MED SURG HESI 2024 NEWEST VERSION 5
COMPLETE 55 QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES
(VERIFIED ANSWERS)
Which nursing intervention
... [Show More] should the nurse implement that best confirms the placement of an
endotracheal tube?
A) Use an end-tital CO2 detector.
B) Ascultate for bilateral breath sounds.
C) Obtain pulse oximeter reading.
D) Check symmetrical chest movement. - AnswersA) Use an end-tital CO2 detector
The end-tital CO2 detector indicates the presence of CO2 by a color change or a number (A), which is
evidence that the ET is in the trachea, not the esophagus. Other assessments, such as breathe
sounds (B), pulse oximetry (C) and chest movement (D), are methods to evaluate the effectiveness
of ventilation and oxygenation, but do not measure CO2 in expired air from the ET.
An older female client is admitted with atrophic vaginitis and perineal cutaneous candidiasis. What is
the priority nursing diagnosis for this client?
A) Risk for injury.
B) Impaired comfort.
C) Disturbed body image.
D) Ineffective health maintenance. - AnswersB) Impaired comfort.
In menopausal women, the vaginal mucous membrane responds to low estrogen levels causing the
vaginal walls to become thinner, drier, and susceptible to infection which leads to atrophic vaginitis.
Perineal cutaneous candidiasis contributes to other manifestations of vaginal infections, such as
vaginal irritation, burning, pruritus, increased leukorrhea, bleeding, and dyspareunia, and support
the primary nursing diagnosis, Impaired comfort (B). Risk for injury (A), body image (C), and
ineffective health maintenance (D) are secondary and linked to impaired comfort.
A man who smokes two packs of cigarettes a day wants to know if smoking is contributing to the
difficulty that he and his wife are having getting pregnant. What information is best for the nurse to
provide? (Select all that apply.)
A) Only marijuana cigarettes affect sperm count.
B) Smoking can decrease the quantity and quality of sperm.
C) The first semen analysis should be repeated to confirm sperm counts.
D) Cessation of smoking improves general health and fertility.
E) Sperm specimens should be collected in 2 subsequent days.
Correct Answer(s): B, C, D - AnswersB) Smoking can decrease the quantity and quality of sperm.
C) The first semen analysis should be repeated to confirm sperm counts.
D) Cessation of smoking improves general health and fertility.
Correct selections are (B, C, and D). Use of tobacco, alcohol, and marijuana may affect sperm counts
(B). Sperm counts vary from day to day and are dependent on emotional and physical status and
sexual activity, so a single analysis may be inconclusive (C). A minimum of two analyses should be
performed several weeks apart to assess male fertility, not (E). (A and D) contain inaccurate
information.
The nurse should explain to a client with lung cancer that pleurodesis is performed to achieve which
expected outcome?
A) Prevent the formation of effusion fluid.
B) Remove fluid from the intrapleural space.
C) Debulk tumor to maintain patency of air passages.
D) Relieve empyema after pneumonectomy. - AnswersA) Prevent the formation of effusion fluid.
Instillation of a sclerosing agent to create pleurodesis (adherence of the parietal and visceral pleura)
is aimed at preventing the formation of pleural effusion fluid (A). (B) refers to thoracentesis. (C) is
achieved by surgical resection. (D) is treated by closed-chest drainage.
The nurse is caring for a client who returns to the unit following a colonoscopy. Which finding should
the nurse report to the healthcare provider immediately?
A) Large amounts of expelled flatus with mucus.
B) Tympanic abdomen and hyperactive bowel sounds.
C) Increased abdominal pain with rebound tenderness.
D) Complaint of feeling weak with watery diarrheal stools. - AnswersC) Increased abdominal pain
with rebound tenderness.
Positive rebound tenderness (C) may be an indication of peritonitis or perforation and needs follow-
up immediately. Clients typically experience a large amount of flatus (A) and may have mucus from
bowel irritation from the procedure. A tympanic abdomen on percussion and hyperactive bowel
sounds are typical post procedure findings (B). Weakness and watery stools are a result from the
preparation and are common symptoms experienced after a colonoscopy (D).
When caring for a client with a percutaneous endoscopic gastrostomy (PEG) tube, what protocols
should the nurse implement for intermittent feedings? (Select all that apply.)
o Assessing residual amounts once a day.
o Keeping the head of the bed elevated 30 degrees.
o Changing the enteral-feeding bag every 24 hours.
o Checking the placement of the tube by means of gastric aspiration.
o Flushing the tube with 50 ml of normal saline solution after each feeding. - Answerseeping the
head of the bed elevated 30 degrees. Correct
o Changing the enteral-feeding bag every 24 hours. Correct
o Checking the placement of the tube by means of gastric aspiration. Correct
o Flushing the tube with 50 ml of normal saline solution after each feeding.
(B, C, D, and E) are correct. Keeping the head of the bed elevated 30 degrees (B), changing the
enteral-feeding bag every 24 hours (C), checking the placement of the tube by means of gastric
aspiration (D), and flushing the tube with 50 ml of normal saline solution after each feeding (E) are
interventions used to provide care of the client with a PEG tube. Residual amounts should be
assessed prior to each feeding, not once daily (A).
The nurse is assessing a client with a cuffed tracheostomy tube in place who is breathing
spontaneously. To evaluate if the client can tolerate cuff deflation to promote speaking and
swallowing, what action should the nurse implement?
Ask the client to try to speak.
Assess for respiratory distress. [Show Less]