MED SURG HESI COMPLETE EXAM WITH
VERRIFIED ANSWERS
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
VERRIFIED ANSWERS
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
