Hesi Med-Surg Review
What instruction should the nurse include in the discharge teaching plan of a client
who had a cataract extraction today?
(ANS- Light housekeeping is permitted but avoid heavy lifting
A male adult comes to the urgent care clinic 5 days after being diagnose with
influenza. He is short of breath, febrile, and coughing green colored sputum.
Which intervention should the nurse implement first?
(ANS- Obtain a sputum sample for culture
An elder male client tells the nurse that he is loosing 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?
(ANS- palpate the bladder above the symphysis pubis
An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract
infection (UTI) Prescriptions for intravenous antibiotics and insulin infusion are
initiated. Which serum laboratory value warrants the most immediate intervention
by the nurse?
(ANS- potassium of 2.5 meq/l
A client with sickle cell anemia develops a fever during the last hour of
administration of a unit of packed red blood cell. When notifying the healthcare
provider what information should the nurse provide first using the SBAR
communication process? (ANS- explain specific reason for urgent notification
An adult male client is admitted for pneumocystis carinil pneumonia (PCP)
secondary to aids. While hospitalize he receives IV pentamidine isethionate
therapy. In preparing this client for discharge what important aspect regarding his
medication therapy should the nurse explain?
(ANS- It will be necessary to continue prophylactic doses of IV or aerosol
pentamine every month
A client subjective data includes dysuria, urgency, and urinary frequency. What
action should the nurse implement next?
(ANS- .collect a clean catch specimen
A client tells the nurse that her biopsy results indicate that the cancer cells are well
differentiated How should the nurse respond?
(ANS- ask the client in the healthcare provider has giving her any information
about the classification of her cancer
A client with a chronic kidney disease is treated on hemodialysis. During the 1
treatment clients blood pressure drops from 150/90 to 80/30 Which action should
the nurse take first?
(ANS- stop dialysis treatment
A client with deep vain thrombosis (DVT) is receiving a continues infusion of
heparin sodium 25,000 unit in 5% dextrose injection 250ml. The prescription
indicates the dosage should be increase 900 units/hr. The nurse should program the
infusion pump to deliver how many ml/hr?
(ANS- 9
The nurse is obtaining the admission history for a client with suspected peptic ulcer
disease (PUD). Which subjective data reported by the client supports this
diagnosis?
(ANS- upper mid abdominal gnawing and burning pain
The nurse is providing preoperative education for a jewish client schedule to
receive a xenograft graft to promote burn healing. Which information should the
nurse provide this client?
(ANS- the xenograft is taken from nonhuman sources
A client who took a camping vacation two weeks ago in a country 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 to report?
(ANS- jaundice sclera
During a home visit the nurse assesses the skin of a client with eczema who reports
than an exacerbation of symptoms has occurred during the last week. Which
information is most useful in determining the possible cause of the symptoms?
(ANS- a grandson and his new dog recently visited
When explaining dietary guidelines to a client with acute glomerulonephritis
(AGN) which instruction should the nurse include in the dietary teaching?
(ANS- restrict sodium intake
A male client who is 24hr post operative for an exploratory laparoctomy complains
that he is starving because he has had no real food since before surgery. Prior to
advancing his diet which intervention should the nurse implememt?
(ANS- Auscultate bowel sound in all four quadrants
A client diagnose with stable angina secondary to ischemic heart disease has a
prescription for sublingual (SL) nitroglycerin (NTG). The nurse should tell the
client to follow which instructions if chest pain is not relieved after taking 3 NTG
tables 5 min apart?
(ANS- call 911 pain is unrelieved and chew a tablet of aspirin 325mg
After taking orlistat (Xenical) for one week a femela client tells the home health
nurse that she is experiencing increasingly frequent oily stools and flatus. What
action should the nurse take?
(ANS- ask the client to describe her dietary intake history for the last several days
Two days after an abscess of the chin was drained the client returns to the clinic
with fever chills and a maculopapular rash with pruritis. The client has taken an
oral antibiotic and cleansed the wound today with provide iodine (Betadine)
solution. Which intervention should the nurse implement first?
(ANS- assess airway patency and oxygen saturation
A client experiences an ABO incompatibility reaction after multiple blood
transfusions. Which finding should the nurse report immediately to the health care
provider?
(ANS- low back pain and hypotension