Med Surg Test bank ( Red HESI Test
bank Med-Surg and other resources)
1. A nurse is reviewing the hematologic test results for a patient in whom the hematocrit
(Hct) is reported at a reading of 30%. Based on this result, the nurse should interpret
that the patient
A. is susceptible to bleeding disorders.
B. has fewer red blood cells than normal. C. is experiencing an inflammatory response.
D. is experiencing an acute hemolytic crisis. - correct answerB. has fewer red blood
cells than normal.The Hct is the measure of the volume of red blood cells in whole blood
expressed as a percentage. This test is useful in the diagnosis of anemia, polycythemia,
and abnormal hydration states. Patients who are susceptible to bleeding disorders likely
will have a low platelet count. The inflammatory response may best be evaluated by
examination of results that include the white blood cell count with differential analysis.
Acute hemolytic crisis develops in patients receiving blood components in which
incompatibility occurs or in patients with bleeding disorders or conditions that promote
cellular damage, such as damage associated with shock.
1. The arterial blood gas (ABG) readings that indicate compensated respiratory acidosis
are a PaCO2 of
A. 30 mm Hg and bicarbonate level of 24 mEq/L.
B. 30 mm Hg and bicarbonate level of 30 mEq/L.
C. 50 mm Hg and bicarbonate level of 20 mEq/L.
D. 50 mm Hg and bicarbonate level of 30 mEq/L. - correct answerD. 50 mm Hg and
bicarbonate level of 30 mEq/L. If compensation is present, carbon dioxide and
bicarbonate are abnormal (or nearly so) in opposite directions (e.g., one is acidotic and
the other alkalotic).
1. When assessing a patient's nutritional-metabolic pattern related to hematologic
health, the nurse would:
A. Inspect the skin for petechiae.
B. Ask the patient about joint pain.
C. Assess for vitamin C deficiency.
D. Determine if the patient can perform ADLs. - correct answerA. Inspect the skin for
petechiae. Any changes in the skin's texture or color should be explored when
assessing the patient's nutritional-metabolic pattern related to hematologic health. The
presences of petechiae or ecchymotic areas could be indicative of hematologic
deficiencies related to poor nutritional intake or related causes.
10. Anticoagulant therapy is used in the treatment of thromboembolic disease because
anticoagulants can
A. dissolve the thrombi.
B. decrease blood viscosity.
C. prevent absorption of vitamin K.
,D. inhibit the synthesis of clotting factors. - correct answerD. inhibit the synthesis of
clotting factors. Anticoagulant therapy is based on the premise that the initiation or
extension of thrombi can be prevented by inhibiting the synthesis of clotting factors or
by accelerating their inactivation. The anticoagulants heparin and warfarin do not induce
thrombolysis but effectively prevent clot extension.
10. During discharge teaching for a 65-year-old patient with emphysema and
pneumonia, which of the following vaccines should the nurse recommend the patient
receive?
A. S. aureus
B. H. influenzae
C. Pneumococcal
D. Bacille Calmette-Guérin (BCG) - correct answerC. Pneumococcal The pneumococcal
vaccine is important for patients with a history of heart or lung disease, recovering from
a severe illness, age 65 or over, or living in a long-term care facility.
10. If a nurse is caring for an 80-year-old patient with a temperature of 100.4° F,
crackles at the right lung base, pain with deep inspiration, and dyspnea, which of the
following orders is the nurse's priority? A. Sputum specimen for culture and sensitivity
B. Codeine 15 mg orally every 6 hours as needed
C. Incentive spirometer every 2 hours while awake
D. Amoxicillin (Amoxil) 500 mg orally 4 times a day - correct answerA. Sputum
specimen for culture and sensitivity The patient presents with signs of a respiratory
infection. To initiate the most effective therapy, the health care prescriber must know the
pathogen causing the infection. Therefore, the sputum specimen is the nurse's priority.
If the antibiotic is administered before the specimen is obtained, the results of the
culture might not be as accurate and could impair the effectiveness of therapy. After the
specimen is obtained, the nurse can administer codeine for coughing and begin the
incentive spirometry to mobilize secretions and improve the patient's ability to
expectorate the secretions.
10. The blood bank notifies the nurse that the two units of blood ordered for an anemic
patient are ready for pick up. The nurse should take which of the following actions to
prevent an adverse effect during this procedure?
A. Immediately pick up both units of blood from the blood bank.
B. Regulate the flow rate so that each unit takes at least 4 hours to transfuse.
C. Set up the Y-tubing of the blood set with dextrose in water as the flush solution.
D. Infuse the blood slowly for the first 15 minutes of the transfusion. - correct answerD.
Infuse the blood slowly for the first 15 minutes of the transfusion. Because a transfusion
reaction is more likely to occur at the beginning of a transfusion, the nurse should
initially infuse the blood at a rate no faster than 2 ml/min and remain with the patient for
the first 15 minutes after hanging a unit of blood.
11. If a patient has pernicious anemia, the nurse should provide information regarding
A. frequent bouts of dyspnea.
B. risks relative to dehydration.
,C. deficiency of intrinsic factor.
D. lack of any effective treatment for this condition. - correct answerC. deficiency of
intrinsic factor. Pernicious anemia is a type of anemia caused by failure of absorption of
vitamin B12 (cobalamin). The most common cause is lack of intrinsic factor, a
glucoprotein produced by the parietal cells of the gastric lining.
11. The nurse evaluates that discharge teaching for a patient hospitalized with
pneumonia has been most effective when the patient states which of the following
measures to prevent a relapse?
A. "I will increase my food intake to 2400 calories a day to keep my immune system
well."
B. "I must use home oxygen therapy for 3 months and then will have a chest x-ray to
reevaluate."
C. "I will seek immediate medical treatment for any upper respiratory infections."
D. "I should continue to do deep-breathing and coughing exercises for at least 6
weeks." - correct answerD. "I should continue to do deep-breathing and coughing
exercises for at least 6 weeks." It is important for the patient to continue with coughing
and deep breathing exercises for 6 to 8 weeks until all of the infection has cleared from
the lungs. A patient should seek medical treatment for upper respiratory infections that
persist for more than 7 days. Increased fluid intake, not caloric intake, is required to
liquefy secretions. Home O2 is not a requirement unless the patient's oxygenation
saturation is below normal.
11. When assessing a patient's respiratory status, which of the following nonrespiratory
data are most important for the nurse to obtain?
A. Height and weight
B. Neck circumference
C. Occupation and hobbies
D. Usual daily fluid intake - correct answerC. Occupation and hobbiesMany respiratory
problems occur as a result of chronic exposure to inhalation irritants. Common
occupational sources of inhalation irritants include mines, granaries, farms, lawn care
companies, paint, plastics and rubber manufacture, and building remodeling. Hobbies
associated with inhalation irritants include woodworking, metal finishing, furniture
refinishing, painting, and ceramics. Daily fluids, height, and weight are more related to
respiratory problems secondary to cardiac issues.
12. A nurse is providing care to an adult female patient and observes that the Hb
laboratory analysis result is 9 g/dl. Based on this finding, the nurse should expect to
observe
A. dyspnea.
B. bradycardia.
C. warm, dry skin.
D. activity tolerance without complaint of fatigue. - correct answerA. dyspnea.Hb levels
are used to determine the severity of anemia. Patients with moderate anemia (Hb 6 to
10 g/dL) may suffer from dyspnea, palpitations, diaphoresis with exertion, and chronic
fatigue. Patients who are anemic usually have cool skin related to compensatory
, mechanism of mild vasoconstriction. Patients who are anemic experience tachycardia
because of increased demands placed on the heart to meet overall metabolic
requirements. Activity tolerance without complaint is not correct because patients with
anemic conditions fatigue readily.
12. After admitting a patient to the medical unit with a diagnosis of pneumonia, the
nurse will verify that which of the following physician orders have been completed
before administering a dose of cefotetan (Cefotan) to the patient?
A. Serum laboratory studies ordered for AM
B. Pulmonary function evaluation
C. Orthostatic blood pressures
D. Sputum culture and sensitivity - correct answerD. Sputum culture and sensitivityThe
nurse should ensure that the sputum for culture and sensitivity was sent to the
laboratory before administering the cefotetan. It is important that the organisms are
correctly identified (by the culture) before their numbers are affected by the antibiotic;
the test will also determine whether the proper antibiotic has been ordered (sensitivity
testing). Although antibiotic administration should not be unduly delayed while waiting
for the patient to expectorate sputum, all of the other options will not be affected by the
administration of antibiotics.
12. If a nurse is assessing a patient whose recent blood gas determination indicated a
pH of 7.32 and respirations are measured at 32 breaths/min, which of the following is
the most appropriate nursing assessment?
A. The rapid breathing is causing the low pH.
B. The nurse should sedate the patient to slow down respirations.
C. The rapid breathing is an attempt to compensate for the low pH.
D. The nurse should give the patient a paper bag to breathe into to correct the low pH. -
correct answerC. The rapid breathing is an attempt to compensate for the low pH. The
respiratory system influences pH (acidity) through control of carbon dioxide exhalation.
Thus, rapid breathing increases the pH. Breathing into a paper bag aids a patient who is
hyperventilating; in respiratory alkalosis, it aids in lowering the pH. The use of sedation
can cause respiratory depression and hypoventilation, resulting in an even lower pH.
13. If a patient with an uncuffed tracheostomy tube coughs violently during suctioning
and dislodges the tracheostomy tube, a nurse should first
A. call the physician.
B. attempt to reinsert the tracheostomy tube.
C. position the patient in a lateral position with the neck extended.
D. cover the stoma with a sterile dressing and ventilate the patient with a manual bag-
mask until the physician arrives. - correct answerB. attempt to reinsert the tracheostomy
tube.Retention sutures may be grasped (if present) and the tracheostomy opening
spread, or a hemostat may be used to spread the opening. The obturator is inserted into
the replacement tube (one size smaller than the original tube), lubricated with saline
solution, and inserted into the stoma at a 45-degree angle to the neck. If the attempt is
successful, the obturator tube should immediately be removed.
bank Med-Surg and other resources)
1. A nurse is reviewing the hematologic test results for a patient in whom the hematocrit
(Hct) is reported at a reading of 30%. Based on this result, the nurse should interpret
that the patient
A. is susceptible to bleeding disorders.
B. has fewer red blood cells than normal. C. is experiencing an inflammatory response.
D. is experiencing an acute hemolytic crisis. - correct answerB. has fewer red blood
cells than normal.The Hct is the measure of the volume of red blood cells in whole blood
expressed as a percentage. This test is useful in the diagnosis of anemia, polycythemia,
and abnormal hydration states. Patients who are susceptible to bleeding disorders likely
will have a low platelet count. The inflammatory response may best be evaluated by
examination of results that include the white blood cell count with differential analysis.
Acute hemolytic crisis develops in patients receiving blood components in which
incompatibility occurs or in patients with bleeding disorders or conditions that promote
cellular damage, such as damage associated with shock.
1. The arterial blood gas (ABG) readings that indicate compensated respiratory acidosis
are a PaCO2 of
A. 30 mm Hg and bicarbonate level of 24 mEq/L.
B. 30 mm Hg and bicarbonate level of 30 mEq/L.
C. 50 mm Hg and bicarbonate level of 20 mEq/L.
D. 50 mm Hg and bicarbonate level of 30 mEq/L. - correct answerD. 50 mm Hg and
bicarbonate level of 30 mEq/L. If compensation is present, carbon dioxide and
bicarbonate are abnormal (or nearly so) in opposite directions (e.g., one is acidotic and
the other alkalotic).
1. When assessing a patient's nutritional-metabolic pattern related to hematologic
health, the nurse would:
A. Inspect the skin for petechiae.
B. Ask the patient about joint pain.
C. Assess for vitamin C deficiency.
D. Determine if the patient can perform ADLs. - correct answerA. Inspect the skin for
petechiae. Any changes in the skin's texture or color should be explored when
assessing the patient's nutritional-metabolic pattern related to hematologic health. The
presences of petechiae or ecchymotic areas could be indicative of hematologic
deficiencies related to poor nutritional intake or related causes.
10. Anticoagulant therapy is used in the treatment of thromboembolic disease because
anticoagulants can
A. dissolve the thrombi.
B. decrease blood viscosity.
C. prevent absorption of vitamin K.
,D. inhibit the synthesis of clotting factors. - correct answerD. inhibit the synthesis of
clotting factors. Anticoagulant therapy is based on the premise that the initiation or
extension of thrombi can be prevented by inhibiting the synthesis of clotting factors or
by accelerating their inactivation. The anticoagulants heparin and warfarin do not induce
thrombolysis but effectively prevent clot extension.
10. During discharge teaching for a 65-year-old patient with emphysema and
pneumonia, which of the following vaccines should the nurse recommend the patient
receive?
A. S. aureus
B. H. influenzae
C. Pneumococcal
D. Bacille Calmette-Guérin (BCG) - correct answerC. Pneumococcal The pneumococcal
vaccine is important for patients with a history of heart or lung disease, recovering from
a severe illness, age 65 or over, or living in a long-term care facility.
10. If a nurse is caring for an 80-year-old patient with a temperature of 100.4° F,
crackles at the right lung base, pain with deep inspiration, and dyspnea, which of the
following orders is the nurse's priority? A. Sputum specimen for culture and sensitivity
B. Codeine 15 mg orally every 6 hours as needed
C. Incentive spirometer every 2 hours while awake
D. Amoxicillin (Amoxil) 500 mg orally 4 times a day - correct answerA. Sputum
specimen for culture and sensitivity The patient presents with signs of a respiratory
infection. To initiate the most effective therapy, the health care prescriber must know the
pathogen causing the infection. Therefore, the sputum specimen is the nurse's priority.
If the antibiotic is administered before the specimen is obtained, the results of the
culture might not be as accurate and could impair the effectiveness of therapy. After the
specimen is obtained, the nurse can administer codeine for coughing and begin the
incentive spirometry to mobilize secretions and improve the patient's ability to
expectorate the secretions.
10. The blood bank notifies the nurse that the two units of blood ordered for an anemic
patient are ready for pick up. The nurse should take which of the following actions to
prevent an adverse effect during this procedure?
A. Immediately pick up both units of blood from the blood bank.
B. Regulate the flow rate so that each unit takes at least 4 hours to transfuse.
C. Set up the Y-tubing of the blood set with dextrose in water as the flush solution.
D. Infuse the blood slowly for the first 15 minutes of the transfusion. - correct answerD.
Infuse the blood slowly for the first 15 minutes of the transfusion. Because a transfusion
reaction is more likely to occur at the beginning of a transfusion, the nurse should
initially infuse the blood at a rate no faster than 2 ml/min and remain with the patient for
the first 15 minutes after hanging a unit of blood.
11. If a patient has pernicious anemia, the nurse should provide information regarding
A. frequent bouts of dyspnea.
B. risks relative to dehydration.
,C. deficiency of intrinsic factor.
D. lack of any effective treatment for this condition. - correct answerC. deficiency of
intrinsic factor. Pernicious anemia is a type of anemia caused by failure of absorption of
vitamin B12 (cobalamin). The most common cause is lack of intrinsic factor, a
glucoprotein produced by the parietal cells of the gastric lining.
11. The nurse evaluates that discharge teaching for a patient hospitalized with
pneumonia has been most effective when the patient states which of the following
measures to prevent a relapse?
A. "I will increase my food intake to 2400 calories a day to keep my immune system
well."
B. "I must use home oxygen therapy for 3 months and then will have a chest x-ray to
reevaluate."
C. "I will seek immediate medical treatment for any upper respiratory infections."
D. "I should continue to do deep-breathing and coughing exercises for at least 6
weeks." - correct answerD. "I should continue to do deep-breathing and coughing
exercises for at least 6 weeks." It is important for the patient to continue with coughing
and deep breathing exercises for 6 to 8 weeks until all of the infection has cleared from
the lungs. A patient should seek medical treatment for upper respiratory infections that
persist for more than 7 days. Increased fluid intake, not caloric intake, is required to
liquefy secretions. Home O2 is not a requirement unless the patient's oxygenation
saturation is below normal.
11. When assessing a patient's respiratory status, which of the following nonrespiratory
data are most important for the nurse to obtain?
A. Height and weight
B. Neck circumference
C. Occupation and hobbies
D. Usual daily fluid intake - correct answerC. Occupation and hobbiesMany respiratory
problems occur as a result of chronic exposure to inhalation irritants. Common
occupational sources of inhalation irritants include mines, granaries, farms, lawn care
companies, paint, plastics and rubber manufacture, and building remodeling. Hobbies
associated with inhalation irritants include woodworking, metal finishing, furniture
refinishing, painting, and ceramics. Daily fluids, height, and weight are more related to
respiratory problems secondary to cardiac issues.
12. A nurse is providing care to an adult female patient and observes that the Hb
laboratory analysis result is 9 g/dl. Based on this finding, the nurse should expect to
observe
A. dyspnea.
B. bradycardia.
C. warm, dry skin.
D. activity tolerance without complaint of fatigue. - correct answerA. dyspnea.Hb levels
are used to determine the severity of anemia. Patients with moderate anemia (Hb 6 to
10 g/dL) may suffer from dyspnea, palpitations, diaphoresis with exertion, and chronic
fatigue. Patients who are anemic usually have cool skin related to compensatory
, mechanism of mild vasoconstriction. Patients who are anemic experience tachycardia
because of increased demands placed on the heart to meet overall metabolic
requirements. Activity tolerance without complaint is not correct because patients with
anemic conditions fatigue readily.
12. After admitting a patient to the medical unit with a diagnosis of pneumonia, the
nurse will verify that which of the following physician orders have been completed
before administering a dose of cefotetan (Cefotan) to the patient?
A. Serum laboratory studies ordered for AM
B. Pulmonary function evaluation
C. Orthostatic blood pressures
D. Sputum culture and sensitivity - correct answerD. Sputum culture and sensitivityThe
nurse should ensure that the sputum for culture and sensitivity was sent to the
laboratory before administering the cefotetan. It is important that the organisms are
correctly identified (by the culture) before their numbers are affected by the antibiotic;
the test will also determine whether the proper antibiotic has been ordered (sensitivity
testing). Although antibiotic administration should not be unduly delayed while waiting
for the patient to expectorate sputum, all of the other options will not be affected by the
administration of antibiotics.
12. If a nurse is assessing a patient whose recent blood gas determination indicated a
pH of 7.32 and respirations are measured at 32 breaths/min, which of the following is
the most appropriate nursing assessment?
A. The rapid breathing is causing the low pH.
B. The nurse should sedate the patient to slow down respirations.
C. The rapid breathing is an attempt to compensate for the low pH.
D. The nurse should give the patient a paper bag to breathe into to correct the low pH. -
correct answerC. The rapid breathing is an attempt to compensate for the low pH. The
respiratory system influences pH (acidity) through control of carbon dioxide exhalation.
Thus, rapid breathing increases the pH. Breathing into a paper bag aids a patient who is
hyperventilating; in respiratory alkalosis, it aids in lowering the pH. The use of sedation
can cause respiratory depression and hypoventilation, resulting in an even lower pH.
13. If a patient with an uncuffed tracheostomy tube coughs violently during suctioning
and dislodges the tracheostomy tube, a nurse should first
A. call the physician.
B. attempt to reinsert the tracheostomy tube.
C. position the patient in a lateral position with the neck extended.
D. cover the stoma with a sterile dressing and ventilate the patient with a manual bag-
mask until the physician arrives. - correct answerB. attempt to reinsert the tracheostomy
tube.Retention sutures may be grasped (if present) and the tracheostomy opening
spread, or a hemostat may be used to spread the opening. The obturator is inserted into
the replacement tube (one size smaller than the original tube), lubricated with saline
solution, and inserted into the stoma at a 45-degree angle to the neck. If the attempt is
successful, the obturator tube should immediately be removed.
