Latest SAUNDERS HESI MED SURG
Questions with 100% verified Answers
2024/2025
A burn client is receiving treatments of topical mafenide acetate to the site of injury. The
nurse monitors the client, knowing which finding indicates that a systemic effect has
occurred?
1. Hyperventilation
2. Elevated blood pressure
3. Local rash at the burn site
4. Local pain at the burn site - correct answers--1
Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of
acid, thereby causing acidosis. Clients receiving this treatment should be monitored for
signs of an acid-base imbalance (hyperventilation). If this occurs, the medication will
probably be discontinued for 1 to 2 days. Options 3 and 4 describe local rather than
systemic effects. Elevated blood pressure may be expected from the pain that occurs
with a burn injury.
A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is
being assessed by the nurse. Which assessment findings would be consistent with
acute pancreatitis? (SELECT ALL THAT APPLY.)
1. Diarrhea
2. Black, tarry stools
3. Hyperactive bowel sounds
4. Gray-blue color at the flank
5. Abdominal guarding and tenderness
6. Left upper quadrant pain with radiation to the back - correct answers--4, 5, 6
Grayish-blue discoloration at the flank is known as Grey-Turner's sign and occurs as a
result of pancreatic enzyme leakage to cutaneous tissue from the peritoneal cavity. The
client may demonstrate abdominal guarding and may complain of tenderness with
palpation. The pain associated with acute pancreatitis is often sudden in onset and is
located in the epigastric region or left upper quadrant with radiation to the back. The
other options are incorrect.
A client arrives at the emergency department following a burn injury that occurred in the
basement at home, and an inhalation injury is suspected. What would the nurse
anticipate to be prescribed
for the client?
,1. 100% oxygen via an aerosol mask
2. Oxygen via nasal cannula at 6 L/minute
3. Oxygen via nasal cannula at 15 L/minute
4. 100% oxygen via a tight-fitting, nonrebreather face mask - correct answers--4
If an inhalation injury is suspected, administration
of 100% oxygen via a tight-fitting nonrebreather face mask is prescribed until
carboxyhemoglobin levels fall (usually below 15%). In inhalation injuries, the oropharynx
is inspected for evidence of erythema, blisters, or ulcerations. The need for
endotracheal intubation also is assessed. Administration of
oxygen by aerosol mask and cannula are incorrect and would not provide the necessary
oxygen supply needed for adequate tissue perfusion for the client with a likely inhalation
injury
A client arriving at the emergency department has experienced frostbite to the right
hand. Which finding would the nurse note on assessment of the client's hand?
1. A pink, edematous hand
2. Fiery red skin with edema in the nail beds
3. Black fingertips surrounded by an erythematous rash
4. A white color to the skin, which is insensitive to touch - correct answers--4
Assessment findings in frostbite include a white or
blue color; the skin will be hard, cold, and insensitive to touch. As thawing occurs,
flushing of the skin, the development of blisters or blebs, or tissue edema appears.
Options 1, 2, and 3 are incorrect.
A client calls the emergency department and tells the nurse that he came directly into
contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on
the skin and asks the nurse what to do. The nurse should make which response?
1. "Come to the emergency department."
2. "Apply calamine lotion immediately to the exposed skin areas."
3. "Take a shower immediately, lathering and rinsing several times."
4. "It is not necessary to do anything if you cannot see anything on your skin." - correct
answers--3
When an individual comes in contact with a poison
ivy plant, the sap from the plant forms an invisible film on the human skin. The client
should be instructed to cleanse the area by showering immediately and to lather the
skin several times and rinse each time in running water. Removing the poison ivy sap
will decrease the likelihood of irritation. Calamine lotion
may be one product recommended for use if dermatitis
develops. The client does not need to be seen in the emergency department at this
time.
,A client had a new colostomy created 2 days earlier and is beginning to pass
malodorous flatus from the stoma. What is the correct interpretation by the nurse?
1. This is a normal, expected event.
2. The client is experiencing early signs of ischemic bowel.
3. The client should not have the nasogastric tube removed.
4. This indicates inadequate preoperative bowel preparation. - correct answers--1
As peristalsis returns following creation of a colostomy, the client begins to pass
malodorous flatus. This indicates returning bowel function and is an expected event.
Within 72 hours of surgery, the client should begin passing stool via the colostomy.
Options 2, 3, and 4 are incorrect interpretations.
A client has a new prescription for metoclopramide. On review of the chart, the nurse
identifies that this medication can be safely administered with which condition?
1. Intestinal obstruction
2. Peptic ulcer with melena
3. Diverticulitis with perforation
4. Vomiting following cancer chemotherapy - correct answers--4
Metoclopramide is a gastrointestinal stimulant and antiemetic. Because it is a
gastrointestinal stimulant, it is contraindicated with gastrointestinal obstruction,
hemorrhage, or perforation. It is used in the treatment of vomiting after surgery,
chemotherapy, or radiation.
A client has a prescription to take guaifenesin. The nurse determines that the client
understands the proper administration of this medication if the client states that he or
she will perform which action?
1. Take an extra dose if fever develops
2. Take the medication with meals only
3. Take the tablet with a full glass of water
4. Decrease the amount of daily fluid intake - correct answers--3
Guaifenesin is an expectorant and should be taken with a full glass of water to decrease
the viscosity of secretions. Extra doses should not be taken. The client should contact
the health care provider if the cough lasts longer than 1 week or is accompanied by
fever, rash, sore throat, or persistent headache. Fluids are needed to decrease the
viscosity of secretions. The medication does not have to be taken with meals.
A client has an as needed prescription for loperamide hydrochloride. For which
condition should the nurse administer this medication?
1. Constipation
, 2. Abdominal pain
3. An episode of diarrhea
4. Hematest-positive nasogastric tube drainage - correct answers--3
Loperamide is an antidiarrheal agent. It is used to manage acute and chronic diarrhea in
conditions such as inflammatory bowel disease. Loperamide also can be used to reduce
the volume of drainage from an ileostomy. It is not used for the conditions in options 1,
2, and 4.
A client has an as-needed prescription for ondansetron. For which condition(s) should
the nurse administer this medication?
1. Paralytic ileus
2. Incisional pain
3. Urinary retention
4. Nausea and vomiting - correct answers--4
Ondansetron is an antiemetic used to treat postoperative nausea and vomiting, as well
as nausea and vomiting associated with chemotherapy. The other options are incorrect
reasons for administering this medication.
A client has been admitted with chest trauma after a motor vehicle crash and has
undergone subsequent intubation. The nurse checks the client when the high-pressure
alarm on the ventilator sounds, and notes that the client has absence of breath sounds
in the right upper lobe of the lung. The nurse immediately assesses for other signs of
which condition?
1. Right pneumothorax
2. Pulmonary embolism
3. Displaced endotracheal tube
4. Acute respiratory distress syndrome - correct answers--1
Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with
respiration, asymmetrical chest expansion, and diminished or absent breath sounds on
the affected side. Pneumothorax can cause increased airway pressure because of
resistance to lung inflation. Acute respiratory distress syndrome and pulmonary
embolism are not characterized by absent breath sounds. An endotracheal tube that is
inserted too far can cause absent breath sounds, but the lack of breath sounds most
likely would be on the left side because of the degree of curvature of the right and left
mainstem bronchi.
A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs
and symptoms indicating a complication of this disorder? (SELECT ALL THAT APPLY.)
1. Fever
2. Nausea
