MED/SURG NCLEX-RN HESI PRACTICE
The nurse assesses a postoperative client whose skin is B
cool, pale, and moist. The client is very restless and has The client is at risk for hypovolemic shock because of the postope
scant urine output. Oxygen is being administered at 2 is exhibiting early signs of shock. A priority intervention is the initia
L/min, and a saline lock is in place. Which intervention (B) to restore tissue perfusion. (A, C, and D) are all important inter
should the nurse implement first? of less priority than (B).
A.Measure the urine specific gravity.
B.Obtain IV fluids for infusion per protocol.
C.Prepare for insertion of a central venous catheter.
D.Auscultate the client's breath sounds.
During a health fair, a male client with emphysema tells A
the nurse that he fatigues easily. Assessment reveals Manifestations of emphysema include an increase in AP diameter
marked clubbing of the fingernails and an increased barrel chest), nail bed clubbing, and fatigue. The nurse can provid
anteroposterior chest diameter. Which instruction is best promote energy management, such as pacing activities and sched
to provide the client? periods (A). (B) may result in a decreased drive to breathe. The cli
exhibiting any symptoms of infection, so (C) is not necessary. (D) i
A."Pace your activities and schedule rest periods." than (A).
B."Increase the amount of oxygen you use at night."
C."Obtain medical evaluation for antibiotic therapy."
D."Reduce your intake of fluids containing caffeine."
, MED/SURG NCLEX-RN HESI PRACTICE
During the change of shift report, the charge nurse C
reviews the infusions being received by clients on the All four of these clients have the potential to have significant com
oncology unit. The client receiving which infusion should client with the morphine epidural infusion (C) is at highest risk for
be assessed first? depression and should be assessed first. (A) can cause hypotensi
receiving (B) is at lowest risk for serious complications. Although (
A.Continuous IV infusion of magnesium nephrotoxicity and phlebitis, these problems are not as immediate
B.One-time infusion of albumin threatening as (C).
C.Continuous epidural infusion of morphine
D.Intermittent infusion of IV vancomycin
The nurse is planning care for a client with diabetes B
mellitus who has gangrene of the toes to the midfoot. The prevention of infection is a priority goal for this client (B). Gan
Which goal should be included in this client's plan of result of necrosis (tissue death). If infection develops, there is insu
care? circulation to fight the infection and the infection can result in ost
sepsis. Because tissue death has already occurred, (A and C) are u
A.Restore skin integrity. goals. (D) is important but of less priority than (B).
B.Prevent infection.
C.Promote healing.
D.Improve nutrition.
, MED/SURG NCLEX-RN HESI PRACTICE
The nurse is conducting an osteoporosis screening clinic A, C, D
at a health fair. What information should the nurse provide (A, C, and D) are factors that decrease the risk for developing ost
to individuals who are at risk for osteoporosis? (Select all Vitamin D and calcium are important supplements to aid in the de
that apply.) loss (B). Regular sleep patterns are important to overall health bu
identified with a decreasing risk for osteoporosis (E).
A.Encourage alcohol and smoking cessation.
B.Suggest supplementing diet with vitamin E.
C.Promote regular weight-bearing exercises.
D.Implement a home safety plan to prevent falls.
E.Propose a regular sleep pattern of 8 hours nightly.
, MED/SURG NCLEX-RN HESI PRACTICE
An 81-year-old male client has emphysema. He lives at A
home with his cat and manages self-care with no Clients with COPD should ingest 3 L of fluids daily but may exper
difficulty. When making a home visit, the nurse notices that deficit because of shortness of breath. The nurse should suggest
this client's tongue is somewhat cracked and his eyeballs to increase the intake of fluids (A), such as having fruit juices in dis
appear sunken into his head. Which nursing intervention is containers readily available. (B) is not indicated. Humidified oxyge
indicated? effectively treat the client's fluid deficit, and there is no indication
needs supplemental oxygen at night (C). These symptoms are not
A.Help the client determine ways to increase his fluid and may unnecessarily upset the client, who depends on his pet f
intake.
B.Obtain an appointment for the client to have an eye
examination.
C.Instruct the client to use oxygen at night and increase
the humidification.
D.Schedule the client for tests to determine his sensitivity
to cat hair.
The nurse assesses a postoperative client whose skin is B
cool, pale, and moist. The client is very restless and has The client is at risk for hypovolemic shock because of the postope
scant urine output. Oxygen is being administered at 2 is exhibiting early signs of shock. A priority intervention is the initia
L/min, and a saline lock is in place. Which intervention (B) to restore tissue perfusion. (A, C, and D) are all important inter
should the nurse implement first? of less priority than (B).
A.Measure the urine specific gravity.
B.Obtain IV fluids for infusion per protocol.
C.Prepare for insertion of a central venous catheter.
D.Auscultate the client's breath sounds.
During a health fair, a male client with emphysema tells A
the nurse that he fatigues easily. Assessment reveals Manifestations of emphysema include an increase in AP diameter
marked clubbing of the fingernails and an increased barrel chest), nail bed clubbing, and fatigue. The nurse can provid
anteroposterior chest diameter. Which instruction is best promote energy management, such as pacing activities and sched
to provide the client? periods (A). (B) may result in a decreased drive to breathe. The cli
exhibiting any symptoms of infection, so (C) is not necessary. (D) i
A."Pace your activities and schedule rest periods." than (A).
B."Increase the amount of oxygen you use at night."
C."Obtain medical evaluation for antibiotic therapy."
D."Reduce your intake of fluids containing caffeine."
, MED/SURG NCLEX-RN HESI PRACTICE
During the change of shift report, the charge nurse C
reviews the infusions being received by clients on the All four of these clients have the potential to have significant com
oncology unit. The client receiving which infusion should client with the morphine epidural infusion (C) is at highest risk for
be assessed first? depression and should be assessed first. (A) can cause hypotensi
receiving (B) is at lowest risk for serious complications. Although (
A.Continuous IV infusion of magnesium nephrotoxicity and phlebitis, these problems are not as immediate
B.One-time infusion of albumin threatening as (C).
C.Continuous epidural infusion of morphine
D.Intermittent infusion of IV vancomycin
The nurse is planning care for a client with diabetes B
mellitus who has gangrene of the toes to the midfoot. The prevention of infection is a priority goal for this client (B). Gan
Which goal should be included in this client's plan of result of necrosis (tissue death). If infection develops, there is insu
care? circulation to fight the infection and the infection can result in ost
sepsis. Because tissue death has already occurred, (A and C) are u
A.Restore skin integrity. goals. (D) is important but of less priority than (B).
B.Prevent infection.
C.Promote healing.
D.Improve nutrition.
, MED/SURG NCLEX-RN HESI PRACTICE
The nurse is conducting an osteoporosis screening clinic A, C, D
at a health fair. What information should the nurse provide (A, C, and D) are factors that decrease the risk for developing ost
to individuals who are at risk for osteoporosis? (Select all Vitamin D and calcium are important supplements to aid in the de
that apply.) loss (B). Regular sleep patterns are important to overall health bu
identified with a decreasing risk for osteoporosis (E).
A.Encourage alcohol and smoking cessation.
B.Suggest supplementing diet with vitamin E.
C.Promote regular weight-bearing exercises.
D.Implement a home safety plan to prevent falls.
E.Propose a regular sleep pattern of 8 hours nightly.
, MED/SURG NCLEX-RN HESI PRACTICE
An 81-year-old male client has emphysema. He lives at A
home with his cat and manages self-care with no Clients with COPD should ingest 3 L of fluids daily but may exper
difficulty. When making a home visit, the nurse notices that deficit because of shortness of breath. The nurse should suggest
this client's tongue is somewhat cracked and his eyeballs to increase the intake of fluids (A), such as having fruit juices in dis
appear sunken into his head. Which nursing intervention is containers readily available. (B) is not indicated. Humidified oxyge
indicated? effectively treat the client's fluid deficit, and there is no indication
needs supplemental oxygen at night (C). These symptoms are not
A.Help the client determine ways to increase his fluid and may unnecessarily upset the client, who depends on his pet f
intake.
B.Obtain an appointment for the client to have an eye
examination.
C.Instruct the client to use oxygen at night and increase
the humidification.
D.Schedule the client for tests to determine his sensitivity
to cat hair.
