Hesi Med-Surg Review 2021 All Questions & Answers with Rationales (Graded A+)
...............The nurse is counseling a healthy 30-year-old female client
... [Show More] regarding osteoporosis prevention. Which activity would be most beneficial in achieving the client’s goal of osteoporosis prevention?
a. Cross-country skiing
b. Scuba diving
c. Horseback riding
d. Kayaking
ANS: A
Weight-bearing exercise is an important measure to reduce the risk of osteoporosis. Of the activities listed, cross-country skiing includes the most weight-bearing, whereas options B, C, and D involve less.
6. Which content about self-care should the nurse include in the teaching plan of a female client who has genital herpes? (Select all that apply.)
a. Encourage annual physical and Pap smear
b. Take antiviral medication as prescribed
c. Use condoms to avoid transmission to others
d. Warms sitz baths may relieve itching
e. Use Nystatin suppositories to control itching
f. Use a douche with weak vinegar solution to decrease itching
ANS: A, B, C, D
The nurse should include (A, B, C, and D) in the teaching plan of a female client with genital herpes. (E) is specific for Candida infections, and option (F) is used to treat Trichomonas.
7. A 55-year-old male client has been admitted to the hospital with a medical diagnosis of chronic obstructive pulmonary disease (COPD). Which risk factor is the most significant in the development of this client’s COPD?
a. The client’s father was diagnosed with COPD in his 50s
b. A close family member contracted tuberculosis last year
c. The client smokes one to two packs of cigarettes per day
d. The client has been 40 pounds overweight for 15 years
ANS: C
Smoking, considered to be a modifiable risk factor, is the most significant risk factor for the development of COPD. The exact mechanism of genetic and hereditary implications for the development of COPD is still under investigation, although exposure to similar predisposing factors (e.g., smoking or inhaling secondhand smoke) may increase the likelihood of COPD incidence among family members. Options B and D do not exceed the risks associated with cigarette smoking in the development of COPD.
8. 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.)
a. Nausea and vomiting
b. Loss of appetite
c. Abdominal cramping
d. Guarding with abdominal palpation
e. Low urine output
f. Cool, clammy skin
ANS: A, B, C, D
The client is showing signs of peritonitis with the sudden spike in temperature. Low urine output and cool clammy skin are not seen with peritonitis. Peritonitis is a medical emergency and the health care provider must be notified immediately.
9. The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is very restless and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which action should the nurse take first?
a. Measure the urine specific gravity
b. Obtain IV fluids for infusion per protocol
c. Prepare for insertion of a central venous catheter
d. Auscultate the client’s breath sounds
ANS: B
The client is at risk for hypovolemic shock because of the postoperative status and is exhibiting early signs of shock. A priority intervention is the initiation of IV fluids to restore tissue perfusion. Options A, C, and D are all important interventions but are of lower priority than option B.
10. A home health nurse is assessing a 70-year-old male client who is convalescing at home following a hip replacement. The nurse is concerned that the client may develop pressure ulcers. Which physical characteristic of aging puts the client at risk?
a. 16% increase in overall body fat
b. Reduced melanin production
c. Thinning of the skin, with loss of elasticity
d. Calcium loss in the bones
ANS: C
Thin nonelastic skin is an important factor in pressure formation. The proportion of body fat to lean mass increases with age and might help decrease ulcer tendency. Option B causes gray hair. Option D can contribute to broken bones, but it is probably not a factor in pressure ulcer formation.
11. A client diagnosed with angina pectoris complains of chest pain while ambulating in the hallway. Which action should the nurse take first?
a. Support the client to a sitting position
b. Ask he client to walk slowly back to the room
c. Administer a sublingual nitroglycerin tablet
d. Provide oxygen via nasal cannula ANS: A
The nurse should safely assist the client to a resting position and then perform options C and D. The client must cease all activity immediately, which will decrease the oxygen requirement of the myocardial muscle. After these interventions are implemented, the client can be escorted back to the room via wheelchair or stretcher.
12. The nurse is caring for a client with a chest tube to water seal drainage that was inserted 10 days ago because of a ruptured bullae and pneumothorax. Which finding should the nurse report to the health care provider before the chest tube is removed?
a. Tidaling of water in water seal chamber
b. Bilateral muffled breath sounds at bases
c. Temperature of 101 °F
d. Absence of chest tube drainage for 2 days
ANS: A
Tidaling (rising and falling of water with respirations) in the water seal chamber should be reported to the health care provider before the chest tube is removed to rule out an unresolved pneumothorax or persistent air leak, which is characteristic of a ruptured bullae caused by abnormally wide changes in negative intrathoracic pressure. Option B may indicate hypoventilation from chest tube discomfort and usually improves when the chest tube is removed. Option C usually indicates an infection, which may not be related to the chest tube. Option D is an expected finding.
13. 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?
a. Increase the ventilator VT to 850 mL
b. Decrease the ventilator IMV to a rate of 8 breaths/min
c. Reduce the FiO 2 to 0.70 and redraw ABGs
d. Add 5 cm positive end-expiratory pressure (PEEP)
ANS: D
Adding PEEP helps improve oxygenation while reducing FiO2 to a less toxic level. Options A, B, and C will not result in improved oxygenation and could cause further complications for this client, who is experiencing respiratory failure.
14. Which nursing action would be appropriate for a client who is newly diagnosed with Cushing syndrome?
a. Monitor blood glucose levels daily
b. Increase intake of fluids high in potassium
c. Encourage adequate rest between activities
d. Offer the client a sodium-enriched menu
ANS: A
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 common finding in Cushing syndrome is generalized edema. Although potassium is needed, it is generally obtained from food intake, not by offering potassium-enhanced fluids. Fatigue is usually not an overwhelming factor in Cushing syndrome,
so an emphasis on the need for rest is not indicated. A low-calorie, low-carbohydrate, low-sodium diet is not recommended.
15. One day after a Billroth II surgery, the client suddenly grabs his right chest and becomes pale and diaphoretic. Vital signs are assessed as blood pressure 100/80 mm Hg, pulse 110 beats/min, and respirations 36 breaths/min. Which action is most important for the nurse to take?
a. Provide a paper bag for his hyperventilation
b. Administer a prescribed PRN analgesic
c. Have the client drink a glass of sweetened fruit juice
d. Apply oxygen at 2 L via nasal cannula
ANS: D
Pulmonary embolism and pneumothorax are risks associated with major abdominal surgery. The nurse should immediately provide oxygen while performing further assessment. A rapid respiratory rate should not be treated as hyperventilation. Option B should not be administered until more ominous causes are ruled out or treated. There is no evidence that the client is hypoglycemic.
16. A client is placed on a mechanical ventilator following a cerebral hemorrhage. What are the priority nursing actions for this client? (Select all that apply.)
a. Assess lung sounds
b. Look for equal and bilateral expansion of the chest
c. Monitor skin color
d. Evaluate the need for suctioning
e. Tell the family the client is expected to fully recover
f. Make sure the ventilator alarms are set
ANS: A, B, C, D, F
The outcome of the client is too early to relay to the family. The nurse must not offer false reassurance. The remaining actions are correct for a client on a ventilator.
17. A 25-year-old client was admitted yesterday after a motor vehicle collision. Neurodiagnostic studies have shown a basal skull fracture in the middle fossa. Assessment on admission revealed both halo and Battle signs. Which new symptom indicates that the client is likely to be experiencing a common life-threatening complication associated with a basal skull fracture?
a. Bilateral jugular venous distention
b. Oral temperature of 102°F
c. Intermittent focal motor seizures
d. Intractable pain in the cervical region [Show Less]