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HESI Med-Surg II Test Bank
- A nurse is reinforcing teaching with a client who has HIV and is being
discharged to home.Which of the following instructions should the nurse
include in the teaching?
A. Take temperature once a day.
B.Wash the armpits and genitals with a gentle cleanser daily.
C. Change the litter boxes while wearing gloves.
D.Wash dishes in warm water. ANS A. - A nurse is caring for a client who is postoperative following a tracheostomy,and has copious and tenacious secretions. Which of the following is an
acceptable method for the nurse to use to thin this client’s secretions?
A. Provide humidified oxygen.
B. Perform chest physiotherapy prior to suctioning.
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C. Prelubricate the suction catheter tip with sterile saline when suctioning theairway.
D. Hyperventilate the client with 100% oxygen before suctioning the airway..-ANS A.
- Following admission, a client with a vascular occlusion of the right lower
extremity calls the nurse and reports difficulty sleeping because of cold feet.Which of the following nursing actions should the nurse take to promote theclient’s comfort?
A. Rub the client’s feet briskly for several minutes.
B. Obtain a pair of slipper socks for the client.
C. Increase the client’s oral fluid intake.
D. Place a moist heating pad under the client’s feet. ANS B. - A nurse is caring for a client is who is 4 hr postoperative following a
transurethral resection of the prostate (TURP). Which of the following is the
priority finding for the nurse report to the provider?
A. Emesis of 100 mL
B. Oral temperature of 37.5° C (99.5° F)
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C.Thick, red-colored urine
D. Pain level of 4 on a 0 to 10 rating scale ANS C.
- A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) andhas a prescription for a hypothermia blanket. The nurse should monitor the
client for which of the following adverse effects of the hypothermia blanket?
A. Shivering
B. Infection
C. Burns
D. Hypervolemia ANS A.
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- A nurse is reinforcing teaching about exercise with a client who has type 1diabetes mellitus.Which of the following statements by the client indicates anunderstanding of the teaching?
A. “I will carry a complex carbohydrate snack with me when I exercise.”
B. “I should exercise first thing in the morning before eating breakfast.”
C. “I should avoid injecting insulin into my thigh if I am going to go running.”D. “I will not exercise if my urine is positive for ketones.” ANS D. - A nurse notes a small section of bowel protruding from the abdominal
incision of a client who
is postoperative. After calling for assistance, which of the following actions
should the nurse take first?
A. Cover the client’s wound with a moist, sterile dressing.
B. Have the client lie supine with knees flexed.
C. Check the client’s vital signs.
D. Inform the client about the need to return to surgery. ANS A. - A nurse is collecting data from a client who has alcohol use disorder and
is experiencing metabolic acidosis. Which of the following manifestations
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HESI Med Surg Test bank
- The nurse assesses a patient with shortness of breath for evidence of
long-standing hypoxemia by inspecting:
A. Chest excursion
B. Spinal curvatures
C.The respiratory pattern
D.The fingernail and its base: D. The fingernail and its base Clubbing, a sign of
long-standing hypoxemia, is evidenced by an increase in the angle between the
base of the nail and the fingernail to 180 degrees or more, usually accompanied byan increase in the depth, bulk, and sponginess of the end of the finger. - 2. The nurse is caring for a patient with COPD and pneumonia who has
an order for arterial blood gases to be drawn. Which of the following is
the minimum length of time the nurse should plan to hold pressure on the
puncture site?
A. 2 minutes
B. 5 minutes
C. 10 minutes
D. 15 minutes: B. 5 minutes Following obtaining an arterial blood gas, the nurse
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should hold pressure on the puncture site for 5 minutes by the clock to be sure thatbleeding has stopped. An artery is an elastic vessel under higher pressure than
veins, and significant blood loss or hematoma formation could occur if the time is
insufficient.
- 3. The nurse notices clear nasal drainage in a patient newly admitted with
facial trauma, including a nasal fracture. The nurse should:
A. test the drainage for the presence of glucose.
B. suction the nose to maintain airway clearance.
C. document the findings and continue monitoring.
D. apply a drip pad and reassure the patient this is normal.: A. test the drainagefor the presence of glucose. Clear nasal drainage suggests leakage of cerebrospinafluid (CSF).The drainage should be tested for the presence of glucose, which wouldindicate the presence of CSF. - 4. When caring for a patient who is 3 hours postoperative laryngectomy, thenurse’s highest priority assessment would be:
A. Airway patency
B. Patient comfort
C. Incisional drainage
D. Blood pressure and heart rate: A. Airway patency Remember ABCs with
prioritization. Airway patency is always the highest priority and is essential for a
patient undergoing surgery surrounding the upper respiratory system.
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- 5. When initially teaching a patient the supraglottic swallow following a
radical neck dissection, with which of the following foods should the nurse
begin?
A. Cola
B. Applesauce
C. French fries
D.White grape juice: A. ColaWhen learning the supraglottic swallow, it may be
helpful to start with carbonated beverages because the effervescence provides
clues about the liquid’s position. Thin, watery fluids should be avoided because
they are difficult to swallow and increase the risk of aspiration. Nonpourable pureedfoods, such as applesauce, would decrease the risk of aspiration, but carbonated
beverages are the better choice to start with. - 6. The nurse is caring for a patient admitted to the hospital with pneumoniaUpon assessment, the nurse notes a temperature of 101.4° F, a productive
cough with yellow sputum and a respiratory rate of 20.Which of the followingnursing diagnosis is most appropriate based upon this assessment? A. Hyperthermia related to infectious illness
B. Ineffective thermoregulation related to chilling
C. Ineffective breathing pattern related to pneumonia
D. Ineffective airway clearance related to thick secretions: A. Hyperthermia
related to infectious illness Because the patient has spiked a temperature and hasa diagnosis of pneumonia, the logical nursing diagnosis is hyperthermia related to
infectious illness. There is no evidence of a chill, and her breathing pattern is withinnormal limits at 20 breaths per minute. There is no evidence of ineffective airway
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clearance from the information given because the patient is expectorating sputum.7. 7. Which of the following physical assessment findings in a patient with
pneumonia best supports the nursing diagnosis of ineffective airway clearance? A. Oxygen saturation of 85%
B. Respiratory rate of 28
C. Presence of greenish sputum
D.Basilar crackles: D.Basilar crackles The presence of adventitious breath soundsindicates that there is accumulation of secretions in the lower airways. This would
be consistent with a nursing diagnosis of ineffective airway clearance because thepatient is retaining secretions.
- 8. Which of the following clinical manifestations would the nurse expect tofind during assessment of a patient admitted with pneumococcal pneumonia?A. Hyperresonance on percussion
B. Fine crackles in all lobes on auscultation
C. Increased vocal fremitus on palpation D.Vesicular breath sounds in all