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TEST BANK NURS 11 MED SURG HESI
EXIT EXAM QUESTIONS AND ANSWERS
CORRECT LATEST 2025
During a home visit, the nurse observed an elderly client with diabetes slip and
fall. What action should the nurse take first?
Correct Answer: Check the client for lacerations or fractures
At 0600 while admitting a woman for a schedule repeat cesarean section (C-
Section), the client tells the nurse that she drank a cup a coffee at 0400 because she
wanted to avoid getting a headache. Which action should the nurse take first?
Correct Answer: Inform the anesthesia care provider
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2
heart sounds. To determine if an S3 heart sound is present, what action should the
nurse take first?
Correct Answer: Listen with the bell at the same location
Following discharge teaching, a male client with duodenal ulcer tells the nurse the
he will drink plenty of dairy products, such as milk, to help coat and protect his
ulcer. What is the best follow-up action by the nurse?
Correct Answer: Review with the client the need to avoid foods that are rich in
milk andcream
A male client with hypertension, who received new antihypertensive prescriptions
at his last visit returns to the clinic two weeks later to evaluate his blood pressure
(BP). His BP is 158/106 and he admits that he has not been taking the prescribed
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medication because the drugs make him "feel bad". In explaining the need for
hypertension control, the nurse should stress that an elevated BP places the client
at risk for which pathophysiological condition?
Correct Answer: Stroke secondary to hemorrhage
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly
admitted client who has a seizure disorder. The client is supine and the UAP is
placing soft pillows along the side rails. What action should the nurse implement?
Correct Answer: Instruct the UAP to obtain soft blankets to secure to the side rails
instead ofpillows.
An adolescent with major depressive disorder has been taking duloxetine
(Cymbalta) for the past 12 days. Which assessment finding requires immediate
follow-up?
Correct Answer: Describes life without purpose
A 60-year-old female client with a positive family history of ovarian cancer has
developed an abdominal mass and is being evaluated for possible ovarian cancer.
Her Papanicolau (Pap) smear results are negative. What information should the
nurse include in the client's teaching plan?
Correct Answer: Further evaluation involving surgery may be needed
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A client who recently underwear a tracheostomy is being prepared for discharge to
home. Which instructions is most important for the nurse to include in the
discharge plan?
Correct Answer: Teach tracheal suctioning techniques
In assessing an adult client with a partial rebreather mask, the nurse notes that the
oxygen reservoir bag does not deflate completely during inspiration and the client's
respiratory rate is 14 breaths / minute. What action should the nurse implement?
Correct Answer: Document the assessment data
Rationale: reservoir bag should not deflate completely during inspiration and the
client's respiratory rate is within normal limits.
During shift report, the central electrocardiogram (EKG) monitoring system
alarms. Which client alarm should the nurse investigate firs?
Correct Answer: Respiratory apnea of 30 seconds
A 66-year-old woman is retiring and will no longer have a health insurance
through her place of employment. Which agency should the client be referred to by
the employee health nurse for health insurance needs?
Correct Answer: Medicare
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A client who is taking an oral dose of a tetracycline complains of gastrointestinal
upset. What snack should the nurse instruct the client to take with the tetracycline?
Correct Answer: Toasted wheat bread and jelly
Following a lumbar puncture, a client voices several complaints. What complaint
indicated to the nurse that the client is experiencing a complication?
Correct Answer: "I have a headache that gets worse when I sit up"
"I am having pain in my lower back when I move my legs"
"My throat hurts when I swallow"
"I feel sick to my stomach and am going to throw up"
An elderly client seems confused and reports the onset of nausea, dysuria, and
urgency with incontinence. Which action should the nurse implement?
Correct Answer: Obtain a clean catch mid-stream specimen
The nurse is assisting the mother of a child with phenylketonuria (PKU) to select
foods that are in keeping with the child's dietary restrictions. Which foods are
contraindicated for this child?
Correct Answer: Foods sweetened with aspartame
Before preparing a client for the first surgical case of the day, a part-time scrub
nurse asks the circulating nurse if a 3 minute surgical hand scrub is adequate
preparation for this client. Which response should the circulating nurse provide?
Correct Answer: Direct the nurse to continue the surgical hand scrub for a 5
minute duration
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TEST BANK NURS 11 MED SURG HESI
EXIT EXAM QUESTIONS AND ANSWERS
CORRECT LATEST 2025
During a home visit, the nurse observed an elderly client with diabetes slip and
fall. What action should the nurse take first?
Correct Answer: Check the client for lacerations or fractures
At 0600 while admitting a woman for a schedule repeat cesarean section (C-
Section), the client tells the nurse that she drank a cup a coffee at 0400 because she
wanted to avoid getting a headache. Which action should the nurse take first?
Correct Answer: Inform the anesthesia care provider
After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2
heart sounds. To determine if an S3 heart sound is present, what action should the
nurse take first?
Correct Answer: Listen with the bell at the same location
Following discharge teaching, a male client with duodenal ulcer tells the nurse the
he will drink plenty of dairy products, such as milk, to help coat and protect his
ulcer. What is the best follow-up action by the nurse?
Correct Answer: Review with the client the need to avoid foods that are rich in
milk andcream
A male client with hypertension, who received new antihypertensive prescriptions
at his last visit returns to the clinic two weeks later to evaluate his blood pressure
(BP). His BP is 158/106 and he admits that he has not been taking the prescribed
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,https://www.stuvia.com/user/passnursingnow https://www.stuvia.com/user/passnursingnow
medication because the drugs make him "feel bad". In explaining the need for
hypertension control, the nurse should stress that an elevated BP places the client
at risk for which pathophysiological condition?
Correct Answer: Stroke secondary to hemorrhage
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly
admitted client who has a seizure disorder. The client is supine and the UAP is
placing soft pillows along the side rails. What action should the nurse implement?
Correct Answer: Instruct the UAP to obtain soft blankets to secure to the side rails
instead ofpillows.
An adolescent with major depressive disorder has been taking duloxetine
(Cymbalta) for the past 12 days. Which assessment finding requires immediate
follow-up?
Correct Answer: Describes life without purpose
A 60-year-old female client with a positive family history of ovarian cancer has
developed an abdominal mass and is being evaluated for possible ovarian cancer.
Her Papanicolau (Pap) smear results are negative. What information should the
nurse include in the client's teaching plan?
Correct Answer: Further evaluation involving surgery may be needed
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,https://www.stuvia.com/user/passnursingnow https://www.stuvia.com/user/passnursingnow
A client who recently underwear a tracheostomy is being prepared for discharge to
home. Which instructions is most important for the nurse to include in the
discharge plan?
Correct Answer: Teach tracheal suctioning techniques
In assessing an adult client with a partial rebreather mask, the nurse notes that the
oxygen reservoir bag does not deflate completely during inspiration and the client's
respiratory rate is 14 breaths / minute. What action should the nurse implement?
Correct Answer: Document the assessment data
Rationale: reservoir bag should not deflate completely during inspiration and the
client's respiratory rate is within normal limits.
During shift report, the central electrocardiogram (EKG) monitoring system
alarms. Which client alarm should the nurse investigate firs?
Correct Answer: Respiratory apnea of 30 seconds
A 66-year-old woman is retiring and will no longer have a health insurance
through her place of employment. Which agency should the client be referred to by
the employee health nurse for health insurance needs?
Correct Answer: Medicare
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, https://www.stuvia.com/user/passnursingnow https://www.stuvia.com/user/passnursingnow
A client who is taking an oral dose of a tetracycline complains of gastrointestinal
upset. What snack should the nurse instruct the client to take with the tetracycline?
Correct Answer: Toasted wheat bread and jelly
Following a lumbar puncture, a client voices several complaints. What complaint
indicated to the nurse that the client is experiencing a complication?
Correct Answer: "I have a headache that gets worse when I sit up"
"I am having pain in my lower back when I move my legs"
"My throat hurts when I swallow"
"I feel sick to my stomach and am going to throw up"
An elderly client seems confused and reports the onset of nausea, dysuria, and
urgency with incontinence. Which action should the nurse implement?
Correct Answer: Obtain a clean catch mid-stream specimen
The nurse is assisting the mother of a child with phenylketonuria (PKU) to select
foods that are in keeping with the child's dietary restrictions. Which foods are
contraindicated for this child?
Correct Answer: Foods sweetened with aspartame
Before preparing a client for the first surgical case of the day, a part-time scrub
nurse asks the circulating nurse if a 3 minute surgical hand scrub is adequate
preparation for this client. Which response should the circulating nurse provide?
Correct Answer: Direct the nurse to continue the surgical hand scrub for a 5
minute duration
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