HESI MEDICAL SURGICAL 2019 V1 (original test)
1. A male client who had a colon surgery 3 days ago is anxious and requesting assistance to reposition.
... [Show More] While the nurse is checking him, the wound dehiscences and discerates. The nurse moistens an available sterile dressing and places it over the wound. Which interventions should the nurse implement next?
a) Bring additional sterile dressing supplies to the room
b) Prepare the client to return to the operating room
c) Obtain a sample of the drainage to send to the lab
d) Auscultate the abdomen for bowel sound activity
2. A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117 mEq/L. Which nursing problem should the nurse include in this client’s plan of care?
a) Altered urinary elimination
b) Impaired gas exchange
c) Fluid volume excess
d) Decreased cardiac output
3. A female client enters the clinic and insists on being seen. She is weak, nervous and reports a racing heart beat and recent weight loss of 15 pounds. After ruling out substance withdrawal, the healthcare provider suspects hyperthyroidism and admits her for further testing. Which action should the nurse implement?
a) Begin preparing the client for thyroidectomy procedure
b) Space the clients care to provide periods of rest
c) Assess the client for hyperactive bowel sounds
d) Provide warm blankets to prevent heat loss
4. The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendations should the nurse encourage the client to follow?
a) Increase intake of high fiber foods such as bran cereal
b) Restrict protein intake by limiting meats and other high protein foods
c) Limit oral fluids intake to 500ml per day
d) Increase intake of potassium rich foods such as bananas
5. An overweight young adult male who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions should the nurse implement?
a) Check his fingerstick glucose level
b) Assess his skin temperature and moisture
c) Measure his pulse and blood pressure
d) Document anxiety on the surgical check list
e) Administer a PRN dose of regular insulin
6. A client with Cushing’s syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse?
a) Irregular apical pulse
b) Purple marks on the skin of the abdomen
c) Quarter size blood spot on dressing
d) Pitting ankle edema
7. An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red and the client reports a burning sensation. What action should the nurse take?
a) Apply a cool compress to the affected fingers for 20 minutes
b) Secure a pulse oximeter to monitor the clients oxygen saturation
c) Report the finding to the healthcare provider as soon as possible
d) Continue to monitor the fingers until color returns to normal
8. A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 1010 F, heart rate 128 beats / minute, respirations 28 breaths / minute, and blood pressure 122/82. Which intervention is most important for the nurse to implement first?
a) Obtain oxygen saturation level
b) Encourage incentive spirometry
c) Assess lower extremity circulation
d) Administer PRN oral antipyretic
9. The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomy under general anesthesia. Which finding warrants notification of the healthcare provider prior to proceeding with the scheduled procedure?
a) Light yellow coloring of the client’s skin and eyes
b) The clients blood pressure reading is a84/88 mm Hg
c) The clients vomits 20ml of clear yellowish fluid
d) The IV insertion site is red, swollen and leaking IV fluid
10. A client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse?
a) Facial puffiness and periorbital edema
b) Hematocrit of 30%
c) Cold and dry skin
d) Further decline in level of consciousness
11. Following surgical repair of the bladder, a female client is being discharged from the hospital to go home with an indwelling urinary catheter. Which instruction is most important for the nurse to provide to this client?
a) Avoid coiling the tubing and keep it free of kinks
b) Cleanse the perennial area with soap and water twice a day
c) Keep the drainage bag lower that the level of the bladder
d) Drink 1000ml of fluids daily to irrigate catheter
12. Which client has the highest risk for developing skin cancer?
a) A 16 year old dark skinned female who tans in tanning beds once a week
b) A 65 year old fair-skinned male who is a construction worker
c) A 25 year old dark-skinned male whose mother had skin cancer
d) A 70 year old fair-skinned female who works as a secretary
13. A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the best initial nursing action?
a) Administer the first dose of prescribed antibiotic therapy
b) Observe the color, consistency and amount of sputum
c) Encourage the client to consume plenty of warm liquids
d) Send the specimen to the lab for analysis immediately
14. A client is brought to the emergency department by ambulance in cardiac arrest with cardiopulmonary resuscitation (CPR) in progress. The client is receiving 100% oxygen per self-inflating bag. The nurse determines that the client is cyanotic, cold, and diaphoretic. Which assessment is most important for the nurse to obtain?
a) Breath sounds over bilateral lung fields
b) Carotid pulsations during compressions
c) Deep tendon reflexes
d) Core body temperature
15. After hospitalization for syndrome of inappropriate antidiuretic hormone (SIADH), a client develops pontine myelinolysis. Which intervention should the nurse implement first?
a) Reorient client to his room
b) Place a patch on one eye
c) Evaluate the client’s ability to swallow
d) Perform range of motion exercises
16. A male client with heart failure (HF) calls the clinic and reports that he ca not put his shoes on because they are too tight. Which additional information should the nurse obtain?
a) What time did he take his last medication
b) Has his weight changed in the last several days
c) Is he still able to tighten his belt buckle
d) How many hours did he sleep last night
17. An older adult woman with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. She is anxious and is complaining of a dry mouth. Which intervention should the nurse include?
a) Administer a prescribed sedative
b) Encourage client to drink water
c) Apply a high flow venture mask
d) Assist her to an upright position
18. A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened, tenacious mucus and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care?
a) Increase the daily intake of oral fluids to liquefy secretions
b) Avoid crowded enclosed areas to reduce pathogen exposure
c) Call the clinic if undesirable side effects of medications occur
d) Teach anxiety reduction methods for feelings of suffocation
19. A cardiac catheterization of a client with heart disease indicates the following [Show Less]