MED SURG HESI EXIT EXAM/Latest
2022/Test Bank
Following discharge teaching, a male client with duodenal ulcer tells the nurse
thehe will drink plenty of dairy products, such as milk, to help coat and
protect his ulcer. What is the best follow-up action by the nurse?
(ANS- Review with the client the need to avoid foods that are rich in milk and
cream
A male client with hypertension, who received new antihypertensive
prescriptionsat his last visit returns to the clinic two weeks later to evaluate
his blood pressure (BP). His BP is 158/106 and he admits that he has not been
taking the prescribed medication because the drugs make him "feel bad". In
explaining the need for hypertension control, the nurse should stress that an
elevated BP places the client at risk for which pathophysiological condition?
(ANS- Stroke secondary to hemorrhage
The nurse observes an unlicensed assistive personnel (UAP) positioning a
newly admitted client who has a seizure disorder. The client is supine and the
UAP is placing soft pillows along the side rails. What action should the nurse
implement? (ANS- Instruct the UAP to obtain soft blankets to secure to the
side rails instead ofpillows.
An adolescent with major depressive disorder has been taking duloxetine
(Cymbalta) for the past 12 days. Which assessment finding requires
immediatefollow-up?
(ANS- Describes life without purpose
A 60-year-old female client with a positive family history of ovarian cancer
,has developed an abdominal mass and is being evaluated for possible ovarian
cancer.Her Papanicolau (Pap) smear results are negative. What information
should the nurse include in the client's teaching plan?
(ANS- Further evaluation involving surgery may be needed
,A client who recently underwear a tracheostomy is being prepared for
discharge tohome. Which instructions is most important for the nurse to
include in the discharge plan?
(ANS- Teach tracheal suctioning techniques
In assessing an adult client with a partial rebreather mask, the nurse notes
that the oxygen reservoir bag does not deflate completely during inspiration
and the client'srespiratory rate is 14 breaths / minute. What action should the
nurse implement? (ANS- Document the assessment data
Rationale: reservoir bag should not deflate completely during inspiration and
theclient's respiratory rate is within normal limits.
During shift report, the central electrocardiogram (EKG) monitoring system
alarms. Which client alarm should the nurse investigate firs?
(ANS- Respiratory apnea of 30 seconds
During a home visit, the nurse observed an elderly client with diabetes
slip andfall. What action should the nurse take first?
(ANS- Check the client for lacerations or fractures
At 0600 while admitting a woman for a schedule repeat cesarean section (C-
Section), the client tells the nurse that she drank a cup a coffee at 0400
because shewanted to avoid getting a headache. Which action should the
nurse take first? (ANS- Inform the anesthesia care provider
After placing a stethoscope as seen in the picture, the nurse auscultates S1
and S2 heart sounds. To determine if an S3 heart sound is present, what
action should thenurse take first?
, (ANS- Listen with the bell at the same location
A 66-year-old woman is retiring and will no longer have a health insurance
through her place of employment. Which agency should the client be referred
to bythe employee health nurse for health insurance needs?
(ANS- Medicare
2022/Test Bank
Following discharge teaching, a male client with duodenal ulcer tells the nurse
thehe will drink plenty of dairy products, such as milk, to help coat and
protect his ulcer. What is the best follow-up action by the nurse?
(ANS- Review with the client the need to avoid foods that are rich in milk and
cream
A male client with hypertension, who received new antihypertensive
prescriptionsat his last visit returns to the clinic two weeks later to evaluate
his blood pressure (BP). His BP is 158/106 and he admits that he has not been
taking the prescribed medication because the drugs make him "feel bad". In
explaining the need for hypertension control, the nurse should stress that an
elevated BP places the client at risk for which pathophysiological condition?
(ANS- Stroke secondary to hemorrhage
The nurse observes an unlicensed assistive personnel (UAP) positioning a
newly admitted client who has a seizure disorder. The client is supine and the
UAP is placing soft pillows along the side rails. What action should the nurse
implement? (ANS- Instruct the UAP to obtain soft blankets to secure to the
side rails instead ofpillows.
An adolescent with major depressive disorder has been taking duloxetine
(Cymbalta) for the past 12 days. Which assessment finding requires
immediatefollow-up?
(ANS- Describes life without purpose
A 60-year-old female client with a positive family history of ovarian cancer
,has developed an abdominal mass and is being evaluated for possible ovarian
cancer.Her Papanicolau (Pap) smear results are negative. What information
should the nurse include in the client's teaching plan?
(ANS- Further evaluation involving surgery may be needed
,A client who recently underwear a tracheostomy is being prepared for
discharge tohome. Which instructions is most important for the nurse to
include in the discharge plan?
(ANS- Teach tracheal suctioning techniques
In assessing an adult client with a partial rebreather mask, the nurse notes
that the oxygen reservoir bag does not deflate completely during inspiration
and the client'srespiratory rate is 14 breaths / minute. What action should the
nurse implement? (ANS- Document the assessment data
Rationale: reservoir bag should not deflate completely during inspiration and
theclient's respiratory rate is within normal limits.
During shift report, the central electrocardiogram (EKG) monitoring system
alarms. Which client alarm should the nurse investigate firs?
(ANS- Respiratory apnea of 30 seconds
During a home visit, the nurse observed an elderly client with diabetes
slip andfall. What action should the nurse take first?
(ANS- Check the client for lacerations or fractures
At 0600 while admitting a woman for a schedule repeat cesarean section (C-
Section), the client tells the nurse that she drank a cup a coffee at 0400
because shewanted to avoid getting a headache. Which action should the
nurse take first? (ANS- Inform the anesthesia care provider
After placing a stethoscope as seen in the picture, the nurse auscultates S1
and S2 heart sounds. To determine if an S3 heart sound is present, what
action should thenurse take first?
, (ANS- Listen with the bell at the same location
A 66-year-old woman is retiring and will no longer have a health insurance
through her place of employment. Which agency should the client be referred
to bythe employee health nurse for health insurance needs?
(ANS- Medicare
