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Med Surg Final HESI
Study materials for Med Surg 3 Final HESI
Course
Med-Surg III (NSG 233)
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Herzing University
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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 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
B. Observe the color, consistency, and amount of sputum
A client is brought to the ED by ambulance in cardiac arrest with
cardiopulmonary resuscitation (CPR) in progress. The client is
intubated and is receiving 100% oxygen per self-inflating (ambu)
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 pulsation during compressions
C. Deep tendon reflexes
D. Core body temperature
A. Breath sounds over bilateral lung fields.
After a hospitalization for Syndrome of Inappropriate Antidiuretic
Hormone (SIADH), a client develops pontine myselinolysis. Which
intervention should the nurse implement first?
A. Reorient client to his room
B. Place a patch on one eye
C. Evaluate client's ability to swallow
D. Perform range of motion exercises
A. Reorient client to his room
A male client with heart failure (HF) calls the clinic and reports
that he cannot put his shoes on because they are too tight. Which
additional information should the nurse obtain?
A. What time did he take his last medications?
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?
B. Has his weight changed in the last several days?
An older adult woman with a long history of chronic obstructive
pulmonary disease (COPD) is admitted with progressive short-
ness of breath and a persistent cough. She is anxious and is
complaining of a dry mouth. Which intervention should the nurse
implement?
A. Administer a prescribed sedative
B. Encourage client to drink water
C. Apply a high-flow venturi mask
D. Assist her to an upright position
D. Assist her to an upright position
A client with a history of asthma and bronchitis arrives at the clinic
with shortness of breath, productive cough with thickened tena-
cious mucous, 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 mediations occur
D. Teach anxiety reduction methods for feelings of suffocation
A. Increase the daily intake of oral fluids to liquefy secretions
A cardiac catherterization of a client with heart disease indicates
the following blockages: 95% proximal left anterior descending
(LAD), 99% proximal circumflex, and? % proximal right coronary
artery (RCA). The client later asks the nurse "what does all this
mean for me?" What information should the nurse provide?
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A. Blood supply to the heart is diminished by artherosclerotic
lesions, which necessitate lifestyle changes.
B. Blood vessels supplying the pumping chamber have blockages
indicating a past heart attack.
C. Three main arteries have major blockages, with only 1 to 5% of
blood flow getting through to the heart muscle.
D. The heart is not receiving enough blood, so there is a risk of
heart failure and fluid retention.
C. Three main arteries have major blockages, with only 1 to 5% of
blood flow getting through to the heart muscle.
A client who weighs 175 pounds is receiving IV bolus dose of
heparin 80 units/kg. The heparin is available in a 2 ml vial, labeled
10,000 units/ml. How many ml should the nurse administer? (En-
ter numeric value only. If rounding is required, round to the nearest
tenth.)
0 ml
What information should the nurse include in the teaching plan of
a client diagnosed with gastroesophageal reflux disease (GERD)?
A. Sleep without pillows at night to maintain neck alignment.
B. Adjust food intake to three full meals per day and no snacks.
C. Minimize symptoms by wearing loose, comfortable clothing
D. Avoid participation in any aerobic exercise programs
C. Minimize symptoms by wearing loose, comfortable clothing
The nurse is caring for a client with a lower left lobe pulmonary
abscess. Which position should the nurse instruct the client to
maintain?
A. left lateral
B. Supine, knees flexed
C. Dorsal recumbent
D. Knee-chest
A. left lateral
A client with cholelithiasis has a gallstone lodged in the common
bile duct and is unable to eat or drink without becoming nause-
ated and vomiting. Which finding should the nurse report to the
healthcare provider.
A. Belching
B. Amber urine
C. Yellow sclera
D. Flatulence
C. Yellow sclera
While caring for a client with Amyotrophic Lateral Sclerosis (ALS),
the nurse performs a neurological assessment every four hours.
Which assessment finding warrants immediate intervention by the
nurse?
A. Inappropriate laughter
B. Increasing anxiety
C. Weakened cough effort
D. Asymmetrical weakness
C. Weakened cough effort
The nurse is providing preoperative education for a Jewish client
scheduled to receive a xenograft graft to promote burn healing.
Which information should the nurse provide this client?
A. Grafting increases the risk for bacterial infections
B. The xenograft is taken from nonhuman sources
C. Grafts are later removed by a debriding procedure
D. As the burn heals, the graft permanently attaches
B. The xenograft is taken from nonhuman sources
A male client who had colon surgery 3 days ago is anxious and
requesting assistance to reposition. While the nurse is turning
him, the wound dehiscences and eviscerates. The nurse moistens
an available sterile dressing and places it over the wound. What
intervention should the nurse implement next?
B. Prepare the client to return to the operating room
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sible
D. Continue to monitor the fingers until color returns to normal
A male client with muscular dystrophy fell in his home and is
admitted with a right hip fracture. His right foot is cool, with pal-
pable pedal pulses. Lungs are coarse with diminished bibasilar
breath sounds. Vital signs are temperature 101F, 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
D. Administer PRN oral antipyretic
The nurse is completing the preoperative assessment of a client
who is scheduled for a laparoscopic cholecystectomy under gen-
eral anesthesia. Which finding warrants notification of the health-
care provider prior to proceeding with the scheduled procedure?
A. Light yellow coloring of the client's skin and eyes
B. The client's blood pressure reading is 184/88 mm Hg.
C. The client vomits 20 ml of clear yellowish fluid
D. The IV insertion site is red, swollen, and leaking IV fluid
B. The client's blood pressure reading is 184/88 mm Hg
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
D. Further decline in level of consciousness
Following surgical repair of the bladder, a female client is being
discharged from the hospital to 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 if free of kinks
B. Cleanse the perineal area with soap and water twice daily
C. Keep the drainage bag lower than the level of the bladder
D. Drink 1,000 ml of fluids daily to irrigate catheter
C. Keep the drainage bag lower than the level of the bladder
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
B. A 65 year-old fair-skinned male who is a construction worker
When caring for a client with nephrotic syndrome, which assess-
ment is most important for the nurse to obtain?
A. Daily weight
B. Vital signs
C. Level of consciousness
D. Bowel sounds
A. Daily weight
A female client who was involved in a motor vehicle collision is
admitted with a fractured left femur which is immobilized using a
fracture traction splint in preparation for an open reduction internal
fixation (ORIF). The nurse determines that her distal pulses are
diminished in the left foot. Which interventions should the nurse
implement? (Select all that apply.)
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A. Offer ice chips and oral clear liquids
B. Verify pedal pulses using a doppler pulse device
C. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure
D. Evaluate the application of the splint to the left leg
E. Administer oral antispasmodics and narcotic analgesics
B. Verify pedal pulses using a doppler pulse device
C. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure
D. Evaluate the application of the splint to the left leg
A male client with Herpes zoster (shingles) on his thorax tells the
nurse that he is having difficulty sleeping. What is the probable
etiology of this problem?
A. Pain
B. Nocturia
C. Dyspnea
D. Frequent cough
A. Pain
When planning care for a client newly diagnosed with open angle
glaucoma, the nurse identifies a priority nursing diagnosis of,
"visual sensory/perceptual alterations." This diagnosis is based
on which etiology?
A. Limited eye movement
B. Decreased peripheral vision
C. Blurred distance vision
D. Photosensitivity
B. Decreased peripheral vision
A client who is newly diagnosed with emphysema is being pre-
pared for discharge. Which instruction is best for the nurse to
provide the client to assist them with dyspnea self-management?
A. Allow additional time to complete physical activities to reduce
oxygen demand
B. Practice inhaling through the nose and exhaling slowly through
pursed lips
C. Use a humidifier to increase home air quality humidity between
30-50%
D. Strengthen abdominal muscles by alternating leg raises during
exhalation
B. Practice inhaling through the nose and exhaling slowly through
pursed lips
A client with cancer is receiving chemotherapy with a known
vesicant. The client's IV has been in place for 72 hours. The nurse
determines that a new IV site cannot be obtained, and leaves the
present IV in place. What is the greatest clinical risk related to this
situation?
A. Impaired skin integrity
B. Fluid volume excess
C. Acute pain and anxiety
D. Peripheral neurovascular dysfunction
A. Impaired skin integrity
A postoperative client reports incisional pain. The client has two
prescriptions for PRN analgesia that accompanied the client from
the postanasthesia unit. Before selecting which medication to
administer, which action should the nurse implement?
A. Document the client's report of pain in the electronic medical
record
B. Determine which prescription will have the quickest onset of
action
C. Compare the client's pain scale rating with the prescribed
dosing
D. Ask the client to choose which mediation is needed for pain
C. Compare the client's pain scale rating with the prescribed
dosing
While assisting a female client to the toilet, the client begins to
have a seizure and the nurse eases her to the floor. The nurse
calls for help and monitors the client until the seizing stops. Which
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A client with acquired immunodeficiency syndrome (AIDS) has
impaired gas exchange from a respiratory infection. Which as-
sessment finding warrants immediate intervention by the nurse?
A. Elevated temperature
B. Generalized weakness
C. Diminished lung sounds
D. Pain when swallowing
D. Pain when swallowing
An older male client tells the nurse that he is losing sleep because
he has to get up several times at night to go to the bathroom, that
he has trouble starting his urinary stream, and that he does not
feel like his bladder is ever completely empty. Which intervention
should the nurse implement?
A. Collect a urine specimen for culture analysis
B. Review the client's fluid intake prior to bedtime
C. Palpate the bladder above the symphysis pubis
D. Obtain a fingerstick blood glucose level
C. Palpate the bladder above the symphysis pubis
Fluids are restricted to 1,500 ml daily for a male client with acute
kidney injury (AKI). He is frustrated and complaining of constant
thirst, and the nurse discovers that the family is providing the
client with additional fluids. Which intervention should the nurse
implement?
A. Remove all sources of liquids from the client's room
B. Allow family to give client a measured amount of ice chips
C. Restrict family visiting until the client's condition is stable
D. Provide the client with oral swabs to moisten his mouth
D. Provide the client with oral swabs to moisten his mouth
During a paracentesis, two liters of fluid are removed from the
abdomen of a client with ascites. A drainage bag is placed, and
50 ml of clear, straw-colored fluid drains within the first hour. What
action should the nurse implement?
A. Palpate for abdominal distention
B. Send fluid to the lab for analysis
C. Continue to monitor the fluid output
D. Clamp the drainage tube for 5 minutes
C. Continue to monitor the fluid output
While assessing a client with degenerative joint disease, the nurse
observes Heberden's nodes, large prominences on the client's
fingers that are reddened. The client reports that the nodes are
painful. Which action should the nurse take?
A. Review the client's dietary intake of high-protein foods
B. Notify the healthcare provider of the finding immediately
C. Discuss approaches to the chronic pain control with the client
D. Assess the client's radial pulses and capillary refill time
C. Discuss approaches to the chronic pain control with the client
A client who took a camping vacation two weeks ago in a coun-
ty with a tropical climate comes to the clinic describing vague
symptoms and diarrhea for the past week. Which finding is most
important for the nurse report to the healthcare provider?
A. Weakness and fatigue
B. Intestinal cramping
C. Weight loss
D. Jaundiced sclera
D. Jaundiced sclera
Ten hours following thrombolysis for an ST elevation myocardial
infarction (STEMI), a client is receiving a lidocaine infusion for iso-
lated runs of ventricular tachycardia (VT). Which finding should the
nurse document in the electronic medical record as a therapeutic
response to the lidocaine infusion?
D. Decreased frequency of episodes of VT
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A. Stabilization of blood pressure ranges
B. Cessation of chest pain
C. Reduce heart rate
D. Decreased frequency of episodes of VT
After a computer tomography (CT) scan with intravenous contrast
medium, a client returns to the room complaining of shortness
of breath and itching. Which intervention should the nurse imple-
ment?
A. Call respiratory therapy to give a breathing treatment
B. Send another nurse for an emergency tracheotomy set
C. Prepare a dose of epinephrine (Adrenalin)
D. Review the client's complete list of allergies
C. Prepare a dose of epinephrine (Adrenalin)
The nurse reports that a client is at risk for a brain attack (stroke)
based on which assessment finding?
A. Nuchal rigidity
B. Carotid bruit
C. Jugular vein distention
D. Palpable cervical lymph node
B. Carotid bruit
The nurse is preparing to administer enoxaparin (Lovenox) 135
mg subcutaneously. The medication is available in a cartridge
labeled 150 mg/ml. How many ml should the nurse administer?
(enter numeric value only. If rounding is required, round to the
nearest tenth.)
0 ml
The nurse is obtaining a client's fingerstick glucose level. After
gently milking the client's finger, the nurse observes that the distal
tip of the finger appears reddened and engorged. What action
should the nurse take?
A. Collect the blood sample
B. Assess radial pulse volume
C. Apply pressure to the site
D. Select another finger
A. Collect the blood sample
A client admitted to a surgical unit is being evaluated for an
intestinal obstruction. The healthcare provider prescribes a naso-
gastric tube (NGT) to be inserted and placed to intermittent low
wall suction. Which intervention should the nurse implement to
facilitate proper tube placement?
A. Soak nasogastric tube in warm water
B. Insert tube with client's head tilted back
C. Apply suction while inserting tube
D. Elevate head of bed 60 to 90 degrees
D. Elevate head of bed 60 to 90 degrees
A young female client with seven children is having frequent morn-
ing headaches, dizziness, and blurred vision. Her blood pressure
(BP) is 168/104 mmHg. The client reports that her husband re-
cently lost his job and she is not sleeping well. After administering
a STAT dose of an antihypertensive IV medication, which inter-
vention is most important for the nurse to implement?
A. Measure urine output hourly to assess for rental perfusion
B. Request a prescription for pain medication
C. Use an automated BP machine to monitor for hypotension
D. Provide a quiet environment with low lighting
C. Use an automated BP machine to monitor for hypotension
The wife of a client with Parkinson's disease expresses concern
because her husband has lost so much weight. Which teaching is
best for the nurse to provide?
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B. Encourage deep breathing and coughing exercises
C. Provide an eye shield to be worn while sleeping
D. Obtain vital signs every 2 hours during hospitalization
A client with Guillain-Barre syndrome has paralysis of all extremi-
ties and requires mechanical ventilation. The nurse observes that
the client is not blinking. Which action should the nurse
implement?
Protect cornea with lubricant and eye shields
An older adult man recently diagnosed with chronic obstructive
pulmonary disease (COPD) is admitted with shortness of breath.
The nurse observes the client sitting upright and leaning over the
bedside table, using accessory muscles to assist in breathing.
What action should the nurse take?
A. Assist the lien tot a high Fowler's position in bed
B. Observe the client for the presence of a barrel chest
C. Prepare to transfer the client to a critical care unit
D. Instruct the client to pursed lip breathing techniques
D. Instruct the client in pursed lip breathing techniques
A client with multiple sclerosis has urinary retention related to
sensorimotor deficits. Which action should the nurse include in the
client's plan of care?
Teach the client techniques for performing intermittent catheteri-
zation
When providing care for a client following bronchoscopy, which
assessment finding should he nurse immediately report to the
healthcare provider?
A. Slight blood-tinged sputum
B. Dyspnea and dysphagia
C. Sore throat and hoarseness
D. No gag reflex after thirty minutes
D. No gag reflex after thirty minutes
The nurse is assessing clients in an outpatient diabetic clinic.
Which entry provides the best medication that the client is adher-
ing to the prescribed diabetic regimen?
Hemoglobin A1C of 6%
A male client in skeletal traction tells the nurse that he is frustrated
because he needs help repositioning himself in bed. Which inter-
vention should the nurse implement?
Provide an overhead trapeze to the bed for the client to use
An older client is admitted after falling while walking. The left leg is
externally rotated and shorter than the right leg, and the client is
having severe pain and tingling in the left foot. The nurse is unable
to palpate the left pedal pulses. Which action is most important for
the nurse to implement?
Use a doppler to assess bilateral pedal pulses
A client who had a biliopancreatic diversion procedure (BDP) 3
months ago is admitted with a severe dehydration. Which assess-
ment finding warrants immediate intervention by the nurse.
A. Strong foul-smelling flatus
B. Gastroccult positive emesis
C. Complaint of poor night vision
D. Loose bowel movements
B. Gastroccult positive emesis
A female client who was involved in a motor vehicle collision with a
fractured left femur which is immobilized using a fracture traction
splint in preparation for an open reduction internal fixation (ORIF).
The nurse determines that her distal pulses are diminished in the
left foot. Which interventions should the nurse implement? Select
all that apply
Monitor left leg for pain, pallor, paresthesia, paralysis, pressure.
Verify pedal pulses using a doppler pulse device. Evaluate the
application of the splint to the left leg
A client returns to the unit following a suprapubic prostatectomy.
He has a three-way catheter in place with a continuous bladder
irrigation infusing. Which assessment finding warrants
immediate intervention by the nurse?
A. True urinary output of 50ml/hr
D. Urine leaking around the meatus
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B. Lower abdominal tenderness
C. Blood urine output with clots
D. Urine leaking around the meatus
A client tells the nurse that her biopsy results indicate that the
cancer cells are
well-differentiated. How should the nurse respond?
Ask the client if the healthcare provider has given her any infor-
mation about the classification of her cancer
The nurse is assessing a client who has tinea pedis. Which ques-
tion will allow the nurse to gather further information about this
condition?
Do you see any improvement when using tolnaftate?
A male client who had abdominal surgery 5 days ago, and hospi-
talized because of a surgical wound infection, tells the nurse that
he feels like his insides just spilled out when he coughed. What
action should the nurse take first?
A. Notify the healthcare provider
B. Assure the client that such feelings occur with wound infections
C. Visualize the abdominal incision
D. Obtain sterile towels soaked in saline
C. Visualize the abdominal incision
A male client with pernicious anemia takes supplemental folate
and self-administers monthly Vitamin B12 injections. He reports
feeling increasingly fatigued. Which laboratory value should the
nurse review?
Complete blood count
A male client is recovering from an episode of urinary tract cal-
culi. During discharge teaching, the client asks about the dietary
restriction he should follow. In discussing fluid intake, the nurse
should include which type of fluid limitation
A. Low-sodium soups.
B. Over all fluid intake
C. Tea and hot chocolate
D. Citrus fruit juices
C. Tea and hot chocolate
A male client complains of pain in his right calf, and the nurse
determines that his calf is edematous and deep red. What inter-
vention has the highest priority?
Tell the client to remain in bed
An older woman who experienced a cerebrovascular accident
(CVA) has difficulty with visual perception and she only eats half
of the food on her meal tray. Her family expresses concern about
her nutritional status. How should the nurse respond to the family's
concern?
A. Encourage the family to offer to feed the client when she does
not eat her entire meal.
B. Suggest that the family bring foods from home that the client
enjoys
C. Explain that weight loss will be reversed after the acute phase
of the stroke has ended.
D. Demonstrate the use of visual scanning during meals to the
client and family.
D. Demonstrate the use of visual scanning during meals to the
client and family
A client with stage IV bone cancer is admitted to the hospital for
pain control. The client verbalizes continuous, severe pain of 8 on
a 1 to 10 scale. Which intervention should the nurse implement?
Administer opioid and non-opioid medication simultaneously
A female client who received partial-thickness and full-thickness
burns over 40% of her body in a house fire is admitted to the
inpatient burn unit. What fluid should the nurse prepare to
administer during the acute phase of the client's burn recovery?
Ringer's Lactate
A client uses triamcinolone (Kenalog), a corticosteroid ointment,
to manage pruritus caused by a chronic skin rash. The client
calls the clinic nurse to report increased erythema with purulent
exudate at the site. Which action should the nurse implement?
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include? (select all that apply)
A. Monitor dryness of mucous membranes
B. Check for changes in mentation
C. Observe color of skin and nailbeds
D. Note appearance of jugular veins
E. Assess breathing patterns
B. Check for changes in mentation.
C. Observe color of skin and mucous.
E. Assess breathing patterns
An adult client is admitted with flank pain and is diagnosed with
acute pyelonephritis. What is the priority nursing action?
A. Auscultate for presence of bowl sounds.
B. Monitor hemoglobin and hematocrit
C. Encourage turning and deep breathing
D. Administer IV antibiotics as prescribed.
D. Administer IV antibiotics as prescribed
A client's telemetry monitor indicates ventricular fibrillation (VF).
After delivering one counter shock, the nurse resumes chest
compression. After another minute of compressions, the client's
rhythm converts to supraventricular tachycardia (SVT) on the
monitor. At this point, what is the priority intervention for the nurse?
A. Prepare for transcutaneous pacing
B. Deliver another defibrillator shock
C. Administer IV Epinephrine per ACLS protocol
D. Give IV dose of adenosine rapidly over 1-2 seconds.
D. Give IV dose of adenosine rapidly over 1-2 seconds
Two days following abdominal surgery a client begins to report
camping abdominal pain, and the nurse's inspection the abdomen
indicates slight distention. Which action should the nurse imple-
ment first?
A. Encourage the client to ambulate
B. Offer ice ships or warm liquids
C. Auscultate the client's abdomen
D. Assess the client's temperature
C. Auscultate the client's abdomen
A client with a liver abscess undergoes surgical evacuation and
drainage of the abscess. Which laboratory value is most important
for the nurse to monitor following the procedure?
A. Serum creatinine
B. Blood urea nitrogen (BUN)
C. White blood cell count
D. Serum glucose
C. White blood cell count
A client with draining skin lesions of the lower extremity is admitted
with possible
Methicillin-Resistant Staphylococcus Aureus (MRSA). Which
nursing interventions should the nurse include in the plan on care?
(Select all that apply.)
Institute contact precautions for staff and visitors.
Send wound drainage for culture and sensitivity.
Monitor the client's white blood cell count.
During preoperative teaching for a male client schedule for repair
of an inguinal hernia, the client tells the nurse that he has had
several surgeries and understand the need to perform coughing
and deep breathing exercise after surgery. How should the nurse
respond?
A. Ask for a demonstration of these exercises
B. Explain that coughing should be avoided
C. Review the client previous surgical history
D. Document the clients understanding of teaching
A. Ask for a demonstration of these exercises
An older adult with heart failure is hospitalized during an acute ex-
acerbation. To reduce cardiac workload, which intervention should
the nurse include in the client's plan of care?
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A. Assist with ambulation in the hallway
B. Encourage active range of motion exercises
C. Provide a bedside commode for toileting
D. Teach to sleep in a slide-laying position
C. Provide a bedside commode for toileting
Which instruction should the nurse include in the discharge teach-
ing for a client who has gastroesophageal reflux?
A. Teach the client to elevate the head of the bed on blocks
B. Remind the client to avoid high-fiber foods
C. Encourage the client to lie down and rest after meals.
D. Instruct the client to use antacids only as a last resort
A. Teach the client to elevate the head of the bed on blocks
A client with pheochromocytoma reports the onset of a severe
headache. The nurse observes that the client is very diaphoretic.
Which assessment data should the nurse obtain next?
Blood pressure
The healthcare provider prescribes epoetin alfa (Procrit) 8,
units subcutaneously for a client with chronic kidney disease
(CKD). The 2 ml multidose vial is labeled, "Each 1 ml of solution
contains 10,000 units of epoetin alfa." How many ml should the
nurse administer?
0.
A nurse assists a male client with Parkinson's disease (PD) to
ambulate in the hallway. The client appears to "freeze" and then
carefully lifts one leg and steps forward. He tells the nurse that
he is pretending to step over a crack on the floor. How should the
nurse respond?
A. Re-orient the client to his present location and circumstances
B. Confirm that this is an effective technique to help with ambula-
tion
C. Assist the client to a carpeted area where he can walk more
easily.
D. Plan to assess the client's cognition after returning to his room.
B. Confirm that this is an effective technique to help with ambula-
tion
Which food is most important for the nurse to encourage a male
client with osteomalacia to include in his daily diet?
Fortified milk and cereals
A client with ulcerative colitis is admitted to the medical unit during
an acute exacerbation. The nurse should instruct the unlicensed
assistive personnel (UAP) to report which finding related to the
client's bowel movements?
A. Hard pellets of stool
B. Clay-colored stool
C. Stool with fatty streaks
D. Blood in the stool
C. Stool with fatty streaks
The healthcare provider prescribes an IV solution of regular in-
sulin (Hummulin-R) 100 units in 250 ml of 0% saline to infuse
at 12 units/hour. The nurse should program the infusion pump to
deliver how many ml/hour?
30
A client with chronic kidney disease (CDK) arrives at the clinic
reporting shortness of breath on exertion and extreme weakness.
Vital signs are temperature 100 F (38 C), heart rate 110
beats/minute, respirations 28 breaths/minute, and blood pressure
175/98 mmHg. The client usually receives dialysis three times a
week but missed the last treatment. STAT blood specimens are
sent to the laboratory for analysis. Which laboratory results should
the nurse report to the healthcare provider immediately?
Potassium 6 mEq/L (mmol/L)
A client with unstable asthma had an emergent cardiac catheter-
ization. Which complication should the nurse monitor for in the
initial 24 hours after the procedure?
Thrombus formation
A male client with a history of asthma reports having episodes of
bronchoconstriction and
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An adult male client is admitted for Pneumocystis carinal pneu-
monia (PCP) secondary to AIDSs. While hospitalized, he receives
IV pentamidine isethionate therapy. In preparing this client for dis-
charge, what important aspect regarding his medication therapy
should the nurse explain?
A. IV pentamidine may offer protection to other AIDS-related
conditions, such as Kaposi's sarcoma
B. It will be necessary to continue prophylactic doses of IV or
aerosol pentamidine every month
C. IV pentamidine will be given until oral pentamidine can be
tolerated
D. AZT (Azidothymidine) therapy must be stopped when IV or
aerosol pentamidine is being used.
B. It will be necessary to continue prophylactic doses of IV or
aerosol pentamidine every month
A male client with bilateral carpal tunnel syndrome reports to the
nurse that the pain and tingling he is experiencing worsens at
night. What client teaching should the nurse provide?
A. Elevate the hands on two pillows at night
B. Notify the healthcare provider as soon as possible
C. Wear braces as both writs during the night
D. Apply cold compresses for 30 min before bedtime
C. Wear braces as both writs during the night
An adult female client is diagnosed with restless leg syndrome and
is referred to the sleep clinic. The healthcare provider prescribes
ferrous sulfate (Feosol) 325 mg PO daily. Which laboratory values
should the nurse monitor?
A. Serum electrolytes
B. Neutrophils and eosinophils
C. Serum iron and ferritin
D. Platelet count and hematocrit
C. Serum iron and ferritin
The nurse is evaluating a male client understanding of diet teach-
ing about the DASH (Dietary Approaches to Stop Hypertension)
eating plan. Which behavior indicates that the client is adhering to
the eating plan?
A. Uses only lactose-free dairy products.
B. Enjoys fat free yogurt as an occasional snack food
C. No longer includes grains in his daily diet
D. Carefully cleans and peels all fresh fruit and vegetables
D. Carefully cleans and peels all fresh fruit and vegetables
An adult client is admitted with diabetic ketoacidosis (DKA) and a
urinary tract infection (UTI). Prescriptions for intravenous antibi-
otics and an insulin infusion are initiated. Which serum laboratory
value warrants the most immediate intervention by the nurse?
A. Glucose of 350 mg/dl
B. White blood cell count of 15, 000 mm
C. Blood PH of 7.
D. Potassium of 2 mEq/L
D. Potassium of 2 mEq/L
A client with acute renal injury (AKI) who weighs 50 kg and has
potassium level of 6 mEq/L (6 mmol/l) is admitted to the hospi-
tal. Which prescribed medication should the nurse administer first
A. Sevelamer (RenaGel) one tablet PO.
B. Epoetin alfa, recombinant (Epogen) 2, 500 units SUBQ
C. Sodium polystyrene (Kayexalate) 15 grams PO
D. Calcium acetate (Phos-Lo) one tablet PO
C. Sodium polystyrene (Kayexalate) 15 grams PO
Two days after a nephrectomy, the client reports abdominal pres-
sure and nausea, which assessment should the nurse implement?
Study online at quizlet/_8koqi
A. Palpate the abdomen
B. Measure hourly urine output
C. Ambulate client in hallway
D. Auscultate bowels sounds.
D. Auscultate bowels sounds.
An older female client with long term type 2 diabetes mellitus (DM)
is seen in the clinic for a routine health assessment. To determine if
the client is experiencing any long-term complication 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. Visual acuity
E Signs of respiratory tract infection
A. Serum creatinine and blood urea nitrogen (BUN)
B. Sensation in feet and legs
C. Skin condition of lower extremities
D. Visual acuity
A hospitalized client with chemotherapy-induced stomatitis com-
plains of mouth pain. What is the best initial nursing action?
A. Encourage frequent mouth care
B. Cleanse the tongue and mouth with glycerin swabs
C. Obtain a soft diet for the client
D. Administer a topical analgesic per PRN protocol.
D. Administer a topical analgesic per PRN protocol.
The nurse is preparing a client for discharge who recently diag-
nosed with Addison's disease. Which instruction is most important
for the nurse to include in the client's discharge teaching plan?
A. Use a walker when weakness occurs
B. Avoid extreme environmental temperatures
C. Increase daily intake of sodium in diet
D. Take prescribed cortisone accurately
C. Increase daily intake of sodium in diet
To reduce the risk for pulmonary complication for a client with
Amyotrophic Lateral Sclerosis (ALS), what interventions should
the nurse implement? (Select all that apply)
A. Initiate passive range of motion exercises
B. Establish a regular bladder routine
C. Teach the client breathing exercises
D. Perform chest physiotherapy
E. Encourage use of incentive spirometer
C. Teach the client breathing exercises
D. Perform chest physiotherapy
E. Encourage use of incentive spirometer
A male client who reports feeling chronically fatigued has a he-
moglobin of 11 grams/dl (110mmol/L), hematocrit of 34%, and
microcytic and hypochromic red blood cells (RBCs). Based on
these findings, which dinner selection should the nurse suggest
to the client?
A. Cheese pasta and a lettuce and tomato salad
B. Beef steak with steamed broccoli and orange slices
C. Broiled white fish with a baked sweet potato
D. Grilled shrimp and season rice with asparagus salad
B. Beef steak with steamed broccoli and orange slices
A client who suffered an electrical injury with the entrance site on
the left hand and the exit site on the left foot is admitted to the burn
unit. Which intervention is most important for the nurse to include
in this client plan of care?
A. Continuous cardiac monitoring
B. Perform passive range of motion
C. Evaluate level of consciousness
D. Assess lung sounds q4 hours.
A. Continuous cardiac monitoring
An adult female with multiple sclerosis (MS) fells while walking to
the bathroom. On transfer to the intensive care unit, she is con-
fused and has had projectile vomiting twice. Which intervention
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Med Surg Final HESI
Course: Med-Surg III (NSG 233)
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Med Surg Final HESI
Study online at https://quizlet.com/_8koqi6
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 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
B. Observe the color, consistency, and amount of sputum
A client is brought to the ED by ambulance in cardiac arrest with
cardiopulmonary resuscitation (CPR) in progress. The client is
intubated and is receiving 100% oxygen per self-inflating (ambu)
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 pulsation during compressions
C. Deep tendon reflexes
D. Core body temperature
A. Breath sounds over bilateral lung fields.
After a hospitalization for Syndrome of Inappropriate Antidiuretic
Hormone (SIADH), a client develops pontine myselinolysis. Which
intervention should the nurse implement first?
A. Reorient client to his room
B. Place a patch on one eye
C. Evaluate client's ability to swallow
D. Perform range of motion exercises
A. Reorient client to his room
A male client with heart failure (HF) calls the clinic and reports
that he cannot put his shoes on because they are too tight. Which
additional information should the nurse obtain?
A. What time did he take his last medications?
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?
B. Has his weight changed in the last several days?
An older adult woman with a long history of chronic obstructive
pulmonary disease (COPD) is admitted with progressive short-
ness of breath and a persistent cough. She is anxious and is
complaining of a dry mouth. Which intervention should the nurse
implement?
A. Administer a prescribed sedative
B. Encourage client to drink water
C. Apply a high-flow venturi mask
D. Assist her to an upright position
D. Assist her to an upright position
A client with a history of asthma and bronchitis arrives at the clinic
with shortness of breath, productive cough with thickened tena-
cious mucous, 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 mediations occur
D. Teach anxiety reduction methods for feelings of suffocation
A. Increase the daily intake of oral fluids to liquefy secretions
A cardiac catherterization of a client with heart disease indicates
the following blockages: 95% proximal left anterior descending
(LAD), 99% proximal circumflex, and ? % proximal right coronary
artery (RCA). The client later asks the nurse "what does all this
mean for me?" What information should the nurse provide?
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