MED SURG HESI 2025 Question And
Answers
A0client0has0had0surgery0to0repair0a0fractured0left0hip.0When0repositioning0the0client0from0
side0to0side0in0the0bed,0what0should0the0nurse0plan0to0use0as0the0most0important0item0for
0this0maneuver?0-0CORRECT00ANSWER-Abductor0splint
Rationale:0After0surgery0to0repair0a0fractured0hip,0an0abductor0splint0is0used0to0maintain0t
he0affected0extremity0in0good0alignment.0A0bed0pillow0and0an0overhead0trapeze0also0are0
used,0but0neither0is0the0priority0item0to0be0used0in0repositioning0the0client0from0side0to0sid
e
A0client0is0admitted0to0the0hospital0emergency0department0after0receiving0a0burn0injury0in
0a0house0fire.0The0skin0on0the0client's0trunk0is0tan,0dry,0and0hard.0It0is0edematous0but0not0
very0painful.0The0nurse0determines0that0this0client's0burn0should0be0classified0as0which0ty
pe?0-0CORRECT00ANSWER-Full-thickness
Rationale:0Full-
thickness0burns0involve0the0epidermis,0the0full0dermis,0and0some0of0the0subcutaneous0fa
t0layer.0The0burn0appears0to0be0a0tan0or0fawn0color,0with0skin0that0is0hard,0dry,0and0inelas
tic.0Edema0is0severe,0and0the0accumulated0fluid0compresses0tissue0underneath0because
0of0eschar0formation.0Some0nerve0endings0have0been0damaged,0and0the0area0may0be0in
sensitive0to0touch,0with0little0or0no0pain.
A0client0is0admitted0with0suspected0diabetic0ketoacidosis0(DKA).0Which0clinical0manifest
ations0best0support0a0diagnosis0of0DKA?0-0CORRECT00ANSWER-
Blood0glucose03500mg/dL0(19.40mmol/L);0arterial0blood0gases:0pH07.28,0PaCo2030,0HCO
3-014.
Rationale:0DKA0is0caused0by0a0profound0deficiency0of0insulin0and0is0characterized0by0hy
perglycemia
(blood0glucose0level0greater0than0or0equal0to02500mg/dL0[13.90mmol/L]),0ketosis0(ketones
0in0urine0or
serum),0metabolic0acidosis,0and0dehydration.0The0correct0option0is04,0as0it0represents0an
0elevated0blood
glucose0and0the0arterial0blood0gases0(ABGs)0indicate0metabolic0acidosis.
A0client0is0readmitted0to0the0hospital0with0dehydration0after0surgery0for0creation0of0an0ileo
stomy.0The0nurse0assesses0that0the0client0has0lost030lb0of0weight,0has0poor0skin0turgor,0a
nd0has0concentrated0urine.0The0nurse0interprets0the0client's0clinical0picture0as0correlating
, 0most0closely0with0recent0intake0of0which0medication,0which0is0contraindicated0for0the0ile
ostomy0client?0-0CORRECT00ANSWER-Biscodyl
Rationale:0The0client0with0an0ileostomy0is0prone0to0dehydration0because0of0the0location0o
f0the0ostomy0in0the0gastrointestinal0tract0and0should0not0take0laxatives
A0client0is0scheduled0for0surgical0creation0of0an0internal0arteriovenous0(AV)0fistula0on0the
0following0day.0The0client0says0to0the0nurse,0"I'll0be0so0happy0when0the0fistula0is0made0to
morrow.0This0means0I0can0have0that0other0hemodialysis0catheter0pulled0right0out."0Which
0interpretation0should0the0nurse0make0based0on0the0client's0statement?0-
0CORRECT00ANSWER-
The0client0does0not0understand0that0the0site0needs0to0mature0or0develop0for010to020weeks
0before0use.
Rationale:0An0AV0fistula0is0the0internal0creation0of0an0arterial-to-
venous0anastomosis.0This0causes
engorgement0of0the0vein,0allowing0both0the0artery0and0the0vein0to0be0easily0cannulated0f
or0hemodialysis.
Fistulas0take010to020weeks0to0mature0(engorgement)0or0develop0before0they0can0be0used
0for0dialysis,0so
the0current0method0of0access0must0remain0in0place0to0be0used0during0that0period
A0client0uses0triamcinolone0(kenalog),0a0corticosteroid0ointment,0to0manage0pruritis0caus
ed0by0a0chronic0skin0rash.0The0client0calls0the0clinic0nurse0to0report0increased0erythema0
with0purulent0exudate0at0the0site.0What0action0should0the0nurse0implement?0-
0CORRECT00ANSWER-
Schedule0an0appointment0for0the0client0to0the0healthcare0provider.
A0client0who0has0undergone0gastric0surgery0has0a0nasogastric0(NG)0tube0connected0to0l
ow0intermittent0suction0that0is0not0draining0properly.0Which0action0should0the0nurse0take0i
nitially?
A.0call0the0surgeon0to0report0the0problem.
B.0Reposition0the0NG0tube0to0the0proper0location.
C.0Check0the0suction0device0to0make0sure0it0is0working.
D.0Irrigate0the0NG0tube0with0saline0to0remove0the0obstruction.0-0CORRECT00ANSWER-
C.0Check0the0suction0device0to0make0sure0it0is0working.
Rationale:
After0gastric0surgery,0the0client0will0have0an0NG0tube0in0place0until0bowel0function0returns
.0It0is0important
for0the0NG0tube0to0drain0properly0to0prevent0abdominal0distention0and0vomiting.0The0nurs
e0must0ensure0that0the0NG0tube0is0attached0to0suction0at0the0level0prescribed0and0that0th
e0suction0device0is0working
correctly.0The0tip0of0the0NG0tube0may0be0placed0near0the0suture0line.0Because0of0this0po
ssibility,0the0nurse
Answers
A0client0has0had0surgery0to0repair0a0fractured0left0hip.0When0repositioning0the0client0from0
side0to0side0in0the0bed,0what0should0the0nurse0plan0to0use0as0the0most0important0item0for
0this0maneuver?0-0CORRECT00ANSWER-Abductor0splint
Rationale:0After0surgery0to0repair0a0fractured0hip,0an0abductor0splint0is0used0to0maintain0t
he0affected0extremity0in0good0alignment.0A0bed0pillow0and0an0overhead0trapeze0also0are0
used,0but0neither0is0the0priority0item0to0be0used0in0repositioning0the0client0from0side0to0sid
e
A0client0is0admitted0to0the0hospital0emergency0department0after0receiving0a0burn0injury0in
0a0house0fire.0The0skin0on0the0client's0trunk0is0tan,0dry,0and0hard.0It0is0edematous0but0not0
very0painful.0The0nurse0determines0that0this0client's0burn0should0be0classified0as0which0ty
pe?0-0CORRECT00ANSWER-Full-thickness
Rationale:0Full-
thickness0burns0involve0the0epidermis,0the0full0dermis,0and0some0of0the0subcutaneous0fa
t0layer.0The0burn0appears0to0be0a0tan0or0fawn0color,0with0skin0that0is0hard,0dry,0and0inelas
tic.0Edema0is0severe,0and0the0accumulated0fluid0compresses0tissue0underneath0because
0of0eschar0formation.0Some0nerve0endings0have0been0damaged,0and0the0area0may0be0in
sensitive0to0touch,0with0little0or0no0pain.
A0client0is0admitted0with0suspected0diabetic0ketoacidosis0(DKA).0Which0clinical0manifest
ations0best0support0a0diagnosis0of0DKA?0-0CORRECT00ANSWER-
Blood0glucose03500mg/dL0(19.40mmol/L);0arterial0blood0gases:0pH07.28,0PaCo2030,0HCO
3-014.
Rationale:0DKA0is0caused0by0a0profound0deficiency0of0insulin0and0is0characterized0by0hy
perglycemia
(blood0glucose0level0greater0than0or0equal0to02500mg/dL0[13.90mmol/L]),0ketosis0(ketones
0in0urine0or
serum),0metabolic0acidosis,0and0dehydration.0The0correct0option0is04,0as0it0represents0an
0elevated0blood
glucose0and0the0arterial0blood0gases0(ABGs)0indicate0metabolic0acidosis.
A0client0is0readmitted0to0the0hospital0with0dehydration0after0surgery0for0creation0of0an0ileo
stomy.0The0nurse0assesses0that0the0client0has0lost030lb0of0weight,0has0poor0skin0turgor,0a
nd0has0concentrated0urine.0The0nurse0interprets0the0client's0clinical0picture0as0correlating
, 0most0closely0with0recent0intake0of0which0medication,0which0is0contraindicated0for0the0ile
ostomy0client?0-0CORRECT00ANSWER-Biscodyl
Rationale:0The0client0with0an0ileostomy0is0prone0to0dehydration0because0of0the0location0o
f0the0ostomy0in0the0gastrointestinal0tract0and0should0not0take0laxatives
A0client0is0scheduled0for0surgical0creation0of0an0internal0arteriovenous0(AV)0fistula0on0the
0following0day.0The0client0says0to0the0nurse,0"I'll0be0so0happy0when0the0fistula0is0made0to
morrow.0This0means0I0can0have0that0other0hemodialysis0catheter0pulled0right0out."0Which
0interpretation0should0the0nurse0make0based0on0the0client's0statement?0-
0CORRECT00ANSWER-
The0client0does0not0understand0that0the0site0needs0to0mature0or0develop0for010to020weeks
0before0use.
Rationale:0An0AV0fistula0is0the0internal0creation0of0an0arterial-to-
venous0anastomosis.0This0causes
engorgement0of0the0vein,0allowing0both0the0artery0and0the0vein0to0be0easily0cannulated0f
or0hemodialysis.
Fistulas0take010to020weeks0to0mature0(engorgement)0or0develop0before0they0can0be0used
0for0dialysis,0so
the0current0method0of0access0must0remain0in0place0to0be0used0during0that0period
A0client0uses0triamcinolone0(kenalog),0a0corticosteroid0ointment,0to0manage0pruritis0caus
ed0by0a0chronic0skin0rash.0The0client0calls0the0clinic0nurse0to0report0increased0erythema0
with0purulent0exudate0at0the0site.0What0action0should0the0nurse0implement?0-
0CORRECT00ANSWER-
Schedule0an0appointment0for0the0client0to0the0healthcare0provider.
A0client0who0has0undergone0gastric0surgery0has0a0nasogastric0(NG)0tube0connected0to0l
ow0intermittent0suction0that0is0not0draining0properly.0Which0action0should0the0nurse0take0i
nitially?
A.0call0the0surgeon0to0report0the0problem.
B.0Reposition0the0NG0tube0to0the0proper0location.
C.0Check0the0suction0device0to0make0sure0it0is0working.
D.0Irrigate0the0NG0tube0with0saline0to0remove0the0obstruction.0-0CORRECT00ANSWER-
C.0Check0the0suction0device0to0make0sure0it0is0working.
Rationale:
After0gastric0surgery,0the0client0will0have0an0NG0tube0in0place0until0bowel0function0returns
.0It0is0important
for0the0NG0tube0to0drain0properly0to0prevent0abdominal0distention0and0vomiting.0The0nurs
e0must0ensure0that0the0NG0tube0is0attached0to0suction0at0the0level0prescribed0and0that0th
e0suction0device0is0working
correctly.0The0tip0of0the0NG0tube0may0be0placed0near0the0suture0line.0Because0of0this0po
ssibility,0the0nurse
