HESI MED SURG EXAM A&B
What instruction should the nurse include in the discharge teaching plan of a client who had a cataract extraction today?
a. sexual activities may be resumed upon return home
b. light housekeeping is permitted but avoid heavy lifting
c. use a metal eye shield on operativ...
HESI MED SURG EXAM 2021-2022 A&B
What instruction should the nurse include in the discharge teaching plan of a client who
had a cataract extraction today?
a. sexual activities may be resumed upon return home
b. light housekeeping is permitted but avoid heavy lifting
c. use a metal eye shield on operative eye during the day
d. administer eye ointment before applying eye drops
{{ANS}}b. light housekeeping is permitted but avoid heavy lifting
A male adult comes to the urgent care clinic 5 days after being diagnosed with
influenza. He is short of breath, febrile, and coughing green colored sputum. Which
intervention should the nurse implement first?
a. Obtain a sputum sample for culture
b. Check his oxygen saturation level
c. Administer an oral antipyretic
d. Auscultate bilateral lung sound
{{ANS}}a. obtain a sputum sample for culture
An elder male client tells the nurse that he is loosing sleep because he has to get up
several times at night to go to the bathroom that he has trouble starting his urinary
stream and that he does not feel like his bladder is ever completely empty. Which
intervention should the nurse implement?
a. collect a urine specimen for culture analysis
b. obtain a fingerstick blood glucose level
c. palpate the bladder above the symphysis pubis
d. review the client fluid intake
{{ANS}}c. palpate the bladder above the symphysis pubis
An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection
(UTI) Prescriptions for intravenous antibiotics and insulin infusion are initiated. Which
serum laboratory value warrants the most immediate intervention by the nurse?
a. blood ph of 7.30
b. glucose of 350 mg /dl
c. white blood cell count of 15000mm
d. potassium of 2.5 meq/l
{{ANS}}d. potassium of 2.5 meq/l
A client with sickle cell anemia develops a fever during the last hour of administration of
a unit of packed red blood cell. When notifying the healthcare provider what information
should the nurse provide first using the SBAR communication process?
a. explain specific reason for urgent notification
b. preface the report by stating the clients name and admitting diagnosis
c. communicate the pre-transfusion temperatures
d. optain prn prescription for acetaminophen for fever 101f
{{ANS}}a. explain specific reason for urgent notification
,An adult male client is admitted for pneumocystis carinil pneumonia (PCP) secondary to
aids. While hospitalized he receives IV pentamidine isethionate therapy. In preparing
this client for discharge what important aspect regarding his medication therapy should
the nurse explain?
a. AZT therapy must be stopped when IV aerosol pentamine is being used.
b. IV pentamine will be given until oral pentamine can be tolerated
c. It will be necessary to continue prophylactic doses of IV or aerosol pentamine every
month
d. IV pentamine may offer protection to others aids related conditions such as kaposis
sarcoma
{{ANS}}c. it will be necessary to continue prophylactic doses of IV or aerosol pentamine
every month
A client subjective data includes dysuria, urgency, and urinary frequency. What action
should the nurse implement next?
a. collect a clean catch specimen
b. palpate the suprapubic region
c. instruct to wipe from front to back
d. inquire about recent sexual activity
{{ANS}}a. collect a clean catch specimen
A client tells the nurse that her biopsy results indicate that the cancer cells are well
differentiated How should the nurse respond?
a. offer the client reassurance that this information indicates that the clients cancer cells
are benign
b. explain that these tissue cells often respond more effectively to radiation than to
chemotherapy
c. ask the client if the healthcare provider has given her any information about the
classification of her cancer
d. help the client make plans to begin immediate treatment since her cancer is likely to
spread quickly
{{ANS}}c. ask the client if the healthcare provider has given her any information about
the classification of her cancer
A client with a chronic kidney disease is treated on hemodialysis. During the 1 treatment
clients blood pressure drops from 150/90 to 80/30 Which action should the nurse take
first?
a. monitor bp q45 minutes
b. lower the head of the chair and elevate feet
c. stop dialysis treatment
d. administer 5% albumin IV
{{ANS}}c. stop dialysis treatment
A client with deep vain thrombosis (DVT) is receiving a continues infusion of heparin
sodium 25,000 unit in 5% dextrose injection 250ml. The prescription indicates the
,dosage should be increase 900 units/hr. The nurse should program the infusion pump
to deliver how many ml/hr?
{{ANS}}9 mL/hour
The nurse is obtaining the admission history for a client with suspected peptic ulcer
disease (PUD). Which subjective data reported by the client supports this diagnosis?
a. upper mid abdominal gnawing and burning pain
b. severe abdominal cramps and diarrhea after eating spicy foods
c. marked loss of weight and appetite over the last few months
d. use of chewable and liquid antacids for indigestion
{{ANS}}a. upper mid abdominal gnawing and burning pain
The nurse is providing preoperative education for a jewish client schedule to receive a
xenograft graft to promote burn healing. Which information should the nurse provide this
client?
a. the xenograft is taken from nonhuman sources
b. grafting increases the risk for bacterial infection
c. as the burn heals the graft permanently attaches
d. grafts are later removed by debriding procedure
{{ANS}}a. the xenograft is taken from nonhuman sources
A client who took a camping vacation two weeks ago in a country with a tropical climate
comes to the clinic describing vague symptoms and diarrhea for the past week. Which
finding is most important for the nurse to report?
a. jaundice sclera
b. intestinal cramping
c. weakness and fatigue
d. weight loss
{{ANS}}a. jaundice sclera
During a home visit the nurse assesses the skin of a client with eczema who reports
that an exacerbation of symptoms has occurred during the last week. Which information
is most useful in determining the possible cause of the symptoms?
a. an old friend with eczema came for visit
b. recently received an influenza immunization
c. corticosteroid cream was applied to eczema
d. a grandson and his new dog recently visited
{{ANS}}d. a grandson and his new dog recently visited
When explaining dietary guidelines to a client with acute glomerulonephritis (AGN)
which instruction should the nurse include in the dietary teaching?
a. select a protein rich food daily
b. restrict sodium intake
c. eat high potassium foods
d. Avoid foods high in carbohydrate
{{ANS}}b. restrict sodium intake
, A male client who is 24hr post operative for an exploratory laparoctomy complains that
he is starving because he has had no real food since before surgery. Prior to advancing
his diet which intervention should the nurse implememt?
a. discontinue intravenous therapy
b. Assess for abdominal distension and tenderness
c. Obtain a prescription for a diet change
d. Auscultate bowel sound in all four quadrants
{{ANS}}d. auscultate bowel sounds in all four quadrants
A client diagnosed with stable angina secondary to ischemic heart disease has a
prescription for sublingual (SL) nitroglycerin (NTG). The nurse should tell the client to
follow which instructions if chest pain is not relieved after taking 3 NTG tablets 5 min
apart?
a. drive to the nearest emergency department
b. take another NTG SL tablet and lie down until angina subsides
c. call primary healthcare provider
d. call 911 if pain is unrelieved and chew a tablet of aspirin 325mg
{{ANS}}d. call 911 if pain is unrelieved and chew a tablet of aspirin 325 mg
After taking orlistat (Xenical) for one week a female client tells the home health nurse
that she is experiencing increasingly frequent oily stools and flatus. What action should
the nurse take?
a. obtain stool specimen to evaluate for occult blood and fat content
b. instruct the client to increase her intake of saturated fats over the next week
c. ask the client to describe her dietary intake history for the last several days
d. advice the client to stop taking the drug and contact the healthcare provider
{{ANS}}c. ask the client to describe her dietary intake history for the last several days
Two days after an abscess of the chin was drained the client returns to the clinic with
fever chills and a maculopapular rash with pruritis. The client has taken an oral antibiotic
and cleansed the wound today with provide iodine (Betadine) solution. Which
intervention should the nurse implement first?
a. determine if the client has a history of diabetes
b. assess airway patency and oxygen saturation
c. review recent medication history and allergies
d. obtain samples for complete blood count and cultures
{{ANS}}b. assess airway patency and oxygen saturation
A client experiences an ABO incompatibility reaction after multiple blood transfusions.
Which finding should the nurse report immediately to the health care provider?
a. low back pain and hypotension
b. rhinitis and nasal stuffiness
c. delayed painful rash with urticarial
d. arthritic joint changes and chronic pain
{{ANS}}a. low back pain and hypotension
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