HESI MED SURG #1 TEST COMPLETE
ACTUAL EXAM STUDY SET WITH
QUESTIONS AND CORRECT/VERIFIED
SOLUTIONS
The nurse is providing care to a client after a percutaneous transluminal coronary angioplasty (PTCA).
What actions will the nurse include in the client's plan of care? (Select all that apply.) - correct answer-
✅A.Frequent vital signs.
B.Determine if the client is allergic to aspirin.
D.Offer fluids of choice.
F.Monitor infusion of IV nitroglycerine.
In assessing a client diagnosed with primary aldosteronism, the nurse expects the laboratory test results
to indicate a decreased serum level of which substance? - correct answer-✅C.Potassium
Clients with primary aldosteronism exhibit a profound decline in serum levels of potassium;
hypokalemia; hypertension is the most prominent and universal sign.
The nurse is providing care for a client diagnosed with trigeminal neuralgia (tic douloureux). Which
symptoms will the nurse be looking for in the focused assessment related to this condition? (Select all
that apply.) - correct answer-✅A.Facial muscle spasms
B.Sudden facial pain
Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the area
innervated by one or more branches of the trigeminal nerve (cranial V).
A 74-year-old male client is admitted to the intensive care unit (ICU) with a diagnosis of respiratory
failure secondary to pneumonia. Currently, the client is ventilator-dependent, with settings of tidal
volume (VT) of 750 mL and an intermittent mandatory ventilation (IMV) rate of 10 breaths/min. Arterial
blood gas (ABG) results are as follows: pH, 7.48; PaCO2, 30 mm Hg; PaO2, 64 mm Hg; HCO3, 25 mEq/L;
and FiO2, 0.80. Which action should the nurse take first? - correct answer-✅D.Add 5 cm positive end-
expiratory pressure (PEEP)
Adding PEEP helps improve oxygenation while reducing FiO2 to a less toxic level
The clinic nurse is providing post-operative teaching for a client scheduled for a myringoplasty. Which
client statements indicate to the nurse that the teaching has been effective? (Select all that apply.) -
correct answer-✅B."I will avoid forceful and deep coughing until my post-op checkup.
C."I must lay flat on my non-operative side for the first 12 hours after surgery."
D."My hearing may be less or muffled until the packing comes out."
The client must keep the ear bandage clean and dry until the packing is removed. Showering and hair
washing is discouraged.
During the shift report, the charge nurse informs a nurse of a reassignment to another unit for the day.
The nurse begins to sigh deeply and tosses about her belongings when preparing to leave. What is the
best immediate action for the charge nurse to take? - correct answer-✅A.
Continue with the shift report and talk to the nurse about the incident at a later time.
Continuing with the shift report is the best immediate action because it allows the nurse who was
floated some cooling off time. At a later time (after the nurse has cooled off) the charge nurse should
discuss the conduct of the nurse in private.
, The nurse is completing an admission interview for a client with Parkinson disease. Which question will
provide additional information about manifestations that the client is likely to experience? - correct
answer-✅C."Have you ever been frozen in one spot, unable to move?"
Clients with Parkinson disease frequently experience difficulty in initiating, maintaining, and performing
motor activities. They may even experience being rooted to the spot and unable to move.
The nurse teaches a client with type 2 diabetes nutritional strategies to decrease obesity. Which food
items chosen by the client indicate understanding of the teaching? (Select all that apply.) - correct
answer-✅B.Salmon
C.Broccoli
E.Banana
Options B, C, and E provide fresh fruits, lean meats and fish, vegetables, whole grains, and low-fat dairy
products. All are recommended by the American Diabetes Association (ADA) and are a part of the My
Plate guidelines recommended by the U.S. Department of Agriculture (USDA).
Which nursing action would be appropriate for a client who is newly diagnosed with Cushing syndrome?
- correct answer-✅A.Monitor blood glucose levels daily.
Cushing syndrome results from a hypersecretion of glucocorticoids in the adrenal cortex. Clients with
Cushing syndrome often develop diabetes mellitus. Monitoring of serum glucose levels assesses for
increased blood glucose levels so that treatment can begin early
A resident in a long-term care facility is diagnosed with hepatitis B. Which action should the nurse take
with the staff caring for this client? - correct answer-✅A.Determine if all employees have had the
hepatitis B vaccine series.
Hepatitis B vaccine should be administered to all health care providers. Hepatitis A (not hepatitis B) can
be transmitted by fecal-oral contamination.
A client in the emergency department is bleeding profusely from a gunshot wound to the abdomen.
What action should the nurse immediately? - correct answer-✅C.Maintain the client in a supine
position to reduce diaphragmatic pressure and visualize the wound.
Placing the client in a supine position reduces diaphragmatic pressure, thereby enhancing oxygenation,
and allows for visualization of the abdominal wound.
While at a home game, the mother of a 6-year-old is heard screaming, "My child is having an asthma
attack! Can anyone help?" The nurse arrives and finds the child gasping for breath with circumoral
cyanosis. What are the nurse's next actions? (Select all that apply.) - correct answer-✅A.Yell, "Call 911."
B.Ask the mother if she has the child's bronchodilator.
E.Stay with the child and mother until the ambulance arrives.
F.Sit the child straight up in Fowler's position.
A client is diagnosed with an acute small bowel obstruction and suddenly spikes a temperature of
102°F/38.9°C. What other assessments should the nurse include in the client's focused assessment?
(Select all that apply.) - correct answer-✅A.Nausea and vomiting
B.Loss of appetite
C.Abdominal cramping
D.Guarding with abdominal palpation
The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which symptom of
hyperglycemia is an older adult most likely to exhibit? - correct answer-✅D.Infection
Signs and symptoms of hyperglycemia in older adults may include fatigue, infection, and evidence of
neuropathy (e.g., sensory changes).
An older client comes to the outpatient clinic complaining of left calf pain. The nurse notices a reddened
area on the calf of the right leg that is warm to the touch, and the nurse suspects that the client may
have thrombophlebitis. Which additional assessment is most important for the nurse to perform? -
correct answer-✅B.Auscultate the client's breath sounds.
ACTUAL EXAM STUDY SET WITH
QUESTIONS AND CORRECT/VERIFIED
SOLUTIONS
The nurse is providing care to a client after a percutaneous transluminal coronary angioplasty (PTCA).
What actions will the nurse include in the client's plan of care? (Select all that apply.) - correct answer-
✅A.Frequent vital signs.
B.Determine if the client is allergic to aspirin.
D.Offer fluids of choice.
F.Monitor infusion of IV nitroglycerine.
In assessing a client diagnosed with primary aldosteronism, the nurse expects the laboratory test results
to indicate a decreased serum level of which substance? - correct answer-✅C.Potassium
Clients with primary aldosteronism exhibit a profound decline in serum levels of potassium;
hypokalemia; hypertension is the most prominent and universal sign.
The nurse is providing care for a client diagnosed with trigeminal neuralgia (tic douloureux). Which
symptoms will the nurse be looking for in the focused assessment related to this condition? (Select all
that apply.) - correct answer-✅A.Facial muscle spasms
B.Sudden facial pain
Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the area
innervated by one or more branches of the trigeminal nerve (cranial V).
A 74-year-old male client is admitted to the intensive care unit (ICU) with a diagnosis of respiratory
failure secondary to pneumonia. Currently, the client is ventilator-dependent, with settings of tidal
volume (VT) of 750 mL and an intermittent mandatory ventilation (IMV) rate of 10 breaths/min. Arterial
blood gas (ABG) results are as follows: pH, 7.48; PaCO2, 30 mm Hg; PaO2, 64 mm Hg; HCO3, 25 mEq/L;
and FiO2, 0.80. Which action should the nurse take first? - correct answer-✅D.Add 5 cm positive end-
expiratory pressure (PEEP)
Adding PEEP helps improve oxygenation while reducing FiO2 to a less toxic level
The clinic nurse is providing post-operative teaching for a client scheduled for a myringoplasty. Which
client statements indicate to the nurse that the teaching has been effective? (Select all that apply.) -
correct answer-✅B."I will avoid forceful and deep coughing until my post-op checkup.
C."I must lay flat on my non-operative side for the first 12 hours after surgery."
D."My hearing may be less or muffled until the packing comes out."
The client must keep the ear bandage clean and dry until the packing is removed. Showering and hair
washing is discouraged.
During the shift report, the charge nurse informs a nurse of a reassignment to another unit for the day.
The nurse begins to sigh deeply and tosses about her belongings when preparing to leave. What is the
best immediate action for the charge nurse to take? - correct answer-✅A.
Continue with the shift report and talk to the nurse about the incident at a later time.
Continuing with the shift report is the best immediate action because it allows the nurse who was
floated some cooling off time. At a later time (after the nurse has cooled off) the charge nurse should
discuss the conduct of the nurse in private.
, The nurse is completing an admission interview for a client with Parkinson disease. Which question will
provide additional information about manifestations that the client is likely to experience? - correct
answer-✅C."Have you ever been frozen in one spot, unable to move?"
Clients with Parkinson disease frequently experience difficulty in initiating, maintaining, and performing
motor activities. They may even experience being rooted to the spot and unable to move.
The nurse teaches a client with type 2 diabetes nutritional strategies to decrease obesity. Which food
items chosen by the client indicate understanding of the teaching? (Select all that apply.) - correct
answer-✅B.Salmon
C.Broccoli
E.Banana
Options B, C, and E provide fresh fruits, lean meats and fish, vegetables, whole grains, and low-fat dairy
products. All are recommended by the American Diabetes Association (ADA) and are a part of the My
Plate guidelines recommended by the U.S. Department of Agriculture (USDA).
Which nursing action would be appropriate for a client who is newly diagnosed with Cushing syndrome?
- correct answer-✅A.Monitor blood glucose levels daily.
Cushing syndrome results from a hypersecretion of glucocorticoids in the adrenal cortex. Clients with
Cushing syndrome often develop diabetes mellitus. Monitoring of serum glucose levels assesses for
increased blood glucose levels so that treatment can begin early
A resident in a long-term care facility is diagnosed with hepatitis B. Which action should the nurse take
with the staff caring for this client? - correct answer-✅A.Determine if all employees have had the
hepatitis B vaccine series.
Hepatitis B vaccine should be administered to all health care providers. Hepatitis A (not hepatitis B) can
be transmitted by fecal-oral contamination.
A client in the emergency department is bleeding profusely from a gunshot wound to the abdomen.
What action should the nurse immediately? - correct answer-✅C.Maintain the client in a supine
position to reduce diaphragmatic pressure and visualize the wound.
Placing the client in a supine position reduces diaphragmatic pressure, thereby enhancing oxygenation,
and allows for visualization of the abdominal wound.
While at a home game, the mother of a 6-year-old is heard screaming, "My child is having an asthma
attack! Can anyone help?" The nurse arrives and finds the child gasping for breath with circumoral
cyanosis. What are the nurse's next actions? (Select all that apply.) - correct answer-✅A.Yell, "Call 911."
B.Ask the mother if she has the child's bronchodilator.
E.Stay with the child and mother until the ambulance arrives.
F.Sit the child straight up in Fowler's position.
A client is diagnosed with an acute small bowel obstruction and suddenly spikes a temperature of
102°F/38.9°C. What other assessments should the nurse include in the client's focused assessment?
(Select all that apply.) - correct answer-✅A.Nausea and vomiting
B.Loss of appetite
C.Abdominal cramping
D.Guarding with abdominal palpation
The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which symptom of
hyperglycemia is an older adult most likely to exhibit? - correct answer-✅D.Infection
Signs and symptoms of hyperglycemia in older adults may include fatigue, infection, and evidence of
neuropathy (e.g., sensory changes).
An older client comes to the outpatient clinic complaining of left calf pain. The nurse notices a reddened
area on the calf of the right leg that is warm to the touch, and the nurse suspects that the client may
have thrombophlebitis. Which additional assessment is most important for the nurse to perform? -
correct answer-✅B.Auscultate the client's breath sounds.
