NURSING MEDSUR2 HESI EXIT Questions with Answers Updated 2023
1.An adult who has recurrent episodes of depression tells the nurse that the
... [Show More] prescribed antidepressant needs to be discontinued because the client is feeling better after taking the medication for the past couple of weeks and does not like the side effects. Which response is best for the nurse to provide.
a. Remind the client that feeling better is the therapeutic effect of the medication.
b. Inform the client that gradual tapering must be used to discontinue the medication.
c. Tell the client to discuss the medication side effects with the HCP.
d. Tell the client that the medication side effects will most likely dissipate over time.
3. The nurse is teaching the parent of a child newly diagnosed with a latex allergy. Which information by the parents indicates a need for further teaching?
a. robber free toys, such as wooden building blocks, are good choices for the child.
b. Only foiled balloons will be used for the child’s birthday party.
c. a diet of healthy fruits, such as bananas and kiwis, are best for the child.
d. an epinephrine auto-injector will be on hand to treat allergic reactions.
4. a child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen?
a. blood transfusion
b. chemotherapy
c. bone marrow transplantation
d. immunosuppressive therapy
5. A client with bladder cancer had surgical placement of a ureteroileostomy (beal conduit) yesterday. Which postoperative assessment finding should the nurse report to the HCP immediately.
a. red edematous stomach appearance
b. liquid brown drainage from stoma
c. stoma output of 40ml in the last hour
d. mucous strings floating in the drainage.
7. The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request to this client? (Select all that apply)
a. apple juice
b. black coffee
c. orange juice
d. hot chocolate
e. chicken broth
8. Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client’s wrist restraints to the movable portion of the client’s bed frame. What action should the nurse take before leaving the room.
a. Tie the knot with a double turn or square knot
b. Ensure that the restraints are snug against the client’s wrists.
c. Ensure that the knot can be quickly released.
d. Move the ties so the restraints are secured to the side rails.
9. The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the procedure?
a. Experiences facial swelling after eating crab
b. Reports left chest wall pain prior to the admission
c. Verbalizes a fear of being in a confined space
d. Drank a glass of water
Q 10. The healthcare provider prescribes ceftazidime 1 gram every 8 hours. The label on the 1-gram vial reads, ‘’reconstitute with 100 ml sterile water’’ This dilution provides a concentration of how many mg/ml (enter numeric value only)
10mg/ml
Q 11 When teaching a group of school-aged children how to reduce the risk for Lyme disease, which instruction should the camp nurse include?
A) Wash hands frequently
B) Avoid drinking lake water
C) Wear long sleeves and pants
D) Do not share personal products.
Q 12 A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor?
A) Serum calcium
B)
C) Erythrocyte sedimentation rate
D) Osmolality.
Q 13 An older woman who was recently diagnosed with end stage metastatic breast cancer is admitted because she is experiencing shortness of breath and confusion. The client refuses to eat and continuously asks to go home. Arterial blood gases indicate hypoxia.
Which intervention is most important for the nurse to implement?
A) Offer sips of favorite beverages
B) Prepare for emergent oral intubation
C) Initiate comfort measures
D) Clarify end of life desires. Correct Answer
15. A client with chronic obstructive pulmonary disease (COPD) is experiencing worsening dyspnea and low oxygen levels. Vitals signs are temperature 99.6 F(37.5 C) heart rate 98 beat, respirations 28 breaths/minute, blood pressure 140/82 mmHg and oxygen saturation 88% ,which action should the nurse implement?
A) Place the client in a forward-leaning position.
B) Prepare client for endotracheal intubation
C) Apply a non-rebreather mask at 100% oxygen
D) Obtain a sputum sample for culture and sensitivity
Q 16 A client with a history of upper respiratory symptoms is admitted with chest tightness, a productive cough, and difficulty breathing. The client arterial blood gasses (ABGS) indicate respiratory acidosis. An increase in laboratory tests support this finding.
A) PaO2
B) PaCO2
C) Arterial pH
D) HCO3
Q 17. The health care provider prescribed a low fiber diet for a client with ulcerative colitis, which food selection indicates to the nurse that the client understands the prescribed diet
A) Roasted Turkey, Canned Vegetable. Correct answer
B) Roast Pork, Fresh Strawberry
C) Baked Potatoes with Skin, Raw Carrot
D) Pancakes, Whole green cereals
Q 18. Which instruction regarding skin care should the nurse provide to a client who is receiving radiation therapy for metastatic breast cancer?
A) Use a sponge to de-breed the affected area
B) Frequently apply moisturizer to prevent dry skin
C) Protect the site from getting wet during bathing
D) Gently path the skin after dry after rinsing with water
Q 19. A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to not before administering the initial dose?
A) Length of time of the exposure to tuberculosis
B) Current diagnosis of hepatitis B
C) History of intravenous drug abuse
D) Conversion of the client PPD test from negative to positive
Q 20. The charge nurse observes a new nurse preparing to insert intravenous (IV) catheter, the new nurse has gathered supplies including intravenous catheter and intravenous insertion kit, 4x4 sterile gauze dressing to cover and secure the insertion site. What action should the charge nurse take?
A) Plan to observe the secured IV sit after the insertion procedure
B) Confirm that the nurse has gathered the necessary supplies
C) Instruct the nurse to use a transparent dressing over the site
D) Remind the nurse to tape the gauze dressing securely in place
Q 21. An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client ran a marathon one year ago, his spouse states that the client no longer runs, but sits and watches television most of the day. Which intervention is the most important for the nurse to include in this client’s plan of care for today?
A) Help client to develop a list of daily affirmation
B) Encourage client to participate for one hour in a team sport
C) Assist client in identifying goals for the day
D) Schedule client for a group that focus on self esteem
Q 22. A client who is pregnant seems confused and presents with the onset of headache, polyuria, fatigue, and blurry vision. Which action should the nurse implement?
A) Palpate bladder for urinary retention
B) Assess client for signs of vertigo
C) Take serial blood pressure readings
D) Determine serum potassium level
Q 23. The nurse knows that several complications can occur with the administration of blood, which finding is an indication of an air emboli?
A) Nausea and vomiting
B) Chills and tremors
C) Increased blood pressure
D) Difficult breathing
24. The nurse caring for a client with chronic obstructive pulmonary disease (COPD) who is unable to effectively cough up thick mucus. When the nurse prepares to suction the airway using a yankauer suction catheter, which action should the nurse include?
A) Instill 3ml of normal saline before suction
B) Wear protective goggles while performing the procedure
C) Apply a water-soluble lubricant to the catheter
D) Instruct the client to cough as the suction tip is removed
25. a nurse determines that more than 25% of the students at middle school are overweight. The nurse presents the information at a parent-teacher meeting. What action is most important for the nurse to include in the meeting?
a. distribute a shopping list of suggested healthy snacks item.
b. have several teachers talk about health risk associated with obesity
c. provide information on ways to increase activity for the family
d. determine the parents’ degree of concern about their children’s weight
27. When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?
a. encourage the client to implement relaxation techniques
b. refer client to the social worker for support therapy
c. explain that insulin is a life-saving drug for the client
d. leave the client’s room and return later in the day.
29. The mother of a 12-month-old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day, and has also experienced a loss of appetite. Which instructions should the nurse provide?
a. perform CPT after meals to increase appetite and improve food intake.
b. stop using CPT during the daytime until the child has regained an appetite
c. perform CPT only in the morning, but increase frequency when appetite improves
d. CPT should be performed more frequently, but at least an hour b4 meals
30. an ambulatory client with a saline lock wants to take a shower. Which action should the nurse take?
a. protect the iv site with a gauze dressing
b. advise the client to take a sponge bath
c. remove the saline lock while the client showers
d. tape a plastic bag over the iv site
31. A 15-years old male client is currently diagnosed with type 1 diabetes mellitus. He tells the nurse that he is having difficulty adhering to his meal plan when he is with his friends. What nursing intervention is best for the nurse to implement ?
A Recommend that he avoid fast food restaurant until he is familiar with his prescribed diet B Assist him in identifying popular fast foods that are within his meal plan for diabetes
C encourage him to find activities to do with his friends that do not involve eating
D advise him to take his own food with him when going to fast food restaurant with his friend
32. When the parents of a 6 years old boy with a brain tumor are told that his condition is terminal . The mother shouted at the father . This is all your fault. It never would have happened if we had sought treatment earlier. Which intervention is best for the nurse to implement?
A. Assure the parents that a terminal diagnosis was inevitable.
B. reference the parent to the chaplain to provide grief counseling
C. explain to the parents that anger is a common response to grief
D. tell the parents blaming each other will not change the situation
33. In preparing a diabetes education program which goal should the nurse identify as the primary emphasis for a class on diabetes self- management?
A. reduce healthcare costs related to diabetes complications.
B. enable client to become active participants in controlling the disease process
C. prepare clients to independently treat their disease process.
D increase clients knowledge of the diabetes disease process and treatment option
34. A client received a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, what action should the nurse implement?
A. obtain a specimen from culture and Sensitivity analysis.
B. assess for fatty yellow streaks in client stool
C. Observe the stool for a clay colored appearance.
;D send a stool sample to the lab for a guaiac test
35 While making rounds, the charge nurse notices a young adult asthma who was admitted yesterday is on the side of the bed and leaning over receiving oxygen at 2
via nasal cannula. The client is wheezing and is using pursed- breathing. Which intervention should the nurse implement?
A. increase oxygen to 6 liters/ minute
B. assist the client to lie back in bed
C. administer a nebulizer treatment
D. call for an ambu resuscitation
37. After placement of a left subclavian central venous catheter (CVC), the nurse receives a report of the X-ray findings that indicate the CVC tip is the client's superior vena cava. Which action should the nurse implement?
A. secure the catheter using aseptic technique
B. remove the catheter and apply direct pressure for 5 minutes
C. initiate intravenous fluids as prescribed.
D. notify the healthcare provider of the need to reposition the catheter
38The nurse is assessing a 4-year-old child with eczema.The child's skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child?
А Bathe the child daily with bath oil.
B. Allow the child to wear only 100 % cotton clothing
C. Apply baby lotion to the skin twice daily
D. Keep the nails trimmed short .
39. The headcare provider changes the client medication prescription from IV To PO Administration and doubles the dose. The nurse Notes in the drug guide that the prescription medication, when given orally , has a high fast pass effect and reduces bio-availability . What action should the nurse implement?
A. continue to administer the medication VIA the IV route
B. give half the prescribed oral dose until the provider is consulted
C. administer the medication via the oral route as prescribed
D. consult with the pharmacist regarding the error in prescription
40. The home care nurse provided self care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instruction should the nurse include in the client's discharge teaching plan? (Select all that apply)
А. Continue wearing compression stockings
B. Maintain the bed flat while sleeping
C. Use recliner for long periods of sitting
D. Cross legs at knee but not at ankle
E. Avoid prolonged standing or sitting
41. A mother brings her child who has a history of asthma to the emergency room. The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic , and has labored respirations. Which assessment is most important for the nurse to obtain?
A. Type of inhaler the child typically uses on a regular basis
B. Frequency that the child uses a rescue inhaler during the week
C. Type allergen exposure or trigger for the current episode
D. Last dose and the type of rescue inhaler used by the child
42. A client with acute renal injury (AKI) has been taking hemodialysis treatments at home. Which laboratory value indicates to the nurse that the hemodialysis treatment is effective?
А. Decreasing creatinine
B. Lowered hemoglobin . C.Elevating potassium
D. Decreased calcium
43. Which conditions are most likely to respond to treatment with antihistamines? ( select all that apply)
A. allergic rhinitis
B. contact dermatitis
C. otitis
D. myocarditis
E. bronchitis
44. The nurse identifies an electrolyte imbalance, an elevated pulse rate, and an elevated blood pressure for a client with chronic kidney disease. Which is the most important for the nurse to take?
A. record usual eating patterns
B. monitor daily sodium intake
C. measure ankle circumference
D. auscultate for irregular heart rate
45. A client with chronic renal insufficiency is preparing for discharge from the hospital. which information for the nurse to include in this client `s discharge teaching?
A. use a topical applications to manage pruritus strategies to promote independent selfcare
B. instructions regarding a restricted protein diet
C. need for maintaining good oral hygiene
46: The nurse is preparing a client with an acoustic neuroma for an MRI: Which client complains is life threatening and should be reported to the healthcare provider immediately?
A: intensifying headache B: right ear hearing loss C: difficulty with balance
D: Facial numbness
47: A client with hemorrhoids asks for information about a high fiber diet? Which should the nurse suggest> Select all that apply
A: Bowl of oatmeal B Bacon slice
C: cup of raspberries D: scrambled eggs E: Raisin bran muffin
48: The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement?
A: Prepare client for spinal anesthesia
B: prepare the coach to accompany the client to delivery C: empty the client bladder using a straight catheter
D: Convey to the client that birth is imminent
49: A 3 year old boy with a congenital heart defect is brought to the clinic by his
mother because he has a fever and an earache. During the assessment the moter ask why her child is at the 5th percentile for weight and height
A: Does you child seem mentally slower than his peers also B: His smaller size is probably due to the heart disease
C: You should not worry about the growth table. They are only average for children D: Haven't you been feeding him according to the recommended daily allowance for children?
50: While caring for a client who is being mechanically ventilated the nurse responds to a high pressure alarm on the ventilator. Which assessment finding warrants immediate intervention?
A: Endotracheal cuff pressure greater than 25 cm H2O B: Decreased lung compliance during ventilation
C: restless client who is biting the endotracheal tube D: Bilateral crackles with increased secretion [Show Less]