz xz
c. Have the client sign the surgical and transfusion permits
xz xz xz xz xz xz xz xz xz
,d. Ensure that the potential for bleeding is explained to the client - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz
a. Notify the healthcare provider of the client's medication history
xz xz xz xz xz xz xz xz xz
5. A client with orthopnea expresses concern about the ability to "get enough air" during a s
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
cheduled thoracentesis. On which information should the nurse's response be based?
xz xz xz xz xz xz xz xz xz xz
a. A thoracentesis is a brief process that has minimal discomfort
xz xz xz xz xz xz xz xz xz xz
b. Orthopnea is frequently caused by a client's uncontrolled anxiety
xz xz xz xz xz xz xz xz xz
c. The procedure is performed with the client in an upright position
xz xz xz xz xz xz xz xz xz xz xz
d. Extra pillows can be used if needed to elevate the client's head - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
c. The procedure is performed with the client in an upright position
xz xz xz xz xz xz xz xz xz xz xz
6. What information should the nurse include in the teaching plan of a client diagnosed with
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
gastroesophageal reflux disease (GERD)? xz xz xz
a. Sleep without pillows at night to maintain neck alignment
xz xz xz xz xz xz xz xz xz
b. Adjust food intake to three full meals per day and no snacks
xz xz xz xz xz xz xz xz xz xz xz xz
c. Minimize symptoms by wearing loose, comfortable clothing
xz xz xz xz xz xz xz
d. Avoid participation in any aerobic exercise programs - ans-
xz xz xz xz xz xz xz xz xz
c. Minimize symptoms by wearing loose, comfortable clothing
xz xz xz xz xz xz xz
7. The nurse is providing teaching to a client with Type 2 diabetes mellitus and peripheral ne
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
uropathy. Which information should the nurse provide?
xz xz xz xz xz xz
a. Family members can help with regular foot exams
xz xz xz xz xz xz xz xz
b. Heating pads are useful if on the low setting
xz xz xz xz xz xz xz xz xz
c. Aching feet may be soaked in lukewarm water for one hour or more
xz xz xz xz xz xz xz xz xz xz xz xz xz
d. Shoes should be worn outside the house, but it is fine to be barefoot inside - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
a. Family members can help with regular foot exams
xz xz xz xz xz xz xz xz
8. A client in the operating room received succinylcholine. The client is experiencing muscl
xz xz xz xz xz xz xz xz xz xz xz xz xz
e rigidity and has an extremely high temperature. What action should the nurse implement?
xz xz xz xz xz xz xz xz xz xz xz xz xz
a. Hold a prescription for dantrolene until fever is reduced
xz xz xz xz xz xz xz xz xz
b. Prepare ice packs for placement in the clients axillary area
xz xz xz xz xz xz xz xz xz xz
c. Call the PACU nurse to prepare for prolonged ventilator support
xz xz xz xz xz xz xz xz xz xz
d. Determine if prescribed antibiotics were administered preoperatively - ans-
xz xz xz xz xz xz xz xz xz
b. Prepare ice packs for placement in the clients axillary area
xz xz xz xz xz xz xz xz xz xz
9. The nurse is developing a plan of care for a client who reports blurred vision and who is n
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
ewly diagnosed with cardiovascular disease. Which outcome should the nurse include in th
xz xz xz xz xz xz xz xz xz xz xz xz
e plan of care for this client?
xz xz xz xz xz xz
a. The nurse will encourage the client to walk thirty minutes every day
xz xz xz xz xz xz xz xz xz xz xz xz
b. The clients family will state signs and symptoms about the disease
xz xz xz xz xz xz xz xz xz xz xz
c. The clients daily blood pressure will be less than 140/80 this month
xz xz xz xz xz xz xz xz xz xz xz xz
,d. The client blood pressure readings will be less than 160/90 - ans-
xz xz xz xz xz xz xz xz xz xz xz xz
c. The clients daily blood pressure will be less than 140/80 this month
xz xz xz xz xz xz xz xz xz xz xz xz
10. The family suspects that acquired immune deficiency syndrome (AIDS) dementia is occ
xz xz xz xz xz xz xz xz xz xz xz xz
uring in their son who is human immunodeficiency virus (HIV) positive. Which symptoms co
xz xz xz xz xz xz xz xz xz xz xz xz xz
nfirm their suspicions? xz xz
a. He has begun to sleep 18 out of 24 hours
xz xz xz xz xz xz xz xz xz xz
b. A change has recently occurred in his handwriting
xz xz xz xz xz xz xz xz
c. He refuses to see any of his friends or to return their phone calls
xz xz xz xz xz xz xz xz xz xz xz xz xz xz
d. He exhibits angry outburst when the subject of dying is approached - ans-
xz xz xz xz xz xz xz xz xz xz xz xz xz
b. A change has recently occurred in his handwriting
xz xz xz xz xz xz xz xz
11. A hospitalized client with peripheral arterial disease (PAD) is instructed regarding leg a
xz xz xz xz xz xz xz xz xz xz xz xz xz
nd foot care. Which statement by the client indicates to the nurse that learning has occurred
xz xz xz xz xz xz xz xz xz xz xz xz xz xz xz
?
a. "Whenever I am sitting in a chair I will keep my legs up to reduce swelling"
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b. "I can use a mirror to check the bottoms of my feet for any signs of breakdown"
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c. "I will try to keep moving if leg pain occurs to help promote good circulation"
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d. "I will use my swimming pool early in the day while the water is still very cool" - ans-
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b. "I can use a mirror to check the bottoms of my feet for any signs of breakdown"
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12. While completing a health assessment for a client with migraine headaches, the nurse a
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ssesses bilateral weakness in the client's hand grips. The client reports joint pain and troubl
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e twisting a door knob due to weakness. Which action should the nurse take in response to t
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hese findings? xz
a. Explain that relief of the migraine pain will reduce related symptoms
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b. Gather additional assessment data about the pain and weakness
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c. Implement fall precautions to reduce the client's risk for injury
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d. Consult with the occupational therapist for a functional assessment - ans-
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d. Consult with the occupational therapist for a functional assessment
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13. The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a
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thoracotomy two hours ago. The nurse observes the following vital signs: heart rate 140 bp
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m, respirations 26 breaths/
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minute and blood pressure 140/90. Which intervention is most important for the nurse to im
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plement?
a. Medicate for pain and monitor vital signs according to protocol
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b. Adminsted intravenous fluid bolus as prescribed by the HCP
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c. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter.
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d. Encourage the client to splint the incision with a pillow to cough and deep breathe - ans-
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a. Medicate for pain and monitor vital signs
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, 14. An adult is diagnosed with restless leg syndrome and is referred to the sleep clinic. The
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HCP prescribed ferrous sulfate 325 PO daily. Which laboratory values should the nurse mo
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nitor ? xz
a. Platelet count and hematocrit
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b. Serum electrolytes
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c. Serum iron and ferritin
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d. Neutrophils and eosinophils - ans-c. Serum iron and ferritin
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15. While caring for a client with a full thickness burn covering 40% of the body, the nurse ob
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serves purulent drainage at the wound. Before reporting this finding to the HCP , the nurse s
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hould review which of the client's laboratory values?
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a. White blood cell count
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b. Platelet count
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c. Blood pH level
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d. Hematocrit - ans-a. White blood cell count
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16. A client with a history of type 1 diabetes mellitus (DM) and asthma is readmitted to the u
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nit for the third time in two months with a current fasting blood sugar of 325 mg/
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dl. The client describes to the nurse of not understanding why the blood glucose level contin
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ues to be out of control. Which interventions should the nurse implement?
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Select all that apply.
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a. Have the client describe a typical day at work, home, and social activities
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b. Determine if the client is using a new insulin needle each administration
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c. Evaluate the clients asthma medications that can elevate the blood glucose
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d. Ask the client if they want a different manufactures glucose monitoring device
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e. Have the client demonstrate techniques used to monitor blood glucose levels - ans-
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a. Have the client describe a typical day at work, home, and social activities
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e. Have the client demonstrate techniques used to monitor blood glucose levels
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17. The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and leg
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s, and massive ascites. Which mechanism contributes to edema and ascites in clients with
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cirrhosis?
a. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules
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b. Decreased portcaval pressure with greater collateral circulation
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c. Decreased renin-angiotensin response related to an increase in renal blood flow
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d. Hypoalbuminemia that results in a decreased colloid oncotic pressure - ans-
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d. Hypoalbuminemia that results in a decreased colloid oncotic pressure
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18. An older client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routi
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ne health assessment. Which assessments would the nurse complete if a patient with type
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2 diabetes mellitus (DM) is experiencing long term complications? Select all that apply.
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