med surg hesi v1 .Final Exam Test 2024\2025.
The nurse obtains a fingerstick glucose level utilizing bedside lancet/glucose meter equipment from a client with
prescribed sliding scale insulin protocol. The meter indicates 56 mg/dl (3.12 mmol/l). At this time which
intervention should the nurse implement first?
A. Collect a blood specimen by venipuncture to send to the laboratory for serum glucose analysis.
B. Prepare the prescribed dose of rapid acting insulin from the sliding scale instructions.
C. Give the client six ounces of non-die
C
To achieve maximum mobility and independence for a client with multiple sclerosis (MS), which intervention is
most important for the nurse to implement?
A. Provide a walker for ambulation
B. Frequently assist the client to the bathroom
C. Apply alternating patches over eyes
D. Teach strengthening exercises
D
A client is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular
assessment requires immediate intervention by the nurse?
A. Pupillary changes to ipsilateral dilation
B. Orientation to person and place only
C. Left- sided drooping and dysphagia
D. Unequal bilateral hand grip strengths
C
The nurse is teaching a client with glomerulonephritis about self care. Which dietary recommendations should the
nurse encourage the client to follow?
A. Limit oral fluid intake to 500 ml per day
B. Restrict protein intake by limiting meats and other high-protein foods
C. Increase intake of potassium-rich foods such as bananas and cantaloupe.
D. Increase intake of high fiber foods such as bran cereal
B
The nurse is caring for a client with Herpes zoster who reports painful, red, blisters that align from the back along
the chest's curvature to the anterior chest. Which intervention is the highest priority for the nurse?
A. Place the client on contact precautions
B. Administer antiviral medications
C. Place wet compresses to ruptured vesicles
D. Administer narcotic analgesics
B
A young adult who suffered a severe brain injury in an automobile collision has been mechanically ventilated for
the past three days and has no spontaneous respiratory effort. After serial electroencephalograms (EEG) reveal
, med surg hesi v1 .Final Exam Test 2024\2025.
no brain activity, the healthcare provider discusses end-of-life options with the family who agree to discontinue
life support. Which intervention should the nurse implement?
A. Ask the family if they wish to remain at the bedside during withdrawal
B. Request a living will b
C
Following a transurethral resection of the prostate (TURP), a client is discharged from the hospital with an
indwelling urinary catheter. which instruction is important for the nurse to include in the discharge teaching plan?
A. Eliminate all spicy foods from your diet
B. Drink 3 liters of water each day
C. Clamp the catheter when taking a shower
D. Avoid driving a car for 2 weeks
B
On the first postoperative day, the nurse finds an older male client disoriented and trying to climb over the bed
railing. Previously, he was oriented to person, place, and time on admission. Which intervention should the nurse
implement first?
A. Apply wrist restraints
B. Determine the clients blood pressure
C. Administer a mild sedative
D. Assess the client for pain
D
Acute soft tissue injuries ( ie sprains, strains) provide the nurse with a variety of teaching opportunities. Which
instruction should the nurse provide to a client with a soft-tissue injury?
A. Watch for shortness of breath which may indicate a fat embolus
B. Begin range of motion exercises within the first 24 hours
C. Apply ice intermittently for the first 24 hours
D. After edema subsides, apply heat continuously
C
A client returns to the unit following a craniotomy for removal of a brain tumor and is obtunded, but arouses to
painful stimuli. Which assessment is most important for the nurse to obtain?
A. Drainage on dressing
B. Last administration of analgesia
C. Body Temperature
D. Serial blood pressure and pulse
B
The nurse obtains a fingerstick glucose level utilizing bedside lancet/glucose meter equipment from a client with
prescribed sliding scale insulin protocol. The meter indicates 56 mg/dl (3.12 mmol/l). At this time which
intervention should the nurse implement first?
A. Collect a blood specimen by venipuncture to send to the laboratory for serum glucose analysis.
B. Prepare the prescribed dose of rapid acting insulin from the sliding scale instructions.
C. Give the client six ounces of non-die
C
To achieve maximum mobility and independence for a client with multiple sclerosis (MS), which intervention is
most important for the nurse to implement?
A. Provide a walker for ambulation
B. Frequently assist the client to the bathroom
C. Apply alternating patches over eyes
D. Teach strengthening exercises
D
A client is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular
assessment requires immediate intervention by the nurse?
A. Pupillary changes to ipsilateral dilation
B. Orientation to person and place only
C. Left- sided drooping and dysphagia
D. Unequal bilateral hand grip strengths
C
The nurse is teaching a client with glomerulonephritis about self care. Which dietary recommendations should the
nurse encourage the client to follow?
A. Limit oral fluid intake to 500 ml per day
B. Restrict protein intake by limiting meats and other high-protein foods
C. Increase intake of potassium-rich foods such as bananas and cantaloupe.
D. Increase intake of high fiber foods such as bran cereal
B
The nurse is caring for a client with Herpes zoster who reports painful, red, blisters that align from the back along
the chest's curvature to the anterior chest. Which intervention is the highest priority for the nurse?
A. Place the client on contact precautions
B. Administer antiviral medications
C. Place wet compresses to ruptured vesicles
D. Administer narcotic analgesics
B
A young adult who suffered a severe brain injury in an automobile collision has been mechanically ventilated for
the past three days and has no spontaneous respiratory effort. After serial electroencephalograms (EEG) reveal
, med surg hesi v1 .Final Exam Test 2024\2025.
no brain activity, the healthcare provider discusses end-of-life options with the family who agree to discontinue
life support. Which intervention should the nurse implement?
A. Ask the family if they wish to remain at the bedside during withdrawal
B. Request a living will b
C
Following a transurethral resection of the prostate (TURP), a client is discharged from the hospital with an
indwelling urinary catheter. which instruction is important for the nurse to include in the discharge teaching plan?
A. Eliminate all spicy foods from your diet
B. Drink 3 liters of water each day
C. Clamp the catheter when taking a shower
D. Avoid driving a car for 2 weeks
B
On the first postoperative day, the nurse finds an older male client disoriented and trying to climb over the bed
railing. Previously, he was oriented to person, place, and time on admission. Which intervention should the nurse
implement first?
A. Apply wrist restraints
B. Determine the clients blood pressure
C. Administer a mild sedative
D. Assess the client for pain
D
Acute soft tissue injuries ( ie sprains, strains) provide the nurse with a variety of teaching opportunities. Which
instruction should the nurse provide to a client with a soft-tissue injury?
A. Watch for shortness of breath which may indicate a fat embolus
B. Begin range of motion exercises within the first 24 hours
C. Apply ice intermittently for the first 24 hours
D. After edema subsides, apply heat continuously
C
A client returns to the unit following a craniotomy for removal of a brain tumor and is obtunded, but arouses to
painful stimuli. Which assessment is most important for the nurse to obtain?
A. Drainage on dressing
B. Last administration of analgesia
C. Body Temperature
D. Serial blood pressure and pulse
B
