MED- SURG HESI questions well
answered 100% correct
Light housekeeping is permitted but avoid heavy lifting - correct answer ✔✔What instruction
should the nurse include in the discharge teaching plan of a client who had a cataract extraction
today?
Obtain a sputum sample for culture - correct answer ✔✔A male adult comes to the urgent care
clinic 5 days after being diagnose with influenza. He is short of breath, febrile, and coughing
green colored sputum. Which intervention should the nurse implement first?
palpate the bladder above the symphysis pubis - correct answer ✔✔An elder male client tells
the nurse that he is loosing sleep because he has to get up several times at night to go to the
bathroom that he has trouble starting his urinary stream and that he does not feel like his
bladder is ever completely empty. Which intervention should the nurse implement?
potassium of 2.5 meq/l - correct answer ✔✔An adult client is admitted with diabetic
ketoacidosis (DKA) and a urinary tract infection (UTI) Prescriptions for intravenous antibiotics
and insulin infusion are initiated. Which serum laboratory value warrants the most immediate
intervention by the nurse?
explain specific reason for urgent notification - correct answer ✔✔A client with sickle cell
anemia develops a fever during the last hour of administration of a unit of packed red blood
cell. When notifying the healthcare provider what information should the nurse provide first
using the SBAR communication process?
It will be necessary to continue prophylactic doses of IV or aerosol pentamine every month -
correct answer ✔✔An adult male client is admitted for pneumocystis carinil pneumonia (PCP)
secondary to aids. While hospitalize he receives IV pentamidine isethionate therapy. In
,preparing this client for discharge what important aspect regarding his medication therapy
should the nurse explain?
.collect a clean catch specimen - correct answer ✔✔A client subjective data includes dysuria,
urgency, and urinary frequency. What action should the nurse implement next?
ask the client in the healthcare provider has giving her any information about the classification
of her cancer - correct answer ✔✔A client tells the nurse that her biopsy results indicate that
the cancer cells are well differentiated How should the nurse respond?
stop dialysis treatment - correct answer ✔✔A client with a chronic kidney disease is treated on
hemodialysis. During the 1 treatment clients blood pressure drops from 150/90 to 80/30 Which
action should the nurse take first?
9 - correct answer ✔✔A client with deep vain thrombosis (DVT) is receiving a continues infusion
of heparin sodium 25,000 unit in 5% dextrose injection 250ml. The prescription indicates the
dosage should be increase 900 units/hr. The nurse should program the infusion pump to deliver
how many ml/hr?
upper mid abdominal gnawing and burning pain - correct answer ✔✔The nurse is obtaining the
admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data
reported by the client supports this diagnosis?
the xenograft is taken from nonhuman sources - correct answer ✔✔The nurse is providing
preoperative education for a jewish client schedule to receive a xenograft graft to promote burn
healing. Which information should the nurse provide this client?
jaundice sclera - correct answer ✔✔A client who took a camping vacation two weeks ago in a
country with a tropical climate comes to the clinic describing vague symptoms and diarrhea for
the past week. Which finding is most important for the nurse to report?
,a grandson and his new dog recently visited - correct answer ✔✔During a home visit the nurse
assesses the skin of a client with eczema who reports than an exacerbation of symptoms has
occurred during the last week. Which information is most useful in determining the possible
cause of the symptoms?
restrict sodium intake - correct answer ✔✔When explaining dietary guidelines to a client with
acute glomerulonephritis (AGN) which instruction should the nurse include in the dietary
teaching?
Auscultate bowel sound in all four quadrants - correct answer ✔✔A male client who is 24hr
post operative for an exploratory laparoctomy complains that he is starving because he has had
no real food since before surgery. Prior to advancing his diet which intervention should the
nurse implememt?
call 911 pain is unrelieved and chew a tablet of aspirin 325mg - correct answer ✔✔A client
diagnose with stable angina secondary to ischemic heart disease has a prescription for
sublingual (SL) nitroglycerin (NTG). The nurse should tell the client to follow which instructions if
chest pain is not relieved after taking 3 NTG tables 5 min apart?
ask the client to describe her dietary intake history for the last several days - correct answer
✔✔After taking orlistat (Xenical) for one week a femela client tells the home health nurse that
she is experiencing increasingly frequent oily stools and flatus. What action should the nurse
take?
assess airway patency and oxygen saturation - correct answer ✔✔Two days after an abscess of
the chin was drained the client returns to the clinic with fever chills and a maculopapular rash
with pruritis. The client has taken an oral antibiotic and cleansed the wound today with provide
iodine (Betadine) solution. Which intervention should the nurse implement first?
low back pain and hypotension - correct answer ✔✔A client experiences an ABO incompatibility
reaction after multiple blood transfusions. Which finding should the nurse report immediately
to the health care provider?
, decrease infusion rate to address fluid overload - correct answer ✔✔A young adult male who
has had type 2 diabetes mellitus (DM) is admitted to the intensive care unit with hyperglycemic
nonketotic symdrome (HHNS). A sliding scale protocol for an isotonic IV solution with regular
insulin is prescribed based on the results of a continuous blood glucose monitoring device that
is attached to the clients central venous catheter. When the clients respirations become labored
and his lungs sound indicate crackles what action should the nurse take?
Apply a new patch in a different location after removing the original patch - correct answer
✔✔When preparing to apply a fentanyl (Duragesic) transdermal patch the nurse notes that the
previously applied patch is intact on the clients upper back and the client denies pain. What
action should the nurse take?
reduce the rate of the nitroglycerin infusion - correct answer ✔✔A client who had a myocardial
infarction is admitted to the coronary critical care unit (CCU) with a nitroglycerin drip infusing.
The clients last blood pressure measurements was 78/36.What action should the nurse
implement?
LDH OR LD, SGOT OR ALT, SGPT OR AST. - correct answer ✔✔An adolescent is admitted to the
hospital because of a suicide attempt with an overdose of acetaminophen (Tylenol). Which
blood values are most important for the nurse to monitor during the first 72 hours following
ingestion of this overdose?
her respiratory rate is 7 breath/minute - correct answer ✔✔An elderly post operative female
client is receiving morphine sulfate via a PCA pump. Which assessment finding should prompt a
nurse to administer the prescribed PRN medication naloxone?
urinary output equal to intake - correct answer ✔✔Which assessment finding indicates to the
nurse that the muscarinic agent bethanechol (Urecholine) is effective for a client diagnose with
urinary retention?
answered 100% correct
Light housekeeping is permitted but avoid heavy lifting - correct answer ✔✔What instruction
should the nurse include in the discharge teaching plan of a client who had a cataract extraction
today?
Obtain a sputum sample for culture - correct answer ✔✔A male adult comes to the urgent care
clinic 5 days after being diagnose with influenza. He is short of breath, febrile, and coughing
green colored sputum. Which intervention should the nurse implement first?
palpate the bladder above the symphysis pubis - correct answer ✔✔An elder male client tells
the nurse that he is loosing sleep because he has to get up several times at night to go to the
bathroom that he has trouble starting his urinary stream and that he does not feel like his
bladder is ever completely empty. Which intervention should the nurse implement?
potassium of 2.5 meq/l - correct answer ✔✔An adult client is admitted with diabetic
ketoacidosis (DKA) and a urinary tract infection (UTI) Prescriptions for intravenous antibiotics
and insulin infusion are initiated. Which serum laboratory value warrants the most immediate
intervention by the nurse?
explain specific reason for urgent notification - correct answer ✔✔A client with sickle cell
anemia develops a fever during the last hour of administration of a unit of packed red blood
cell. When notifying the healthcare provider what information should the nurse provide first
using the SBAR communication process?
It will be necessary to continue prophylactic doses of IV or aerosol pentamine every month -
correct answer ✔✔An adult male client is admitted for pneumocystis carinil pneumonia (PCP)
secondary to aids. While hospitalize he receives IV pentamidine isethionate therapy. In
,preparing this client for discharge what important aspect regarding his medication therapy
should the nurse explain?
.collect a clean catch specimen - correct answer ✔✔A client subjective data includes dysuria,
urgency, and urinary frequency. What action should the nurse implement next?
ask the client in the healthcare provider has giving her any information about the classification
of her cancer - correct answer ✔✔A client tells the nurse that her biopsy results indicate that
the cancer cells are well differentiated How should the nurse respond?
stop dialysis treatment - correct answer ✔✔A client with a chronic kidney disease is treated on
hemodialysis. During the 1 treatment clients blood pressure drops from 150/90 to 80/30 Which
action should the nurse take first?
9 - correct answer ✔✔A client with deep vain thrombosis (DVT) is receiving a continues infusion
of heparin sodium 25,000 unit in 5% dextrose injection 250ml. The prescription indicates the
dosage should be increase 900 units/hr. The nurse should program the infusion pump to deliver
how many ml/hr?
upper mid abdominal gnawing and burning pain - correct answer ✔✔The nurse is obtaining the
admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data
reported by the client supports this diagnosis?
the xenograft is taken from nonhuman sources - correct answer ✔✔The nurse is providing
preoperative education for a jewish client schedule to receive a xenograft graft to promote burn
healing. Which information should the nurse provide this client?
jaundice sclera - correct answer ✔✔A client who took a camping vacation two weeks ago in a
country with a tropical climate comes to the clinic describing vague symptoms and diarrhea for
the past week. Which finding is most important for the nurse to report?
,a grandson and his new dog recently visited - correct answer ✔✔During a home visit the nurse
assesses the skin of a client with eczema who reports than an exacerbation of symptoms has
occurred during the last week. Which information is most useful in determining the possible
cause of the symptoms?
restrict sodium intake - correct answer ✔✔When explaining dietary guidelines to a client with
acute glomerulonephritis (AGN) which instruction should the nurse include in the dietary
teaching?
Auscultate bowel sound in all four quadrants - correct answer ✔✔A male client who is 24hr
post operative for an exploratory laparoctomy complains that he is starving because he has had
no real food since before surgery. Prior to advancing his diet which intervention should the
nurse implememt?
call 911 pain is unrelieved and chew a tablet of aspirin 325mg - correct answer ✔✔A client
diagnose with stable angina secondary to ischemic heart disease has a prescription for
sublingual (SL) nitroglycerin (NTG). The nurse should tell the client to follow which instructions if
chest pain is not relieved after taking 3 NTG tables 5 min apart?
ask the client to describe her dietary intake history for the last several days - correct answer
✔✔After taking orlistat (Xenical) for one week a femela client tells the home health nurse that
she is experiencing increasingly frequent oily stools and flatus. What action should the nurse
take?
assess airway patency and oxygen saturation - correct answer ✔✔Two days after an abscess of
the chin was drained the client returns to the clinic with fever chills and a maculopapular rash
with pruritis. The client has taken an oral antibiotic and cleansed the wound today with provide
iodine (Betadine) solution. Which intervention should the nurse implement first?
low back pain and hypotension - correct answer ✔✔A client experiences an ABO incompatibility
reaction after multiple blood transfusions. Which finding should the nurse report immediately
to the health care provider?
, decrease infusion rate to address fluid overload - correct answer ✔✔A young adult male who
has had type 2 diabetes mellitus (DM) is admitted to the intensive care unit with hyperglycemic
nonketotic symdrome (HHNS). A sliding scale protocol for an isotonic IV solution with regular
insulin is prescribed based on the results of a continuous blood glucose monitoring device that
is attached to the clients central venous catheter. When the clients respirations become labored
and his lungs sound indicate crackles what action should the nurse take?
Apply a new patch in a different location after removing the original patch - correct answer
✔✔When preparing to apply a fentanyl (Duragesic) transdermal patch the nurse notes that the
previously applied patch is intact on the clients upper back and the client denies pain. What
action should the nurse take?
reduce the rate of the nitroglycerin infusion - correct answer ✔✔A client who had a myocardial
infarction is admitted to the coronary critical care unit (CCU) with a nitroglycerin drip infusing.
The clients last blood pressure measurements was 78/36.What action should the nurse
implement?
LDH OR LD, SGOT OR ALT, SGPT OR AST. - correct answer ✔✔An adolescent is admitted to the
hospital because of a suicide attempt with an overdose of acetaminophen (Tylenol). Which
blood values are most important for the nurse to monitor during the first 72 hours following
ingestion of this overdose?
her respiratory rate is 7 breath/minute - correct answer ✔✔An elderly post operative female
client is receiving morphine sulfate via a PCA pump. Which assessment finding should prompt a
nurse to administer the prescribed PRN medication naloxone?
urinary output equal to intake - correct answer ✔✔Which assessment finding indicates to the
nurse that the muscarinic agent bethanechol (Urecholine) is effective for a client diagnose with
urinary retention?
