Med-Surg II HESITest Bank j j j j
A. - A nurse is reinforcing teaching with a client who has HIV and is being discharged to
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home. Which of the following instructions should the nurse include in the teaching?
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A. Take temperature once a day.
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B. Wash the armpits and genitals with a gentle cleanser daily.
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C. Change the litter boxes while wearing gloves.
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D. Wash dishes in warm water.
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A. - A nurse is caring for a client who is postoperative following a tracheostomy, and has
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copious and tenacious secretions. Which of the following is an acceptable method for the
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nurse to use to thin this client's secretions?
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A. Provide humidified oxygen.
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B. Perform chest physiotherapy prior to suctioning.
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C. Prelubricate the suction catheter tip with sterile saline when suctioning the airway.
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D. Hyperventilate the client with 100% oxygen before suctioning the airway..
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B. - Following admission, a client with a vascular occlusion of the right lower extremity
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calls the nurse and reports difficulty sleeping because of cold feet. Which of the following
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nursing actions should the nurse take to promote the client's comfort?
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A. Rub the client's feet briskly for several minutes.
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B. Obtain a pair of slipper socks for the client.
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C. Increase the client's oral fluid intake.
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D. Place a moist heating pad under the client's feet.
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C. - A nurse is caring for a client is who is 4 hr postoperative following a transurethral
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resection of the prostate (TURP). Which of the following is the priority finding for the
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nurse report to the provider?
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A. Emesis of 100 mL
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B. Oral temperature of 37.5° C (99.5° F)
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C. Thick, red-colored urine
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D. Pain level of 4 on a 0 to 10 rating scale
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A. - A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a
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prescription for a hypothermia blanket. The nurse should monitor the client for which of the
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following adverse effects of the hypothermia blanket?
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,A. Shivering
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B. Infection
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C. Burnsj
D. Hypervolemia
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D. - A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes
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mellitus. Which of the following statements by the client indicates an understanding of the
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teaching?
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A. "I will carry a complex carbohydrate snack with me when I exercise."
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B. "I should exercise first thing in the morning before eating breakfast."
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C. "I should avoid injecting insulin into my thigh if I am going to go running."
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D. "I will not exercise if my urine is positive for ketones."
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A. - A nurse notes a small section of bowel protruding from the abdominal incision of a
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client who
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is postoperative. After calling for assistance, which of the following actions should the
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nurse take first?
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A. Cover the client's wound with a moist, sterile dressing.
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B. Have the client lie supine with knees flexed.
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C. Check the client's vital signs. j j j j
D. Inform the client about the need to return to surgery.
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B. - A nurse is collecting data from a client who has alcohol use disorder and is
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experiencing metabolic acidosis. Which of the following manifestations should the
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nurse expect?
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A. Cool, clammy skin.
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B. Hyperventilation
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C. Increased blood pressure
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D. Bradycardia
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A. - A nurse is reinforcing discharge teaching with a client following a cataract extraction.
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Which of the following should the nurse include in the teaching?
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A. Avoid bending at the waist.
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B. Remove the eye shield at bedtime.
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C. Limit the use of laxatives if constipated.
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D. Seeing flashes of light is an expected finding following extraction.
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, C - A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg
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daily. The client refuses breakfast and reports nausea. Which of the following actions
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should the nurse take first?
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1) Suggest that the client rests before eating the meal. j j j j j j j j
2) Request a dietary consult. j j j
3) Check the client's vital signs. j j j j
4) Request an order for an antiemetic. j j j j j
D. - A nurse is caring for a client who is 3 days postoperative following a cholecystectomy.
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The nurse suspects the client's wound is infected because the drainage from the dressing is
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yellow and thick. Which of the following findings should the nurse report as the type of
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drainage found?
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1) Sanguineous
2) Serous
3) Serosanguineous
4) Purulent
A. - A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To
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prevent postoperative complications which of the following actions should be reinforced
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during the teaching?
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1) Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises. j j j j j j j j j j j j j
2) Place the client's affected leg into the CPM machine with the machine in the flexed
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position.
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3) Place the client into a high Fowler's position when initiating the CPM exercises.
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4) Align the joints of the CPM machine with the knee gatch in the client's bed.
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A, B, C, D - A nurse is collecting data from a client who has emphysema. Which of the
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following findings should the nurse expect? (Select all that apply.)
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1) Dyspnea
2) Barrel chest j
3) Clubbing of the fingers j j j
4) Shallow respirations j
5) Bradycardia
D. - A nurse is caring for a client who sustained a basal skull fracture. When performing
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morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of
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the client's right nostril.
j j j j
A. - A nurse is reinforcing teaching with a client who has HIV and is being discharged to
j j j j j j j j j j j j j j j j j
home. Which of the following instructions should the nurse include in the teaching?
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A. Take temperature once a day.
j j j j j
B. Wash the armpits and genitals with a gentle cleanser daily.
j j j j j j j j j j
C. Change the litter boxes while wearing gloves.
j j j j j j j
D. Wash dishes in warm water.
j j j j j
A. - A nurse is caring for a client who is postoperative following a tracheostomy, and has
j j j j j j j j j j j j j j j j
copious and tenacious secretions. Which of the following is an acceptable method for the
j j j j j j j j j j j j j j
nurse to use to thin this client's secretions?
j j j j j j j j
A. Provide humidified oxygen.
j j j
B. Perform chest physiotherapy prior to suctioning.
j j j j j j
C. Prelubricate the suction catheter tip with sterile saline when suctioning the airway.
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D. Hyperventilate the client with 100% oxygen before suctioning the airway..
j j j j j j j j j j
B. - Following admission, a client with a vascular occlusion of the right lower extremity
j j j j j j j j j j j j j j
calls the nurse and reports difficulty sleeping because of cold feet. Which of the following
j j j j j j j j j j j j j j j
nursing actions should the nurse take to promote the client's comfort?
j j j j j j j j j j j
A. Rub the client's feet briskly for several minutes.
j j j j j j j j
B. Obtain a pair of slipper socks for the client.
j j j j j j j j j
C. Increase the client's oral fluid intake.
j j j j j j
D. Place a moist heating pad under the client's feet.
j j j j j j j j j
C. - A nurse is caring for a client is who is 4 hr postoperative following a transurethral
j j j j j j j j j j j j j j j j j
resection of the prostate (TURP). Which of the following is the priority finding for the
j j j j j j j j j j j j j j j
nurse report to the provider?
j j j j j
A. Emesis of 100 mL
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B. Oral temperature of 37.5° C (99.5° F)
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C. Thick, red-colored urine
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D. Pain level of 4 on a 0 to 10 rating scale
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A. - A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a
j j j j j j j j j j j j j j j j j j j j
prescription for a hypothermia blanket. The nurse should monitor the client for which of the
j j j j j j j j j j j j j j j
following adverse effects of the hypothermia blanket?
j j j j j j j
,A. Shivering
j
B. Infection
j
C. Burnsj
D. Hypervolemia
j
D. - A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes
j j j j j j j j j j j j j j j j
mellitus. Which of the following statements by the client indicates an understanding of the
j j j j j j j j j j j j j j
teaching?
j
A. "I will carry a complex carbohydrate snack with me when I exercise."
j j j j j j j j j j j
B. "I should exercise first thing in the morning before eating breakfast."
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C. "I should avoid injecting insulin into my thigh if I am going to go running."
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D. "I will not exercise if my urine is positive for ketones."
j j j j j j j j j j
A. - A nurse notes a small section of bowel protruding from the abdominal incision of a
j j j j j j j j j j j j j j j
client who
j j
is postoperative. After calling for assistance, which of the following actions should the
j j j j j j j j j j j j
nurse take first?
j j j
A. Cover the client's wound with a moist, sterile dressing.
j j j j j j j j
B. Have the client lie supine with knees flexed.
j j j j j j j
C. Check the client's vital signs. j j j j
D. Inform the client about the need to return to surgery.
j j j j j j j j j
B. - A nurse is collecting data from a client who has alcohol use disorder and is
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experiencing metabolic acidosis. Which of the following manifestations should the
j j j j j j j j j j
nurse expect?
j j
A. Cool, clammy skin.
j j j
B. Hyperventilation
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C. Increased blood pressure
j j j
D. Bradycardia
j
A. - A nurse is reinforcing discharge teaching with a client following a cataract extraction.
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Which of the following should the nurse include in the teaching?
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A. Avoid bending at the waist.
j j j j j
B. Remove the eye shield at bedtime.
j j j j j j
C. Limit the use of laxatives if constipated.
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D. Seeing flashes of light is an expected finding following extraction.
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, C - A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg
j j j j j j j j j j j j j j j j j j j
daily. The client refuses breakfast and reports nausea. Which of the following actions
j j j j j j j j j j j j j
should the nurse take first?
j j j j j
1) Suggest that the client rests before eating the meal. j j j j j j j j
2) Request a dietary consult. j j j
3) Check the client's vital signs. j j j j
4) Request an order for an antiemetic. j j j j j
D. - A nurse is caring for a client who is 3 days postoperative following a cholecystectomy.
j j j j j j j j j j j j j j j j
The nurse suspects the client's wound is infected because the drainage from the dressing is
j j j j j j j j j j j j j j j
yellow and thick. Which of the following findings should the nurse report as the type of
j j j j j j j j j j j j j j j j
drainage found?
j j
1) Sanguineous
2) Serous
3) Serosanguineous
4) Purulent
A. - A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To
j j j j j j j j j j j j j
prevent postoperative complications which of the following actions should be reinforced
j j j j j j j j j j j
during the teaching?
j j j
1) Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises. j j j j j j j j j j j j j
2) Place the client's affected leg into the CPM machine with the machine in the flexed
j j j j j j j j j j j j j j
position.
j
3) Place the client into a high Fowler's position when initiating the CPM exercises.
j j j j j j j j j j j j
4) Align the joints of the CPM machine with the knee gatch in the client's bed.
j j j j j j j j j j j j j j
A, B, C, D - A nurse is collecting data from a client who has emphysema. Which of the
j j j j j j j j j j j j j j j j j j
following findings should the nurse expect? (Select all that apply.)
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1) Dyspnea
2) Barrel chest j
3) Clubbing of the fingers j j j
4) Shallow respirations j
5) Bradycardia
D. - A nurse is caring for a client who sustained a basal skull fracture. When performing
j j j j j j j j j j j j j j j j
morning hygiene care, the nurse notices a thin stream of clear drainage coming from out of
j j j j j j j j j j j j j j j j
the client's right nostril.
j j j j
