HESI Med Surg Version 1| Questions and
Verified Answers| 100% Correct| 2023/ 2024
Update
Q: Which reaction should the nurse identify in a client who is responding to stimulation of the
sympathetic nervous system?
A) Pupil constriction.
B) Increased heart rate.
C) Bronchial constriction.
D) Decreased blood pressure.
Answer:
B) Increased heart rate.
Any stressor that is perceived as threatening to homeostasis acts to stimulate the sympathetic
nervous system and manifests as a flight-or-fight response, which includes an increase in heart
rate (B). (A, C, and D) are responses of the parasympathetic nervous system.
Q: A client receiving cholestyramine (Questran) for hyperlipidemia should be evaluated for
what vitamin deficiency?
A) K.
B) B12.
C) B6.
D) C.
Answer:
A) K.
Clients should be monitored for an increased prothrombin time and prolonged bleeding times
which would alert the nurse to a vitamin K deficiency (A). These drugs reduce absorption of the
fat soluble (lipid) vitamins A, D, E, and K. (B, C, and D) are not fat soluble vitamins.
Q: A client experiencing uncontrolled atrial fibrillation is admitted to the telemetry unit. What
initial medication should the nurse anticipate administering to the client?
A) Xylocaine (Lidocaine).
B) Procainamide (Pronestyl).
C) Phenytoin (Dilantin).
D) Digoxin (Lanoxin).
Answer:
D) Digoxin (Lanoxin).
Digoxin (Lanoxin) (D) is administered for uncontrolled, symptomatic atrial fibrillation resulting
in a decreased cardiac output. Digoxin slows the rate of conduction by prolonging the refractory
period of the AV node, thus slowing the ventricular response, decreasing the heart rate, and
effecting cardiac output. (A, B, and C) are not indicated in the initial treatment of uncontrolled
atrial fibrillation.
Q: What instruction should the nurse give a client who is diagnosed with fibrocystic changes
of the breast?
A) Observe cyst size fluctuations as a sign of malignancy.
B) Use estrogen supplements to reduce breast discomfort.
C) Notify the healthcare provider if whitish nipple discharge occurs.
D) Perform a breast self-exam (BSE) procedure monthly.
Answer:
D) Perform a breast self-exam (BSE) procedure monthly.
Fibrocystic changes in the breast are related to excess fibrous tissue, proliferation of mammary
ducts and cyst formation that cause edema and nerve irritation. These changes obscure typical
diagnostic tests, such as mammography, due to an increased breast density. Women with
fibrocystic breasts should be instructed to carefully perform monthly BSE (D) and consider
changes in any previous “lumpiness.” Fibrocystic disease does not increase the risk of breast
cancer (A). Cyst size fluctuates with the menstrual cycle, and typically lessens after menopause,
and responds with a heightened sensitivity to circulating estrogen (B), which is not indicated.
Nipple discharge associated with fibrocystic breasts is often milky or watery-milky and is an
expected finding (C).
Q: The nurse is assessing a client’s laboratory values following administration of
chemotherapy. Which lab value leads the nurse to suspect that the client is experiencing tumor
lysis syndrome (TLS)?
A) Serum PTT of 10 seconds.
B) Serum calcium of 5 mg/dl.
C) Oxygen saturation of 90%.
D) Hemoglobin of 10 g/dl.