MED-SURG HESI EXAM
MS2020 HESI
MED-SURGERY HESI EXAM
1. The nurse empties the nasogastric suction collection canister of a client who had a bowel
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previous day and note that 1000 ml of gastric secretions were collected in the last 4 hours.
a. Metabolic alkalosis
b. Hyperkalemia
c. Metabolic acidosis
d. Hypoglycemia
2. A young client who is being taught to use an inhaler for symptoms of asthma tells the nurse the intention
to use the inhaler but, plans to continue smoking cigarettes in evaluating the client’s response, what is
the best initial action by the nurse?
a. Inform the health care provider of this statement made by the client.
b. Explain that denial of illness can interfere with the treatment regimen.
c. Revise the plan of care based on the client’s plans to continue smoking.
d. Review factors surrounding client’s beliefs about smoking cessation.
3. A client with sudden onset of big toe joint pain and swelling is diagnosed with gout. Which
pathophysiologic process is producing the symptoms of gout?
a. An immune complex and autoantibody deposition in connective tissue results in inflammation.
b. Chondrocyte injury destroys joint cartilage, producing osteophytes and joint inflammation.
c. An autoimmune inflammation involving IgG response to an antigen causes joint destruction.
d. Deposition of crystals in the synovial space of the joint produce inflammation and irritation.
4. An older female client has normal saline infusing at 45ml/hour. She complains of pain the insertion site
of the IV catheter. There is no redness or edema around the IV site. Which action should the nurse take?
a. Determine what IV medications have recently been administered.
b. Explain that without redness or edema, there is no need to re-start the IV.
c. Consult with the healthcare provider about the best localization to start a new IV.
d. Convert the IV to a saline lock and continue to monitor the site.
5. While assessing a female client who is chronically fatigued and was recently diagnosed with adrenal
insufficiency, the client tells the nurse that she is very nervous that her hospitalization will cause her to
lose her job. Which intervention should the nurse implement first?
a. Teach client about risk for infection.
b. Offer support and care measure to reduce anxiety and stress.
c. Encourage the client to rest quietly to reduce fatigue.
d. Place a referral to social service to discuss financial options.
6. The nurse is collecting information from a client with chronic pancreatitis who report persistent gnawing
abdominal pain. To help the client manage the pain. Which assessment data is most important for the
nurse to obtain?
a. Color and consistency of feces.
b. Eating patterns and dietary intake.
c. Presence and activity of bowel sounds.
d. Level and amount of physical activity.
7. A young adult client, admitted to the Emergency Department following a motor vehicle collision, is
transfused with 4 unit of PRBCs (packed red blood cells). The client’s pretransfusion hematocrit is 17%.
Which hematocrit value should the nurse expect the client to have after all the PRBCs have been
transfused?
a. 19%
b. 9%
c. 39%
d. 29%
8. A client admitted with left-sided heart failure has a heart rate of 110 beats per minute and is becoming
increasing dyspneic. Which additional assessment finding by the nurse support the client’s admitting
diagnosis?
a. An enlarged, distended abdomen.
b. Crackles in the bases of both lungs.
c. Jugular vein distension.
d. Peripheral edema.
9. When planning care for a client newly diagnosed with open angle glaucoma, the nurse identifies a
priority nursing problem of “visual sensory/perceptual alterations”. This problem is based on which
etiology?
a. Blurred distance vision.
b. Limited eye movement.
c. Decreased peripheral vision
d. Photosensitivity.
10. A postoperative client report incisional pain. The client has two prescriptions for PRN analgesia that
accompanied the client from the post anesthesia unit. Before selecting which medication to administer,
which action should the nurse implement?
a. Determine which prescription will have the quickest onset of action.
b. Compare the client’s pain scale rating with the prescribed dosing.
c. Ask the client to choose which medication is needed for the pain.
d. Document the client’s report of pain in the electronic medical record.
11. The nurse is caring for a client that had a thyroidectomy 24 hours ago. The client reports experiencing
numbness and tingling and tingling and tingling of the face. Which intervention should the nurse
implement?
a. Open and prepare the tracheostomy kit.
b. Inspect the neck for increase in swelling.
c. Monitor for presence of Chvostek’s sign.
d. Assess lung sound for laryngeal stridor.
12. When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction
should the nurse include?
a. Eat a high-fiber and increase fluid intake.
b. Have small frequent meals and sit up for at least two hours after meal.
c. Eat s bland diet and avoid spicy foods.
d. Eat a soft diet with increased intake of milk and milk products.
13. An older female client with long term type 2 diabetes mellitus (DM) is seen in the client for a routine
health assessment. To determine if the client is experiencing any long – term complications of DM,
which assessments should the nurse obtain? (Select all that apply)
a. Serum creatinine and blood urea nitrogen (BUN).
b. Sensation in feet and legs.
c. Skin condition of lower extremities.
d. Signs of respiratory tract infection
e. Visual acuity.
14. A client with chronic kidney disease missed dialysis yesterday to attend a funeral. The client’s wife the
home health nurse and reports that her husband is lethargic and hard to arouse. Which instruction is most
important for the nurse to provide?
a. Apply the client’s home oxygen.
b. Check for a thrill and bruit at the client’s dialysis access site.
c. Ensure the client avoids salt intake for the rest of the day.
d. Take client to emergency department (ED).
15. The healthcare provider writes several prescriptions for a client diagnosed with hospital-acquired
pneumonia (HAP) that include a combination of broad- spectrum antibiotics. Which intervention should
the nurse implement first?
a. Monitor client’s metabolic panel results during course of antibiotic therapy.
b. Review medical record for results of a chest x-ray obtained on admission.
c. Schedule prescribed nebulizer treatments with respiratory therapy.
d. Collect blood specimens for culture prior to starting antibiotic therapy.
16. The nurse provides dietary instructions about iron rich food to a client with iron deficiency anemia.
Which food selection made by the client indicates a need for additional instructions?
a. Liver.
b. Kidney beans.
c. Oranges.
d. Leafy green vegetable.
17. A client who is experiencing respiratory distress is admitted with respiratory acidosis. Which
pathophysiological process supports the client’s respiratory acidosis.
a. Carbon dioxide is converted in the kidneys for elimination.
b. Blood oxygen levels are stimulating the respiratory rate.
c. Hyperventilation is eliminating carbon dioxide rapidly.
d. High levels of carbon dioxide have accumulated in the blood
18. Methotrexate is prescribed for a client with rheumatoid arthritis (RA) who is also taking aspirin. What is
the best explanation for the nurse to provide as to why a second medication has been added?
a. Methotrexate slows the disease progression while aspirin controls the symptoms.
b. Methotrexate has less harmful side effects than aspirin.
c. Methotrexate helps to reduce the side effects of the aspirin therapy.
d. Methotrexate enhances the effectiveness of the aspirin.
19. A client who has developed acute kidney injury (AKI) due to an aminoglycoside antibiotic has moved
from the oliguric phase to the diuretic phase of AKI. Which parameters are most important for the nurse
to plan to carefully monitor?
a. Side effect of total parental nutrition (TPN) and Intralipids.
b. Uremic irritation of mucous membranes and skin surfaces.
c. Elevated creatinine and blood urea nitrogen (BUN).
d. Hypovolemia and electrocardiographic (ECG) changes.
20. A woman with chronic osteoarthritis is complain of knee pain. Which pathophysiological process is
contributing to her pain?
a. Inflammation results from deposition of crystals in the synovial space of joints producing irritation.
b. Joint destruction happens due to an autoimmune inflammation involving IgG response to an antigen.
c. Joint inflammation occurs when chondrocyte injury destroys joint cartilage, producing osteophytes.
d. Inflammation is caused by immune complex and autoantibody deposition in connective tissue.
21. An adult client who received partial thickness burns 40%bof the body in a house fire is admitted to the
inpatient burn unit. Which fluid should the nurse prepare to administer during the client’s burn recovery?
a. 5% dextrose in water.
b. 5% dextrose in 0.25 normal saline.
c. Total parenteral nutrition
d. Lactate Ringer’s.
22. A client with partial thickness burns to the lower extremities is schedules for whirlpool therapy to
debride the burned area. Which intervention should the nurse implement before transporting the client to
the physical therapy department?
a. Obtain supplies to re- dress the burn area.
b. Verify the client’s signed consent form.
c. Give a prescribed narcotic analgesic agent.
d. Perform active range-of- motion exercise.
23. The nurse determines that an adult client who is admitted to the post anesthesia care unit (PACU)
following abdominal surgery has a tympanic temperature of 94.6 F(34.8*C), a pulse rate of 88
beast/minute, a respiratory rate of 14 breaths/minute, and a blood pressure of 94/64 mmHg. Which
action should the nurse implement?
a. Take the client’s temperature using another method.
b. Raise the head of the bed to 60 to 90 degrees.
c. Ask the client to cough and deep breathe.
d. Check the blood pressure every five minutes for one hour.
24. Based on this strip, what is the interpretation of this rhythm?
a. First degree AV heart block.
b. Sinus bradycardia.
c. Junctional escape rhythm.
d. Normal sinus rhythm.
25. An unlicensed assistive personnel (UAP) reports to the nurse that a client with a postoperative wound
infection has a temperature of 103 F (39.89 C), blood pressure of 90/70, pulse of 124 beats/minute, and
respirations of 28 breath/minute. When assesses the client, finding include mottled skin appearance and
confusion. Which action should the nurse take first?
a. Transfer the client to the ICU.
b. Initiate an infusion of intravenous (IV) fluids.
c. Assess the client’s core temperature.
d. Obtain a wound specimen for culture.
26. Which institution should the nurse include in the discharge teaching plan for a client who has a cataract
extraction today?
a. Use a metal eye shield on operative eye during the day.
b. Administer eye ointment prior to applying eye drops.
c. Sexual activities may be resumed upon return home.
d. Light housekeeping is sale to do but avoid heavy lifting.
27. The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive
ascites. Which mechanism contributes to edema and cite in clients with cirrhosis?
a. Decreased renin-angiotensin response to an increase in renal blood flow.
b. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules.
c. Hypoalbuminemia that results in a decreased colloidal oncotic pressure.
d. Decreased portacaval pressure with greater collateral circulation.
28. A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE).
It is most important to report which assessment finding to the healthcare provider?
a. Joint pain
b. Low grade fever.
c. Muscle atrophy.
d. Hematuria.
29. Four hours following surgical repair of a compound fracture of the right ulna, the nurse is unable to
palpate the client’s right radical pulse. Which action should the nurse take first?
a. Notify the healthcare provider of the finding immediately.
b. Complete a neurovascular assessment of the right hand.
c. Elevate the client’s right hand on one or two pillows.
d. Measure the client’s blood pressure and apical pulse rate.
30. A client’s laboratory finding indicate elevations in thyroxine and triiodothyronine hormones. The nurse
suspects that the client may hyperthyroidism. Which assessment finding is most often associated with
hyperthyroidism?
a. Periorbital edema.
b. Atrophied thyroid gland.
c. Increased pulse rate.
d. Diarrhea stools.
31. A young adult is burned when wearing a shirt that was splashed with lighter fluid and caught on fire
white attempting to light a charcoal grill. The client ripped off the shirt immediately, without
unbuttoning the sleeves, which caused circumferential burns to both wrists. When the client is admitted,
which intervention should the nurse implement first?
a. Monitor pulse intensity,
b. Evaluate extremity sensation.
c. Assess range of motion.
d. Place sterile bandage on both wrists.
32. A client with rheumatoid arthritis has elevated serum rheumatoid factor. Which interpretation of this
finding should the nurse make?
a. Evidence of spread of the disease to the kidney.
b. Confirmation of the autoimmune disease process.
c. Representative of a decline in the client’s condition.
d. Indication of the onset of joint degeneration.
33. The nurse is assessing a client who has a bowel obstruction. Which observations should the nurse expect
to find? Select all that apply.)
a. Dullness on percussion.
b. Abdomen soft on palpation.
c. Hight pitched bowel sounds.
d. Peristaltic waves observed.
e. Abdominal distention.
34. A client is receiving a continuous infusion of normal saline at 125 ml/hour post abdominal surgery. The
client is drowsy and complaining of constant abdominal pain and a headache. Urine output is 800 ml
over the past 24 hours with a central venous pressure of 15 mmHg. The nurse notes respiratory crackles
and bounding central pulse. Vital signs: temperature 101.2 F (38.4 C), heart rate 96 beats/minutes,
respiration24 breaths/minutes, and blood pressure of 160/90 mmHg. Which intervention should the
nurse implement first?
a. Calculate total intake and output for last 24 hours.
b. Administer PRN dose of acetaminophen.
c. Decrease IV fluids to keep vein open (KVO) rate.
d. Review last administration of IV pain medication.
35. In the change-of-shift report. The nurse is told that a client has a Stage 2 pressure ulcer. Which ulcer
appearance is most likely to be observed?
a. Shallow open ulcer with a red-pink wound bed.
b. A deep pocket of infection and necrotic tissues.
c. An area of erythema that is painful to touch.
d. Visible subcutaneous tissue with sloughing.
36. To assess the quality of an adult client’s pain. What approach should the nurse use?
a. Observe body language and movement.
b. Ask the client to describe the pain.
c. Identify effective pain relief measures.
d. Provide a numeric pain scale.
37. A client with chronic obstructive pulmonary disease (COPD) presented with shortness of breath. Oxygen
therapy was started at 2 liters/minute via nasal cannula. The arterial blood gases (ABGs) after treatment
were ph. 7.36, PaO2 62, PaCO2 59, and HCO3. Which statement describes the most likely cause of the
simultaneous increase in both the PaO2 and the PaCO2?
a. The hypercapnia resulted from the rapid respirations.
b. The hypoxic drive was reduced by the oxygen therapy.
c. The client had a pneumothorax which restricted ventilation.
d. The client a pulmonary embolism that reduced perfusion.
38. A client who experienced partial-thickness burns with over 50% body surface area (BSA) 2 weeks ago
has several open wounds and develops watery diarrhea. The client’s blood pressure is 82/40 mmHg and
temperature 96 F (36.6 C). Which action is most important for the nurse to take?
a. Increase the room temperature.
b. Assess the oxygen saturation.
c. Continue to monitor vital sign.
d. Notify the rapid response team.
39. When providing care for an unconscious client who has seizures, which nursing intervention is most
essential?
a. Ensure oral suction is available.
b. Maintain the client in a semi- Fowler’s position.
c. Provide frequent mouth care.
d. Keep the room at a comfortable temperature.
40. Laboratory finding indicate that a client’s serum potassium level is 2.5mEq/L. What action should the
nurse take?
a. Inform the healthcare provider of the need for potassium replacement.
b. Prepare to administer a glucose-insulin potassium replacement.
c. Change the plan of care to include hourly urinary output measurement.
d. Instruct the client to increase daily intake of potassium-rich foods.
41. A client reports new onset hearing loss bilaterally after taking a medication with known ototoxic effects.
Which type of hearing loss should the suspect?
a. Presbycusis.
b. Sensorineural.
c. Mixed sensorineural-conductive.
d. Conductive.
42. The middle-age man who has a 35- year smoking history presents to the Emergency Department
confused and short of breath. Before starting oxygen, these saline arterial blood gases (ABGs) are
obtained: ph.= 7.25, pCO2 = 50 mmHg, HCO3 =30 mEq/L, pO2 = 60 mmHg. These findings indicate to
the nurse that the client is experiencing which acid-base imbalance?
a. Respiratory alkalosis.
b. Metabolic alkalosis.
c. Metabolic acidosis.
d. Respiratory acidosis.
43. A client with multiple injuries from a motorcycle accident is admitted to the intensive care unit with a
left flail chest, liver laceration, and fractured left femur. The nurse records the client’s vital signs and
urine output. Which assessment provides the earliest indication to the nurse that the client is manifesting
signs of hypovolemic shock?
a. Heart rate 120 beats/ minute.
b. Respiratory rate less than 20 breaths/minute.
c. Urine output less than 30ml/hour.
d. Systolic blood pressure less than 90mmHg.
44. While walking to the mailbox, an older adult male experiences sudden chest tightness and drives himself
to the emergency department. When the client gets up to the desk of the triage nurse, he says his heart is
pounding out of his chest as he clutches his chest and falls to the floor. Which intervention should the
nurse implement first?
a. Prepare for cardiac defibrillation.
b. Apply cardiac monitor leads.
c. Obtain serum troponin values.
d. Palpate client’s artery.
45. A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has
describing the exact nature and location of the pain to the nurse. What action should the nurse
implement next?
a. Observe the client’s pupils for dilation.
b. Document the client’s drug tolerance.
c. Assess the client’s vital signs.
d. Administer the analgesic as requested.
46. A client with fluid volume excess has gained 6.6 pounds. The nurse recognizes that this is equivalent to
what volume of fluid?
a. Three liters.
b. Two liters
c. One-half liter
d. One liter
47. The nurse has conducted a cancer prevention community education program. In evaluating the
participant’s understanding of the carcinogens, which statement indicates an accurate understanding?
a. Carcinogens are substances that contain cancerous cells.
b. Environmental factors such as sunlight and chemicals can cause cancer to spread.
c. Carcinogens are in the environment and cannot be avoided.
d. Substance that changes a cell so that it become cancerous are potential sources of cancer.
48. A client who is receiving general anesthesia begins to demonstrate symptoms of malignant
hyperthermia. Which intervention should the perioperative nurse prepare to implement first?
a. Prepare for cessation of the anesthesia and the surgical procedure.
b. Initiate cooling measure using iced normal saline by nasogastric lavage.
c. Ensure patency of an indwelling catheter and measure hourly urine output.
d. Obtain specimen for arterial blood gasses and serum electrolytes.
49. The nurse is preparing a client for surgery who was admitted to the emergency center following a motor
vehicle collision. The client has an open fracture of the femur and bleeding moderately from the bone
protrusion site. During the assessment, the nurse determines that the client receives heparin sodium 5000
unit subcutaneously daily. What is the priority nursing action?
a. Observe the heparin injection site for signs of bruising.
b. Have the client sign the surgical and transfusion.
c. Ensure that the potential for bleeding explained to the client.
d. Notify the healthcare provider of the client’s medication history.
50. How are type IV hypersensitivity reactions different from all other type (I, II or III) of hypersensitivity
reactions?
a. The usual type of reactions is mediated by antibodies.
b. Delayed reactions are characterized by cytokine release. (IV)
c. B lymphocytes produce the offending substances.
d. They typically occur with the first exposure to an antigen.
51. Based on this strip, what is the correct interpretation of this rhythm.
a. Accelerated junctional rhythm.
b. Atrial fibrillation.
c. Premature atrial contractions.
d. Wenckebach, Mobitz Type I AV block.
52. An adult client is admitted with AIDS and oral candidiasis manifested by several painful ulcers. The
nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the
client. Which instruction should the nurse provide the UAP?
a. Wear sterile gloves when cleansing any areas of infected mucosa.
b. Provide a soft-bristled toothbrush for the client to use during oral care.
c. Assist with personal care but leave oral care for them to complete.
d. Offer the client mouthwash for thorough cleansing after brushing teeth.
53. The Hospitalized client with chemotherapy-induced stomatitis complains of mouth pain. What is the
best initial nursing action?
a. Obtain a soft diet for the client.
b. Administer a topical analgesic per PRN protocol.
c. Cleanse the tongue and mouth with glycerin swabs.
d. Encourage frequent mouth care.
54. Which group of food is best for the nurse to recommend for clients with a strong family history of colon
and rectal cancers?
a. Leans beef, salads, and baked potatoes.
b. Potatoes, low-fat breads. And applesauce.
c. Chicken, rice and wheat products.
d. Oatmeal, raisins, and fruit with skin.
55. A client with a pituitary tumor is admitted with dehydration. The client’s urinary output for the past 24
hours is 7500 ml and vital signs are heart rate 134 beats/minute. Blood pressure 90/40 mmHg, and
temperature 102 F (38.9 C). A prescription is received is received to administer vasopressin. Which
action should the nurse implement?
a. Obtain urine specimen before administering the medication.
b. Withhold the medication until the client’s systolic BP is greater than 10.
c. Administer the prescribed medication as soon as possible.
d. Notify the healthcare provider of the fever before giving the medication.
56. The nurse is assessing clients in an outpatient diabetic clinic. Which entry provides the best indication
that the client is adhering to the prescribed diabetic regimen?
a. Hemoglobin A1C of 6.2%
b. Postprandial plasma glucose of 225 mg/dl (12.49 mmol/l).
c. Fasting plasma glucose of 189 mg/dl (10.49).
d. Hight – density lipoprotein of 40 mg/dl (1.03Mmol/l).
57. A client who had surgery yesterday is becoming increasing anxious. The client respiratory rate has
increased to 38 breaths/minute. The client has a nasogastric tube to low intermittent suction with 500 ml
of yellow-green drainage over the last four hours. The client’s arterial blood gases (ABGs) indicate a
decreased CO2 and an increased serum PH. Which serum laboratory value should the nurse monitor
first?
a. Electrolytes.
b. Creatinine.
c. Platelet count.
d. Albumin.
58. A client with a C-7 spinal cord injury is experiencing autonomic dysreflexia. The nurse should first
assess the client for which precipitating factor?
a. An acutely distended bladder.
b. Profuse forehead diaphoresis.
c. Skeletal traction misalignment.
d. A severe pounding headache.
59. The nurse assesses an adult male client 24 hours following abdominal surgery and finds that his blood
pressure 98/40 mm Hg, he is tachycardiac, restless, and irritable. Which action should the nurse take
first?
a. Check under his back for evidence of bleeding.
b. Listen to lung sound.
c. Notify the health care provider of the finding.
d. Ensure that the IV is infusing at the prescribed rate.
60. The nurse teaching a client how to collect a sputum specimen. Which steps should the nurse instruct the
client to follow when collecting sputum?
a. Restrict fluids before expectorating the sputum specimen.
b. Obtain the specimen before bedtime.
c. Avoid mouth care prior to collecting the sputum.
d. Breathe deeply, followed by coughing up the sputum.
61. When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD),
which approach the nurse use?
a. Explain that the client may be placed in five positions.
b. Obtain arterial blood gases (ABGs) prior to procedure.
c. Perform the drainage immediately after meals.
d. Instruct the client to breathe shallow and fast.
62. When teaching a client newly diagnosed with multiple sclerosis (MS), which approach should the nurse
emphasize as most likely as most likely to prevent an exacerbation of symptoms?
a. Obtain assistance when performing activities of daily living to avoid relapse.
b. Develop preplanned strategies to avoid or minimize the effects of triggers.
c. Schedule frequent follow-up visits for monitoring disease progression.
d. Focus on positive aspects of living and avoid situations that induce emotional upset.
63. The healthcare provider prescribes a diagnostic mammogram for a client who has detected a lump in the
breast. Which instructions should the nurse provide the client to prepare for the procedure?
a. Schedule the mammogram during the menstrual cycle.
b. Refrain from wearing deodorant and lotions under the arms the day of the exam.
c. Avoid using vaginal medications, lubricants, or contraceptives 2 days prior to the test.
d. Wear loose-fitting clothing without a bra for the procedure.
64. The nurse is monitoring a client with a transcutaneous pacemaker that is periodically falling to capture.
Which intervention should the nurse implement first?
a. Check the adhesion of the pacemaker pads.
b. Shave chest and replace pacemaker pads.
c. Confirm lead wires are secured to pacemaker generator.
d. Change the batteries in the pacemaker.
65. Which nursing problem has the highest priority when planning care for a client with Meniere’s disease?
a. Impaired skin integrity related to immobility.
b. Potential for injury related to vertigo.
c. Alteration in comfort related to pain in the ear.
d. Alteration in body temperature related to decreased hypothalamic functioning.
66. While Changing the dressing of a client with a leg ulcer, the nurse observes a red, tender, and swollen
wound at the site of the lesion. Before reporting this finding to the healthcare provider, the nurse should
note which of the client’s laboratory values?
a. Blood pH level.
b. Neutrophil count
c. Hematocrit.
d. Serum potassium and sodium levels.
67. A young adult male is admitted to Intensive Care Unit with multiple rib fractures and pulmonary
contusions after falling 20 feet from a rooftop. His chest X-ray suggests acute respiratory distress
syndrome (ARDS). Which assessment finding warrants immediate intervention by the nurse?
a. Core body temperature 100.8 F (38.2 C).
b. Apical pulse 58 beats/minute.
c. Multiple bruises over chest wall.
d. Tachypnea with dyspnea.
68. A client who has a history of unstable angina is admitted to the emergency department with chest pain.
Which assessment finding indicative of a possible myocardial infarction (MI) is most important for the
nurse to report to the healthcare provider?
a. Chest pain unrelieved after taking 3 sequential nitroglycerin tablets.
b. Shoulder pain, headache, jaw pain radiating to ear.
c. Bilateral edema in lower extremities with diminished pedal pulse.
d. Anxiety and fear of dying in the emergency department.
69. Which information should the nurse include in the teaching plan of a client diagnosed with
gastroesophageal reflux disease (GERD)?
a. Minimize symptoms by wearing loose, comfortable clothing.
b. Sleep without pillows at night to maintain neck alignment.
c. Avoid participation in any aerobic exercise programs
d. Adjust food intake to three full meals per day and no snacks
70. Based on the interpretation of this strip, which action should be implemented next?
a. Begin chest compression.
b. Deliver artificial ventilation.
c. Call a code.
d. Open the airway.
71. A 55 years-old client symptoms of osteoarthritis ask which form of exercise would be most beneficial.
What is the best response by the nurse?
a. “Swimming is an excellent exercise for you”.
b. “Jogging or running are excellent aerobic exercises”
c. “Limit your exercise to just your daily activities”
d. “Tennis or racquetball will increase your muscle strength”
72. er a penile implant, a male client complains of pain at “9” on a 1 to 10 scale. The observes the surgical
site, notes that his scrotum is edematous, and is the client to use his patient-controlled analgesia (PCA).
Which intervention should the nurse implement next?
a. Reassure him that the swelling will subside.
b. Document finding in the medical record.
c. Elevate the scrotum with a soft support.
d. Ask the client if he feels the need to void.
73. A male client with acquired immune deficiency syndrome (AIDS) and Pneumocystis carinii pneumonia
has a CD4+ T cell count of 200 cells/microliter. The client asks the nurse why he keeps getting these
massive infections. Which pathophysiologic mechanism should the nurse describe in response to this
client’s question?
a. Exposure to multiple environmental infectious agents overburdens the immune system until it fails.
b. Bone marrow suppression of white blood cells causes insufficient cells to phagocytize organisms.
c. The humoral immune response lacks B cells that form antibodies and opportunistic infections result.
d. Inadequate numbers of T lymphocytes are available to initiate cellular immunity and macrophage.
74. Which instruction should the nurse provide a client who was recently diagnosed with Raynaud’s
disease?
a. Wear knee-high support stockings during the day.
b. Wear gloves when removing package from freezer.
c. Walk regularly to increase circulation.
d. Use a heating pad at night to keep feet warm.
75. A female client returns to the client after being treated for chlamydia with azithromycin IM and report
that she still has symptoms. The healthcare provider obtains a swab of the discharge from the cervix
from the cervix for testing for chlamydia. The client reports maintaining a monogamous relationship
when the laboratory results are positive for the sexually transmitted infection. Which information should
the nurse obtain to evaluate the ineffective results of treatment?
a. Confer with the healthcare provider about a different course of antibiotics.
b. Ask the client if the complete course of antibiotics was completed.
c. Determine if the client’s sexual partner received treatment for chlamydia.
d. Inquire further about all sexual encounters and any other sexual activity.
76. Twelve hours following a unilateral total knee replacement, a client reports being unable to sleep
because of severe incisional pain. What is the best initial nursing action?
a. Assist the client in assuming a Lateral Sims’s position for comfort.
b. Apply ice to the incision for twenty for twenty minutes prior to joint flexion exercises.
c. Initiate continuous passive motion (CPM) to relive muscle spasms.
d. Instruct the client in use of the prescribed patient-controlled analgesia (PCA) pump.
77. The nurse is assessing a client who has herpes zoster. Which questions will allow the nurse to gather
further information about this condition?
a. Do you have any dry patches on your feet and hands?
b. Do you family members share combs and brushes?
c. Has everyone at home already had effective?
d. Has everyone at home already had varicella?
78. While caring for a client with Guillain-Barre syndrome, the nurse performs a neurological assessment
every four hours. Which assessment finding warrants immediate intervention by the nurse?
a. Lower leg weakness.
b. Sensory loss at T-8.
c. Leg pain worsening at night.
d. Profuse diaphoresis.
79. Which intervention should the nurse include in the plan of care for a client who has a chest tube due to a
hemothorax?
a. Keep the arm and shoulder of the affected side immobile at all time.
b. Encourage the client to breathe deeply and cough at frequent intervals.
c. Ensure that there is no fluctuation in the water-seal chamber.
d. Maintain the Pleuravac slightly above the chest level.
80. The nurse is providing teaching to a client who has had an arteriovenous (AV) fistula placed for
hemodialysis. Which statement by the client indicates an understanding about the fistula?
a. The fistula can be used for hemodialysis in 2 weeks.
b. The arm with the fistula is not used for blood pressures or needle sticks.
c. A bruised area will persist around the fistula for several months
d. The arm with the fistula will feel cold to touch.
81. The nurse is evaluating teaching about drug therapy to treat gout. Which statement by the client
demonstrates an understanding of the use of allopurinol to treat gout?
a. “I need to take this drug every day to keep from having any flare-ups”.
b. “I should take this drug when I have gout attacks to reduce symptoms”
c. “I need to take the prescribed amount of the drug to get rid of my gout”
d. “The pain and swelling can be controlled by this drug every day”.
82. Which instruction should the nurse include in the discharge teaching plan for an adult client with
hypernatremia?
a. Review food labels for sodium content.
b. Monitor daily urine output volume
c. Use salt tablets after strenuous exercise
d. Drink plenty of water whenever thirsty
83. A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin
test. The nurse’s assessment of the best after 62 hours indicates 5 mm of erythema without induration.
Which is the best initial nursing action? Refer client to a healthcare provider for isoniazid (INH) therapy.
a. Instruct the client to return for a repeat test in 1 week.
b. Document negative results in the client’s medical record.
c. Review client’s history for story for possible exposure to TB.
d. Refer client to a healthcare provide for isoniazid (INH) therapy.
84. In assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the
procedure was successful?
a. Stone fragments are collected when straining the client’s urine.
b. Client denies urinary frequency, urgency or dysuria.
c. Urine is pale pink with no observable blood clots.
d. Serum creatinine and BUN levels are within normal limits. [Show Less]