2017 HESI MED SURG WITH SAMPLE ANSWERS

1. 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 2. A male adult comes to the urgent care clinic 5 days after being diagnose 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 3. 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 4. 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 5. 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 6. An adult male client is admitted for pneumocystis carinil pneumonia (PCP) secondary to aids. While hospitalize he receives IV pentamidine isethionate 1 | Pagetherapy. 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 7. 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 8. 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 in the healthcare provider has giving her any information about the classification of her cancer d. help the client make plans to begin inmediate treatment since her cancer is likely to spread quickly 9. 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 10. 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? =9 11. 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 2 | Pagec. marked loss of weight and appetite over the last few months d. use of chewable and liquid antacids for indigestion 12. 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 13. 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 14. During a home visit the nurse assesses the skin of a client with eczema who reports than 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 15. 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 16. 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 3 | Page17. A client diagnose 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 tables 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 pain is unrelieved and chew a tablet of aspirin 325mg 18. After taking orlistat (Xenical) for one week a femela 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 19. 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 ( POSSIBLE ANSWER TOO) d. obtain samples for complete blo