Med Surg Final HESI (2020/2021)
Questions and Answers
A client with a productive cough has obtained a sputum specimen for culture as
instructed. What is the best initial nursing action?
A. Administer the first dose of antibiotic therapy
B. Observe the color, consistency, and amount of sputum
C. Encourage the client to consume plenty of warm liquids
D. Send the specimen to the lab for analysis
B. Observe the color, consistency, and amount of sputum
A client is brought to the ED by ambulance in cardiac arrest with cardiopulmonary
resuscitation (CPR) in progress. The client is intubated and is receiving 100% oxygen
per self-inflating (ambu) bag. The nurse determines that the client is cyanotic, cold, and
diaphoretic. Which assessment is most important for the nurse to obtain?
A. Breath sounds over bilateral lung fields.
B. Carotid pulsation during compressions
C. Deep tendon reflexes
D. Core body temperature
A. Breath sounds over bilateral lung fields.
After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a
client develops pontine myselinolysis. Which intervention should the nurse implement
first?
A. Reorient client to his room
B. Place a patch on one eye
C. Evaluate client's ability to swallow
D. Perform range of motion exercises
A. Reorient client to his room
A male client with heart failure (HF) calls the clinic and reports that he cannot put his
shoes on because they are too tight. Which additional information should the nurse
obtain?
A. What time did he take his last medications?
B. Has his weight changed in the last several days?
C. Is he still able to tighten his belt buckle?
D. How many hours did he sleep last night?
B. Has his weight changed in the last several days?
An older adult woman with a long history of chronic obstructive pulmonary disease
(COPD) is admitted with progressive shortness of breath and a persistent cough. She is
anxious and is complaining of a dry mouth. Which intervention should the nurse
,implement?
A. Administer a prescribed sedative
B. Encourage client to drink water
C. Apply a high-flow venturi mask
D. Assist her to an upright position
D. Assist her to an upright position
A client with a history of asthma and bronchitis arrives at the clinic with shortness of
breath, productive cough with thickened tenacious mucous, and the inability to walk up
a flight of stairs without experiencing breathlessness. Which action is most important for
the nurse to instruct the client about self-care?
A. Increase the daily intake of oral fluids to liquefy secretions
B. Avoid crowded enclosed areas to reduce pathogen exposure
C. Call the clinic if undesirable side effects of mediations occur
D. Teach anxiety reduction methods for feelings of suffocation
A. Increase the daily intake of oral fluids to liquefy secretions
A cardiac catherterization of a client with heart disease indicates the following
blockages: 95% proximal left anterior descending (LAD), 99% proximal circumflex, and
? % proximal right coronary artery (RCA). The client later asks the nurse "what does all
this mean for me?" What information should the nurse provide?
A. Blood supply to the heart is diminished by artherosclerotic lesions, which necessitate
lifestyle changes.
B. Blood vessels supplying the pumping chamber have blockages indicating a past
heart attack.
C. Three main arteries have major blockages, with only 1 to 5% of blood flow getting
through to the heart muscle.
D. The heart is not receiving enough blood, so there is a risk of heart failure and fluid
retention.
C. Three main arteries have major blockages, with only 1 to 5% of blood flow getting
through to the heart muscle.
A client who weighs 175 pounds is receiving IV bolus dose of heparin 80 units/kg. The
heparin is available in a 2 ml vial, labeled 10,000 units/ml. How many ml should the
nurse administer? (Enter numeric value only. If rounding is required, round to the
nearest tenth.)
0.6 ml
What information should the nurse include in the teaching plan of a client diagnosed
with gastroesophageal reflux disease (GERD)?
A. Sleep without pillows at night to maintain neck alignment.
B. Adjust food intake to three full meals per day and no snacks.
C. Minimize symptoms by wearing loose, comfortable clothing
D. Avoid participation in any aerobic exercise programs
C. Minimize symptoms by wearing loose, comfortable clothing
, The nurse is caring for a client with a lower left lobe pulmonary abscess. Which position
should the nurse instruct the client to maintain?
A. left lateral
B. Supine, knees flexed
C. Dorsal recumbent
D. Knee-chest
A. left lateral
A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable
to eat or drink without becoming nauseated and vomiting. Which finding should the
nurse report to the healthcare provider.
A. Belching
B. Amber urine
C. Yellow sclera
D. Flatulence
C. Yellow sclera
While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a
neurological assessment every four hours. Which assessment finding warrants
immediate intervention by the nurse?
A. Inappropriate laughter
B. Increasing anxiety
C. Weakened cough effort
D. Asymmetrical weakness
C. Weakened cough effort
The nurse is providing preoperative education for a Jewish client scheduled to receive a
xenograft graft to promote burn healing. Which information should the nurse provide this
client?
A. Grafting increases the risk for bacterial infections
B. The xenograft is taken from nonhuman sources
C. Grafts are later removed by a debriding procedure
D. As the burn heals, the graft permanently attaches
B. The xenograft is taken from nonhuman sources
A male client who had colon surgery 3 days ago is anxious and requesting assistance to
reposition. While the nurse is turning him, the wound dehiscences and eviscerates. The
nurse moistens an available sterile dressing and places it over the wound. What
intervention should the nurse implement next?
A. Bring additional sterile dressing supplies to the room
B. Prepare the client to return to the operating room
C. Obtain a sample of the drainage to send to the lab
D. Auscultate the abdomen for bowel sound activity
B. Prepare the client to return to the operating room
Questions and Answers
A client with a productive cough has obtained a sputum specimen for culture as
instructed. What is the best initial nursing action?
A. Administer the first dose of antibiotic therapy
B. Observe the color, consistency, and amount of sputum
C. Encourage the client to consume plenty of warm liquids
D. Send the specimen to the lab for analysis
B. Observe the color, consistency, and amount of sputum
A client is brought to the ED by ambulance in cardiac arrest with cardiopulmonary
resuscitation (CPR) in progress. The client is intubated and is receiving 100% oxygen
per self-inflating (ambu) bag. The nurse determines that the client is cyanotic, cold, and
diaphoretic. Which assessment is most important for the nurse to obtain?
A. Breath sounds over bilateral lung fields.
B. Carotid pulsation during compressions
C. Deep tendon reflexes
D. Core body temperature
A. Breath sounds over bilateral lung fields.
After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a
client develops pontine myselinolysis. Which intervention should the nurse implement
first?
A. Reorient client to his room
B. Place a patch on one eye
C. Evaluate client's ability to swallow
D. Perform range of motion exercises
A. Reorient client to his room
A male client with heart failure (HF) calls the clinic and reports that he cannot put his
shoes on because they are too tight. Which additional information should the nurse
obtain?
A. What time did he take his last medications?
B. Has his weight changed in the last several days?
C. Is he still able to tighten his belt buckle?
D. How many hours did he sleep last night?
B. Has his weight changed in the last several days?
An older adult woman with a long history of chronic obstructive pulmonary disease
(COPD) is admitted with progressive shortness of breath and a persistent cough. She is
anxious and is complaining of a dry mouth. Which intervention should the nurse
,implement?
A. Administer a prescribed sedative
B. Encourage client to drink water
C. Apply a high-flow venturi mask
D. Assist her to an upright position
D. Assist her to an upright position
A client with a history of asthma and bronchitis arrives at the clinic with shortness of
breath, productive cough with thickened tenacious mucous, and the inability to walk up
a flight of stairs without experiencing breathlessness. Which action is most important for
the nurse to instruct the client about self-care?
A. Increase the daily intake of oral fluids to liquefy secretions
B. Avoid crowded enclosed areas to reduce pathogen exposure
C. Call the clinic if undesirable side effects of mediations occur
D. Teach anxiety reduction methods for feelings of suffocation
A. Increase the daily intake of oral fluids to liquefy secretions
A cardiac catherterization of a client with heart disease indicates the following
blockages: 95% proximal left anterior descending (LAD), 99% proximal circumflex, and
? % proximal right coronary artery (RCA). The client later asks the nurse "what does all
this mean for me?" What information should the nurse provide?
A. Blood supply to the heart is diminished by artherosclerotic lesions, which necessitate
lifestyle changes.
B. Blood vessels supplying the pumping chamber have blockages indicating a past
heart attack.
C. Three main arteries have major blockages, with only 1 to 5% of blood flow getting
through to the heart muscle.
D. The heart is not receiving enough blood, so there is a risk of heart failure and fluid
retention.
C. Three main arteries have major blockages, with only 1 to 5% of blood flow getting
through to the heart muscle.
A client who weighs 175 pounds is receiving IV bolus dose of heparin 80 units/kg. The
heparin is available in a 2 ml vial, labeled 10,000 units/ml. How many ml should the
nurse administer? (Enter numeric value only. If rounding is required, round to the
nearest tenth.)
0.6 ml
What information should the nurse include in the teaching plan of a client diagnosed
with gastroesophageal reflux disease (GERD)?
A. Sleep without pillows at night to maintain neck alignment.
B. Adjust food intake to three full meals per day and no snacks.
C. Minimize symptoms by wearing loose, comfortable clothing
D. Avoid participation in any aerobic exercise programs
C. Minimize symptoms by wearing loose, comfortable clothing
, The nurse is caring for a client with a lower left lobe pulmonary abscess. Which position
should the nurse instruct the client to maintain?
A. left lateral
B. Supine, knees flexed
C. Dorsal recumbent
D. Knee-chest
A. left lateral
A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable
to eat or drink without becoming nauseated and vomiting. Which finding should the
nurse report to the healthcare provider.
A. Belching
B. Amber urine
C. Yellow sclera
D. Flatulence
C. Yellow sclera
While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a
neurological assessment every four hours. Which assessment finding warrants
immediate intervention by the nurse?
A. Inappropriate laughter
B. Increasing anxiety
C. Weakened cough effort
D. Asymmetrical weakness
C. Weakened cough effort
The nurse is providing preoperative education for a Jewish client scheduled to receive a
xenograft graft to promote burn healing. Which information should the nurse provide this
client?
A. Grafting increases the risk for bacterial infections
B. The xenograft is taken from nonhuman sources
C. Grafts are later removed by a debriding procedure
D. As the burn heals, the graft permanently attaches
B. The xenograft is taken from nonhuman sources
A male client who had colon surgery 3 days ago is anxious and requesting assistance to
reposition. While the nurse is turning him, the wound dehiscences and eviscerates. The
nurse moistens an available sterile dressing and places it over the wound. What
intervention should the nurse implement next?
A. Bring additional sterile dressing supplies to the room
B. Prepare the client to return to the operating room
C. Obtain a sample of the drainage to send to the lab
D. Auscultate the abdomen for bowel sound activity
B. Prepare the client to return to the operating room
