HESI Med-Surg II Test Bank

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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?

• Take temperature once a day.
• Wash the armpits and genitals with a gentle cleanser daily.
• Change the litter boxes while wearing gloves.
• 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?

• Provide humidified oxygen.
• Perform chest physiotherapy prior to suctioning. 1 / 4

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• Prelubricate the suction catheter tip with sterile saline when suctioning the

airway.

• 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 the client's comfort?

• Rub the client's feet briskly for several minutes.
• Obtain a pair of slipper socks for the client.
• Increase the client's oral fluid intake.
• 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?

• Emesis of 100 mL
• Oral temperature of 37.5° C (99.5° F) 2 / 4

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• Thick, red-colored urine
• 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) and

has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket?

• Shivering
• Infection
• Burns
• Hypervolemia ANS A. 3 / 4

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• A nurse is reinforcing teaching about exercise with a client who has type 1

diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

• "I will carry a complex carbohydrate snack with me when I exercise."
• "I should exercise first thing in the morning before eating breakfast."
• "I should avoid injecting insulin into my thigh if I am going to go running."
• "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?

• Cover the client's wound with a moist, sterile dressing.
• Have the client lie supine with knees flexed.
• Check the client's vital signs.
• 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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