MedSurg 1 HESI Review
Which blood gas result should the nurse expect a client with diabetic ketoacidosis to exhibit? a. pH 7.35, CO2 47 mm Hg, HCO3- 24 mEq/L (24 mmol/L) b. pH 7.30, CO2 40 mm Hg, HCO3- 20 mEq/L (20 mmol/L) c. pH 7.46, CO2 30 mm Hg, HCO3- 24 mEq/L (24 mmol/L) d. pH 7.50, CO2 50 mm Hg, HCO3- 22 mEq/L (22 mmol/L)
b. pH 7.30, CO2 40 mm Hg, HCO3- 20 mEq/L (20 mmol/L)
A registered nurse is teaching a student nurse regarding the interventions for a client with human immunodeficiency virus (HIV) infection. Which statement by the student nurse indicates the nurse needs to follow up? a. "I will ask the client to avoid exposure to new infectious agents." b. "I will ask the client about intake of vitamins and micronutrients." c. "I will ask the client to avoid involvement in community activities." d. "I will ask the client if he or she is up to date with recommended vaccines."
c. "I will ask the client to avoid involvement in community activities."
A client develops respiratory alkalosis. When the nurse is reviewing the laboratory results, which finding is consistent with respiratory alkalosis? a. An elevated pH, elevated PCO2 b. A decreased pH, elevated PCO2 c. An elevated pH, decreased PCO2 d. A decreased pH, decreased PCO2
c. An elevated pH, decreased PCO2
While receiving a blood transfusion, a client develops acute dyspnea, generalized urticaria, a heart rate of 128, and a blood pressure of 70/38. What type of reaction does the nurse conclude that the client probably is experiencing? a. Panic b. Hemolytic c. Anaphylactic d. Pyrogenic
c. Anaphylactic
On admission to the intensive care unit, a client is diagnosed with compensated metabolic acidosis. During the assessment, what is the nurse most likely to identify? a. Muscle twitching b. Mental instability c. Deep and rapid respirations d. Tachycardia and cardiac dysrhythmias
c. Deep and rapid respirations
A client reports nausea, vomiting, and seeing a yellow light around objects. A diagnosis of hypokalemia is made. Upon a review of the client's prescribed medication list, the nurse determines that what is the likely cause of the clinical findings? a. Furosemide (Lasix) b. Propranolol (Inderal) c. Digoxin (Lanoxin) d. Spironolactone (Aldactone)
c. Digoxin (Lanoxin)
A circulating nurse in the operating room learns of being HIV positive. What should this nurse do regarding participation in exposure-prone procedures? a. Adhere to standard precautions at all times b. Avoid handling equipment used in direct client care c. Discuss procedures that can be performed with a review panel d. Disinfect all equipment used for non-invasive procedures
c. Discuss procedures that can be performed with a review panel
A client with upper gastrointestinal (GI) bleeding develops mild anemia. What should the nurse expect to be prescribed for this client? a. Dextran b. Iron salts c. Vitamin B 12 d. Erythropoietin
b. Iron salts
A nurse is caring for a client after abdominal surgery and encourages the client to turn from side to side and to engage in deep-breathing exercises. What complication is the nurse trying to prevent? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis
Respiratory acidosis
During administration of a whole blood transfusion, the client begins to complain of shortness of breath. The nurse notes the presence of jugular venous distension, bibasilar crackles, and tachycardia. Prioritize the following nursing actions a. Elevate the head of the bed to 45 degrees b. Apply oxygen via nasal cannula c. Reduce the flow rate of the transfusion d. Administer furosemide (Lasix) per provider prescription e. Document findings in the client record
a, b, c, d, e
Which conditions may result from immunoglobulin IgE antibodies on mast cells reacting with antigens? Select all that apply. a. Asthma b. Hayfever c. Sarcoidosis d. Myasthenia gravis e. Rheumatoid arthritis
a. Asthma b. Hayfever
The nurse is taking care of four clients with human immunodeficiency virus (HIV) infections. Which client's condition should the nurse report to the primary healthcare provider within 24 hours after observation? a. Burning, itching, and discharge from the eyes b. Blood in the urine c. Yellow discoloration of the skin d. Nausea and vomiting accompanied by abdominal pain
a. Burning, itching, and discharge from the eyes
A nurse is caring for a client with pruritic lesions from an IgE-mediated hypersensitivity reaction. Which mediator of injury is involved? a. Histamine b. Cytokine c. Neutrophil d. Macrophage
a. Histamine
A nurse is assessing a client with a diagnosis of kidney failure for clinical indicators of metabolic acidosis. What should the nurse conclude is the reason metabolic acidosis develops with kidney failure? a. Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate b. Depressed respiratory rate due to metabolic wastes, causing carbon dioxide retention c. Inability of the renal tubules to reabsorb water to dilute the acid contents of blood d. Impaired glomerular filtration, causing retention of sodium and metabolic waste products
a. Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate
An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20 mEq/L. Which disturbance should the nurse identify based on these results? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis
a. Metabolic acidosis
During the progressive stage of shock, anaerobic metabolism occurs. Which complication should the nurse anticipate in this client? Correct! a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis
a. Metabolic acidosis
The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider? a. Oxygen saturation is 88%. b. Blood pressure is 145/90 mm Hg. c. Respiratory rate is 22 breaths/minute when lying flat. d. Pain level is 5 (on 0 to 10 scale) with a deep breath.
a. Oxygen saturation is 88%.
A patient experiences a chest wall contusion as a result of being struck in the chest with a baseball bat. The emergency department nurse would be most concerned if which finding is observed during the initial assessment? a. Paradoxic chest movement b. Complaint of chest wall pain c. Heart rate of 110 beats/minute d. Large bruised area on the chest
a. Paradoxic chest movement
Which medication reported by a client during nursing history could be associated with the development of hypocalcemia? a. Phenytoin b. Calcium carbonate c. Calcitriol d. Hydrochlorothiazide
a. Phenytoin
A client is admitted to the emergency department with allergic rhinitis and asthma. The laboratory report shows histamines and prostaglandins. Which type of hypersensitivity reaction may have occurred? a. Type I b. Type II c. Type III d. Type IV
a. Type I
The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed? a. A large air leak in the water-seal chamber b. 400 mL of blood in the collection chamber c. Complaint of pain with each deep inspiration d. Subcutaneous emphysema at the insertion site
b. 400 mL of blood in the collection chamber
Which hormone synthesis does the nurse state is inhibited by hypokalemia? a. Somatostatin b. Aldosterone c. Norepinephrine d. Androstenedione
b. Aldosterone
A client presents with sneezing; lacrimation; swelling with an airway obstruction; and pruritus around the eyes, nose, throat, and mouth. The nurse interprets these findings as a Type I hypersensitivity reaction. Which disease might have occurred in the client? a. Angioedema b. Allergic rhinitis c. Contact dermatitis d. Goodpasture syndrome
b. Allergic rhinitis
Which type of immunity will clients acquire through immunizations with live or killed vaccines? a. Natural active immunity b. Artificial active immunity c. Natural passive immunity d. Artificial passive immunity
b. Artificial active immunity
Which conditions result in humoral immunity? Select all that apply. a. Tuberculosis b. Atopic diseases c. Bacterial infection d. Anaphylactic shock e. Contact dermatitis
b. Atopic diseases c. Bacterial infection d. Anaphylactic shock
A nurse is preparing to administer an intravenous piggyback medication to a client who is receiving a continuous infusion of intravenous (IV) fluids. What is the priority nursing intervention? a. Get an additional IV infusion pump for the medication. b. Check the compatibility of the medication and the continuous IV solution. c. Disconnect the continuous IV solution while administering the piggyback medication. d. Flush the client's venous access device to ensure patency.
b. Check the compatibility of the medication and the continuous IV solution.
A client presents with red, inflamed skin covered with papules, vesicles, and bullae from a type IV hypersensitivity reaction. Which condition/disease will the nurse most likely observe written in the client's electronic medical record? a. Allergic rhinitis b. Contact dermatitis c. Goodpasture syndrome d. Systemic lupus erythematosus
b. Contact dermatitis
The nurse is preparing a blood transfusion for a client with renal failure. Why does anemia often complicate renal failure? a. Increase in blood pressure b. Decrease in erythropoietin c. Increase in serum phosphate levels d. Decrease in serum sodium concentration
b. Decrease in erythropoietin
When caring for a client with pneumonia, which nursing intervention is the highest priority? a. Increase fluid intake. b. Employ breathing exercises and controlled coughing. c. Ambulate as much as possible. d. Maintain a nothing-by-mouth (NPO) status.
b. Employ breathing exercises and controlled coughing.
A prescribed blood transfusion of packed red blood cells was started five minutes ago. Now the client is complaining of chest pain, flank pain, difficulty breathing, and chills. The blood pressure has dropped from 140/88 to 110/60 mm Hg, temperature is 100.8° F (38.2° C), and the client seems less alert. What should the nurse suspect? a. Urticarial reaction b. Hemolytic reaction c. Circulatory overload d. Anaphylactic reaction
b. Hemolytic reaction
Findings on a client's cardiac monitor indicate a need for an intravenous infusion that contains potassium for a client with hypokalemia. The nurse concludes that what finding on the monitor indicated a need for potassium replacement? a. Elevation of the ST segment b. Lowering of the T wave c. Shortening of the QRS complex d. Increased deflection of the Q wave
b. Lowering of the T wave
Which leukocytes should the nurse include when teaching about antibody-mediated immunity? Select all that apply. a. Monocyte b. Memory cell c. Helper T cell d. B-lymphocyte e. Cytotoxic T cell
b. Memory cell d. B-lymphocyte
The nurse is caring for a client with the following arterial blood gas (ABG) values: PO2 89 mm Hg, PCO2 35 mm Hg, and pH of 7.37. These findings indicate that the client is experiencing which condition? a. Respiratory alkalosis b. Normal acid-base balance c. Poor oxygen perfusion d. Compensated metabolic acidosis
b. Normal acid-base balance
A client is admitted to the hospital with a diagnosis of dehydration and hypokalemia. Which statement/intervention is most accurate when administering potassium chloride intravenously to this client with hypokalemia? a. Rapid infusion of potassium prevents burning at the IV site. b. Oliguria is an indication for withholding intravenous (IV) potassium. c. Clients with severe deficits should be given IV push potassium. d. Average IV dosage of potassium should not exceed 60 mEq in one hour.
b. Oliguria is an indication for withholding intravenous (IV) potassium.
Which is the most common opportunistic infection in a client infected with human immunodeficiency virus (HIV)? a. Pneumocystis jiroveci pneumonia b. Oropharyngeal candidiasis c. Cryptosporidiosis d. Toxoplasmosis encephalitis
b. Oropharyngeal candidiasis
A client on diuretic therapy developed metabolic alkalosis. What does the nurse consider to be the priority nursing care while correcting alkalosis? a. Monitoring electrolytes b. Preventing falls c. Administering antiemetics d. Adjusting the diuretic therapy
b. Preventing falls
The laboratory report of a client reveals the presence of 350 cells/mm3 (350 cells/uL) of CD4+ T-cell count. According to the Centers for Disease Control and Prevention (CDC), which stage of human immunodeficiency virus (HIV) disease is present in the client? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4
b. Stage 2
While caring for a client receiving blood transfusion care, the nurse notices that the client is having an acute hemolytic reaction. What is the priority nursing intervention in this situation? a. Report to the primary healthcare provider. b. Stop the blood transfusion immediately. c. Recheck identifying tags and numbers on the client. d. Maintain a patent intravenous (IV) line with saline solution.
b. Stop the blood transfusion immediately.
Ten minutes after the initiation of a blood transfusion, a client reports lumbar pain. What is the next nursing action? a. Obtain the vital signs. b. Stop the transfusion. c. Assess the pain further d. Increase the flow of normal saline.
b. Stop the transfusion.
A patient is admitted to the emergency department with an open stab wound to the left chest. What is the first action that the nurse should take? a. Position the patient so that the left chest is dependent. b. Tape a nonporous dressing on three sides over the chest wound c. Cover the sucking chest wound firmly with an occlusive dressing. d. Keep the head of the patient's bed at no more than 30 degrees elevation.
b. Tape a nonporous dressing on three sides over the chest wound
A client has received ABO-incompatible blood from a donor by mistake. Which type of hypersensitivity reaction will occur in the client? a. Type I b. Type II c. Type III d. Type IV
b. Type II
A 60-year-old client with gastric cancer has a shiny tongue, paresthesias of the limbs, and ataxia. The laboratory results show cobalamin levels of 125 pg/mL. Which medication would the nurse consider to be a high priority for the client? a. Oral hydroxyurea b. Vitamin B 12 injections c. Oral iron supplements d. Erythropoietin injections
b. Vitamin B 12 injections
A client comes to the clinic for a physical and asks to be tested for acquired immune deficiency syndrome (AIDS). Which test should the nurse explain will be used for the initial screening for human immunodeficiency virus (HIV)? a. CD4 T cell count b. Western blot test c. Enzyme-linked immunosorbent assay (ELISA) d. Polymerase chain reaction test
c. Enzyme-linked immunosorbent assay (ELISA)
The nurse is preparing to insert an intravenous catheter in a thin, emaciated patient who is scheduled to begin intravenous fluid therapy. Which interventions should the nurse follow to provide high-quality care? Select all that apply. a. Insert an 18 gauge IV catheter b. Change the intravenous line every 7 days c. Flush the intravenous line with normal saline d. Insert the intravenous catheter in the patient's femur e. Stop the insertion procedure when there is a break in technique
c. Flush the intravenous line with normal saline e. Stop the insertion procedure when there is a break in technique
A nurse is caring for a client with severe dehydration and its associated acid-base imbalance. What compensatory mechanism within the body is activated to counteract the effects of the client's acid-base imbalance? a. Profuse diaphoresis b. Increased temperature c. Increased respiratory rate d. Renal retention of hydrogen ions
c. Increased respiratory rate
The nurse is evaluating the actions of a client with pneumonia performing incentive spirometry. Which action by the client indicates a need for correction? a. Recording the volume of the air inspired b. Performing 10 breaths per session every hour c. Inhaling air fully before inserting the mouthpiece d. Taking a long, slow, deep breath keeping the mouthpiece in place
c. Inhaling air fully before inserting the mouthpiece
The registered nurse instructs the nursing student about caring for a hospitalized client with a human immunodeficiency (HIV) infection. Which action made by the nursing student indicates effective learning? a. Keeping fresh flowers in the client's room b. Encouraging the client to eat fresh fruits and vegetables c. Keeping a dedicated disposable glove box in the client's room d. Changing gauze-containing wound dressings every other day
c. Keeping a dedicated disposable glove box in the client's room
Which assessment finding in a client signifies a mild form of hypocalcemia? a. Seizures b. Hand spasms c. Numbness around the mouth d. Severe muscle cramps
c. Numbness around the mouth
When monitoring fluids and electrolytes, the nurse recalls that the major cation-regulating intracellular osmolarity is what? a. Calcium b. Sodium c. Potassium d. Calcitonin
c. Potassium
Which medication requires the nurse to monitor the client for signs of hyperkalemia? a. Furosemide b. Metolazone c. Spironolactone d. Hydrochlorothiazide
c. Spironolactone
A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is most appropriate? a. Document the presence of a large air leak. b. Notify the surgeon of a possible pneumothorax. c. Take no further action with the collection device d. Adjust the dial on the wall regulator to decrease suction
c. Take no further action with the collection device
An elderly adult suffered an injury after falling down in the washroom. The primary healthcare provider performed a surgical procedure on the client and orders a blood transfusion. A family member of the client mentions that blood transfusions are not permitted in their community. What should the nurse do in order to handle the situation? a. The nurse should wait for the court's order to give blood to the client. b. The nurse should proceed with the transfusion in order to save the client's life. c. The nurse should inform the primary healthcare provider and not give blood to the client. d. The nurse should explain to the family member that the client needs this transfusion.
c. The nurse should inform the primary healthcare provider and not give blood to the client.
A client is admitted with systemic lupus erythematosus (SLE). The laboratory report shows the presence of neutrophils and monocytes as mediators of injury. Which type of hypersensitivity reaction most likely occurred in the client? a. Type I b. Type II c. Type III d. Type IV
c. Type III
Arrange the sequence of steps required to stimulate antibody-mediated immunity in its correct sequence. a. Antigen elimination b. Sensitization c. Antibody production d. Exposure of antigen e. Antigen recognition f. Antibody-antigen binding
d, e, b, c, f, a
A client presents to emergency department following a motor cycle accident. The client is in hypovolemic shock. The healthcare provider has ordered plasma expansion. What blood product should the nurse anticipate that the client will receive? a. Packed Red blood Cells b. Cryoprecipitate c. Platelets d. Albumin
d. Albumin
Which type of allergic condition of the skin manifests in the client as delayed hypersensitivity? a. Utricaria b. A drug reaction c. Atopic dermatitis d. Allergic contact dermatitis
d. Allergic contact dermatitis
A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client? a. Skin turgor b. Intake and output results c. Client's report about fluid intake d. Blood lab results
d. Blood lab results
The nurse is caring for some clients with chronic anemia who are on blood transfusion therapy. The nurse notices that one of the clients requires immediate treatment. Which client is the nurse addressing in this situation? a. Client with itching b. Client with flushing c. Client with pruritus d. Client with wheezing
d. Client with wheezing
Which healthcare provider prescription for potassium chloride (KCL) should the nurse question for a client with hypokalemia? a. Infuse 1000ml NS with 20 meq KCL over 8 hours b. Give KCL 20 meq PO daily after meals c. Infuse 1000 ml normal saline with 40 meq KCL IV at 200 ml/hour. d. Give 20 meq KCL IV over 10 minutes
d. Give 20 meq KCL IV over 10 minutes
A client is seen in the clinic with sickle cell anemia. The parents of the client ask how their child got sickle cell anemia. What is an accurate explanation? a. Sickle cell anemia is a random condition with no known cause. b. If one parent is a carrier and one is negative for the gene, the child will get the disease. c. If both parents are carriers, all of their offspring will probably get this disease, and they should consider sterilization. d. If both parents are carriers, the odds are one in four that an offspring will get the disease, and one in four that an offspring will be disease free.
d. If both parents are carriers, the odds are one in four that an offspring will get the disease, and one in four that an offspring will be disease free.
The nurse is caring for a client with iron deficiency anemia that has decreased hemoglobin and hematocrit levels. The nurse expects to identify what other abnormal laboratory level? a. Macrocytic red blood cells (RBCs) b. Thrombocytopenia c. Decreased folate levels d. Increased total iron-binding capacity (TIBC)
d. Increased total iron-binding capacity (TIBC)
The nurse is teaching a client who is prescribed iron supplements for iron-deficiency anemia. Which food should the nurse encourage the patient to take to enhance absorption of iron? a. Cereal b. Spinach c. Whole milk d. Orange juice
d. Orange juice