HESI Med Surg BSN 266 2023 2024
Client87is87recovering87from87a87transurethral87prostatectomy.87Which87activity87should87
be87limited87until87after87the87first87postoperative87visit87with87the87healthcare87provider?
87-87Drink873L
A87client87with87stage87IV87bone87cancer87is87admitted87to87the87hospital87for87a871-
1087scale.87Which87intervention87should87the87nurse87implement?87-
87Administer87opioid87and87non-opioid87medications87simultaneously
A87client87experiences87an87AOB87incompatibility87reaction87after87multiple87blood87transf
usions.87Which87finding87should87the87nurse87report87immediately87to87the87health87care
87provider?
a. low87back87pain87and87hypotension
b. rhinitis87and87nasal87stuffiness
c. delayed87painful87rash87with87urticarial
d. arthritic87joint87changes87and87chronic87pain87-
87a.87low87back87pain87and87hypotension
ANSWER:87(A)87LOW87BACK87PAIN87AND87HYPOTENSTION
When87conducting87discharge87teaching87for87a87client
diagnosed87with87diverticulosis,87which87diet87instruction87should87the87nurse87include?
a. Have87small87frequent87meals87and87sit87up87for87at87least87two87hours87after87meals.
b. Eat87a87bland87diet87and87avoid87spicy87foods.
c. Eat87a87high87fiber87diet87and87increase87fluid87intake.
d. Eat87a87soft87diet87with87increased87intake87of87milk87and87milk87products87-
87c.87Eat87a87high87fiber87diet87and87increase87fluid87intake.
ANSWER87(C)87EAT87A87HIGH-FIBER87DIET87AND87INCREASE87FLUID87INTAKE
The87nurse87observes87an87increased87number87of87blood87clots87in87the87drainage87
tubing87of87a87client87with87continuous87bladder87irrigation87following87a87transurethr
al87resection87of87the87prostate87(TURP).87What87is87the87best87initial87nursing87actio
n?
a. Provide87additional87oral87fluid87intake
b. Measure87the87client's87intake87and87output.
c. Increase87the87flow87of87the87bladder
,irrigation
d. Administer87a87PRN87dose87of87an87antispasmodic87agent87-
87c.87Increase87the87flow87of87the87bladder
irrigation
ANSWER87(C)87Increase87the87flow87of87the87bladder87irrigation
A87client87wit87lung87cancer87who87wears87a87subcutaneous87morphine87sulfate87patch87f
or87pain87is87short87of87breath87and87difficult87to87arouse.87When87performing87a87head
-to-toe87assessment,87the87nurse87discovers87four87analgesic87patches87on87-
87Remove87all87morphine87patches
Coming87down87the87basement87steps,87a87client87is87brought87to87the87emergency87roo
m87X-ray87...87cast,87which87assessment87finding87warrants87immediate
Intervention87by87the87nurse?87-87Right87foot87pale87with87sluggish87capillary87refill
An87overweight,87young87adult87who87was
recently87Check87finger87stick87glucose87diagnosed87with87type87287diabetes87mellitus87is
87admitted87for87a87hernia87repair.87He87tells87the87nurse87that87he87is87feeling87very87we
ak87and87jittery.
Which87actions87should87the87nurse87implem
ent?87(Select87all87that87apply.)
a. Check87finger87sti
ck87glucose
b. Assess87skin87temperatu
re87and87moisture
c. Measure87pulse87and87blood
87pressure87-
87a.87Check87finger87stick87gluc
ose
b.87Assess87skin87temperature
87and87moisture
c.87Measure87pulse87and87bloo
d87pressure
ANSWER:87(CAM)
A87client87who87underwent87cardiac87stent87placement87four87days87ago87arrive
s87to87the87emergency87department87reporting87a87sudden87onset87of87chest87
pressure87and87shortness87of87breath.87Which87action87should87the87nurse87ta
ke87next?
, a. Listen87for87extra87heart87sounds,87murmurs,8
7and87r87hythm87with87the87bell87of
the87stethoscope.
b. Evaluate87upper87and87lower87extremities87for87perfusion,87pulse87
volume,87and87pitting87edema.
c. Verify87troponin87level87assessments87are87scheduled87every873-
687hours87for87a87series87of87three.
d. Obtain87a8712-lead87electrocardiogram87and87begin87continuous87cardiac87monitoring
.87-87d.87Obtain87a8712-
lead87electrocardiogram87and87begin87continuous87cardiac87monitoring
While87completing87a87health87assessment87for87a87client87with87migraine87headaches,87
the87nurse87assesses87bilateral87weakness87in87the87clients87hand87grips.87The87client87r
eports87joint87pain87and87trouble87twisting87a87door87knob87due87to87weaknesses.87Whic
h87action87should87the87nurses87take87in87response87to87these87figures?
a. Implement87fall87precautions87to87reduce87the87clients87risk87of87injury.
b. Explain87that87relief87of87the87migraine87pain87will87reduce87related87symptoms.
c. Gather87additional87assessment87data87about87the87pain87and87weakness.
d. Consult87with87the87occupational87therapist87for87a87functional87assessment87-
87c.87Gather87additional87assessment87data87about87the87pain87and87weakness.
The87nurse87is87caring87for87a87client87diagnosed87with87psoriasis87vulgaris87who87is87rec
eiving87psoralen87and87ultraviolet87A87light87(PUVA)87treatment.
Which87assessment87finding87indicates87that87the87client87has87been87overexposed87to87t
he87treatment?
a. Thick87skin87plaques87topped87by87silvery87white87scales
b. Tenderness87upon87palpation87and87generalized87erythema
c. Brown,87rough,87greasy,87wart-like87papules87on87the87face
d. Requires87sunglasses87because87sunlight87hurts87eyes87-
87b.87Tenderness87upon87palpation87and87generalized87erythema
An87adult87client87who87had87a87gastric87bypass87surgery87287weeks87ago,87is87admitted8
7with87possible87anastomosis87leakage.87The87client's87abdomen87is87tender87to87touch,8
7and87the87vital87signs87are87temperature87101*87F87(38873*87C).87heart87rate8713087beat
s/minute,87Respiratory87rate872687breaths/minute,87and87blood87pressure87100/5087mm
Hg.
Client87is87recovering87from87a87transurethral87prostatectomy.87Which87activity87should87
be87limited87until87after87the87first87postoperative87visit87with87the87healthcare87provider?
87-87Drink873L
A87client87with87stage87IV87bone87cancer87is87admitted87to87the87hospital87for87a871-
1087scale.87Which87intervention87should87the87nurse87implement?87-
87Administer87opioid87and87non-opioid87medications87simultaneously
A87client87experiences87an87AOB87incompatibility87reaction87after87multiple87blood87transf
usions.87Which87finding87should87the87nurse87report87immediately87to87the87health87care
87provider?
a. low87back87pain87and87hypotension
b. rhinitis87and87nasal87stuffiness
c. delayed87painful87rash87with87urticarial
d. arthritic87joint87changes87and87chronic87pain87-
87a.87low87back87pain87and87hypotension
ANSWER:87(A)87LOW87BACK87PAIN87AND87HYPOTENSTION
When87conducting87discharge87teaching87for87a87client
diagnosed87with87diverticulosis,87which87diet87instruction87should87the87nurse87include?
a. Have87small87frequent87meals87and87sit87up87for87at87least87two87hours87after87meals.
b. Eat87a87bland87diet87and87avoid87spicy87foods.
c. Eat87a87high87fiber87diet87and87increase87fluid87intake.
d. Eat87a87soft87diet87with87increased87intake87of87milk87and87milk87products87-
87c.87Eat87a87high87fiber87diet87and87increase87fluid87intake.
ANSWER87(C)87EAT87A87HIGH-FIBER87DIET87AND87INCREASE87FLUID87INTAKE
The87nurse87observes87an87increased87number87of87blood87clots87in87the87drainage87
tubing87of87a87client87with87continuous87bladder87irrigation87following87a87transurethr
al87resection87of87the87prostate87(TURP).87What87is87the87best87initial87nursing87actio
n?
a. Provide87additional87oral87fluid87intake
b. Measure87the87client's87intake87and87output.
c. Increase87the87flow87of87the87bladder
,irrigation
d. Administer87a87PRN87dose87of87an87antispasmodic87agent87-
87c.87Increase87the87flow87of87the87bladder
irrigation
ANSWER87(C)87Increase87the87flow87of87the87bladder87irrigation
A87client87wit87lung87cancer87who87wears87a87subcutaneous87morphine87sulfate87patch87f
or87pain87is87short87of87breath87and87difficult87to87arouse.87When87performing87a87head
-to-toe87assessment,87the87nurse87discovers87four87analgesic87patches87on87-
87Remove87all87morphine87patches
Coming87down87the87basement87steps,87a87client87is87brought87to87the87emergency87roo
m87X-ray87...87cast,87which87assessment87finding87warrants87immediate
Intervention87by87the87nurse?87-87Right87foot87pale87with87sluggish87capillary87refill
An87overweight,87young87adult87who87was
recently87Check87finger87stick87glucose87diagnosed87with87type87287diabetes87mellitus87is
87admitted87for87a87hernia87repair.87He87tells87the87nurse87that87he87is87feeling87very87we
ak87and87jittery.
Which87actions87should87the87nurse87implem
ent?87(Select87all87that87apply.)
a. Check87finger87sti
ck87glucose
b. Assess87skin87temperatu
re87and87moisture
c. Measure87pulse87and87blood
87pressure87-
87a.87Check87finger87stick87gluc
ose
b.87Assess87skin87temperature
87and87moisture
c.87Measure87pulse87and87bloo
d87pressure
ANSWER:87(CAM)
A87client87who87underwent87cardiac87stent87placement87four87days87ago87arrive
s87to87the87emergency87department87reporting87a87sudden87onset87of87chest87
pressure87and87shortness87of87breath.87Which87action87should87the87nurse87ta
ke87next?
, a. Listen87for87extra87heart87sounds,87murmurs,8
7and87r87hythm87with87the87bell87of
the87stethoscope.
b. Evaluate87upper87and87lower87extremities87for87perfusion,87pulse87
volume,87and87pitting87edema.
c. Verify87troponin87level87assessments87are87scheduled87every873-
687hours87for87a87series87of87three.
d. Obtain87a8712-lead87electrocardiogram87and87begin87continuous87cardiac87monitoring
.87-87d.87Obtain87a8712-
lead87electrocardiogram87and87begin87continuous87cardiac87monitoring
While87completing87a87health87assessment87for87a87client87with87migraine87headaches,87
the87nurse87assesses87bilateral87weakness87in87the87clients87hand87grips.87The87client87r
eports87joint87pain87and87trouble87twisting87a87door87knob87due87to87weaknesses.87Whic
h87action87should87the87nurses87take87in87response87to87these87figures?
a. Implement87fall87precautions87to87reduce87the87clients87risk87of87injury.
b. Explain87that87relief87of87the87migraine87pain87will87reduce87related87symptoms.
c. Gather87additional87assessment87data87about87the87pain87and87weakness.
d. Consult87with87the87occupational87therapist87for87a87functional87assessment87-
87c.87Gather87additional87assessment87data87about87the87pain87and87weakness.
The87nurse87is87caring87for87a87client87diagnosed87with87psoriasis87vulgaris87who87is87rec
eiving87psoralen87and87ultraviolet87A87light87(PUVA)87treatment.
Which87assessment87finding87indicates87that87the87client87has87been87overexposed87to87t
he87treatment?
a. Thick87skin87plaques87topped87by87silvery87white87scales
b. Tenderness87upon87palpation87and87generalized87erythema
c. Brown,87rough,87greasy,87wart-like87papules87on87the87face
d. Requires87sunglasses87because87sunlight87hurts87eyes87-
87b.87Tenderness87upon87palpation87and87generalized87erythema
An87adult87client87who87had87a87gastric87bypass87surgery87287weeks87ago,87is87admitted8
7with87possible87anastomosis87leakage.87The87client's87abdomen87is87tender87to87touch,8
7and87the87vital87signs87are87temperature87101*87F87(38873*87C).87heart87rate8713087beat
s/minute,87Respiratory87rate872687breaths/minute,87and87blood87pressure87100/5087mm
Hg.
