Med Surg 1 HESI Final T2
32. Which definition relates to steatorrhea? A.) Fatty stools B.) Loose, watery stools C.) Hard, formed stools D.) Stools that are red in color
Answer: A
40. Which blood type is considered a universal blood recipient? A.) A B.) B C.) AB D.) O
Answer: C
44. A nurse is preparing a list of instructions regarding stoma and laryngectomy care to a client who has undergone laryngectomy. Which instructions should be included in the list? Select all that apply. A.) Keep humidity in the home low. B.) Avoid wearing high-collared clothing. C.) Prevent debris from entering the stoma. D.) Avoid swimming and use care when showering.
Answer: C, D
37. Which action of a client with ankylosing spondylitis would be beneficial in treatment? A.) Turning every 15 minutes B.) Avoiding breathing exercises C.) Avoiding lying on the abdomen D.) Applying heat to the back and hips
Answer: D
27. Which statement by a client with hypertension prescribed a 2-g sodium diet provides evidence that the nurse's dietary instructions are understood? A.) "My fluid intake should be restricted." B.) "I should limit the number of daily food servings." C.) "Salt should not be used during cooking but can be used at the table." D.) "Labels on prepackaged food products should be evaluated before purchase."
Answer: D
4. A nurse reinforces teaching given to a client with gastroesophageal reflux disease (GERD) about measures to manage the disease. What does the nurse encourage the client to do to obtain relief of the symptoms? A.) Limit intake of coffee and tea. B.) Eat three large, well-balanced meals per day. C.) Rest in a supine position for 30 minutes after each meal. D.) Elevate the head of the bed at least 6 to 8 inches for sleep.
Answer: D
41. Which explanation about the mechanism of action would the nurse give to a client who is prescribed enoxaparin 40 mg subcutaneously daily after abdominal surgery? A.) "It controls expected postoperative fever." B.) "It provides a constant source of mild analgesia." C.) "It limits the inflammatory response associated with surgery." D.) "It provides prophylaxis against postoperative thrombus formation."
Answer: D
8. A nurse is caring for a client who has just had a plaster leg cast applied. Which measure does the nurse implement to prevent the development of compartment syndrome? A.) Elevating the limb and applying ice to the affected leg B.) Elevating the limb and covering the limb with bath blankets C.) Keeping the leg horizontal and applying ice to the affected leg D.) Placing the leg in a slightly dependent position and applying ice to the affected leg
Answer: A
43. A client who sustained a major burn injury is beginning to take an oral diet again. Which between-meal menu selections meet the client's needs for wound healing and tissue repair? Select all that apply. A.) Apple slices and skim milk B.) Whole-milk shake and granola C.) Baked potato topped with cheese D.) Cheese and whole-wheat crackers E.) Cauliflower with low-fat ranch dip
Answer: B, C, D
46. Which of the following findings are specific characteristics of right-sided heart failure? Select all that apply. A.) Cough B.) Allow sips of clear fluids only. C.) Crackles on auscultation D.) Pitting dependent edema E.) Abdominal pain and bloating
Answer: B, D, E
24. The nurse provides information to a client treated for cystitis about measures to prevent its recurrence. Which statement by the client indicates a need for further instruction? A.) "I should wear cotton underpants." B.) "I should urinate and drink a glass of water after sex." C.) "I need to wipe from front to back when I use the bathroom." D.) "I can soak in a bathtub to relieve the pain and prevent infections in the future."
Answer: D
36. Which statement regarding rheumatoid arthritis (RA) is true? A.) "It is a systemic condition." B.) "It affects only the hips and hands." . C.) "It involves bone spur formation." D.) "It affects males and females equally."
Answer: A
10. A nurse in the emergency department is assisting with data collection from a client who sustained an open leg fracture in a fall from a ladder. Which question is most important for the nurse to ask the client? A.) "When was your last tetanus vaccine?" B.) "Have you ever had a tuberculin test?" C.) "Have you had a chest x-ray recently?" D.) "When was your last physical examination?"
Answer: A
26. Which action would the nurse take when caring for a client who just returned from a cardiac catheterization and reports that the pressure bandage on the right groin is tight? A.) Loosen the dressing slightly. B.) Notify the health care provider. C.) Assess the pulses distal to the dressing. D.) Have the client flex the joints of the right leg.
Answer: C
3. A nurse assessing the skin of a client who is immobile notes this change in appearance of the skin in the sacral area: The nurse documents this finding in which way? A.) Stage I pressure ulcer B.) Stage II pressure ulcer C.) Stage III pressure ulcer D.) Stage IV pressure ulcer
Answer: A
33. Which symptom would the nurse observe on a client who sustained a superficial partial-thickness burn? A.) Painful, pink to red skin B.) Large blisters and exposed dermis C.) Blistered, weepy, pale to red skin D.) Dry, leathery, and red, brown, or black patches
Answer: C
48. The nurse provides self-care instructions to a client with a venous disorder. Which of these statements by the client indicate the need for further instruction? Select all that apply. A.) "I need to order a MedicAlert bracelet." B.) "I should watch my legs and ankles for swelling." C.) "I can massage my leg gently when it's sore." D.) "I can put pillows under my knees if it's more comfortable." E.) "I should elevate my legs above the level of my heart when I'm in bed."
Answer: C, D
51. The nurse is educating a group of older adults regarding osteoporosis. The nurse should mention which factors that increase the risk of osteoporosis? Select all that apply. A.) Obesity B. Late menopause C.) Cigarette smoking D.) Sedentary lifestyle E.) African heritage F.) Family history of osteoporosis
Answer: C, D, F
47. Which of the following clients are at risk for venous thrombosis? Select all that apply. A.) A client with a diagnosis of hypothyroidism B.) A client who reports that he is a marathon runner C.) A client who sustained a pelvic fracture after falling from a horse D.) A client with a seizure disorder who is taking phenytoin (Dilantin) E.) A client who reports using oral contraceptives as a means of birth control
Answer: C, E
28. Which is the priority nursing intervention when providing postprocedure care to a client who had a cardiac catheterization via a brachial artery in the first hour after the procedure? A.) Monitor vital signs every 15 minutes. B.) Maintain the client in the supine position. C.) Keep the client's lower extremities in extension. D.) Administer the prescribed oxygen at 4 L/min via nasal cannula.
Answer: A
35. Which intervention by the nurse promotes perfusion and healing of the surgical wound in an older adult? A.) Minimizing the use of tape on the skin B.) Keeping the client adequately hydrated C.) Changing the dressings as soon as they get wet D.) Providing rest for the client throughout the day
Answer: B
38. Which intervention would a nurse implement when initially caring for an older bedridden client who is incontinent of urine? A.) Restricting fluid intake B.) Offering the urinal regularly . C.) Applying incontinence pants D.) Inserting an indwelling urinary catheter
Answer: B
2. A nurse planning care for a client who has undergone transurethral resection of the prostate (TURP) remembers that the most common cause of postoperative pain is which factor? A.) Bladder spasms B.) Bleeding within the bladder C.) The location of the incision D.) Tension on the Foley catheter
Answer: A
53. Which sign or symptom is expected with advanced cirrhosis? Select all that apply. One, some, or all responses may be correct A.) Ascites B.) Jaundice C.) Esophageal varices D.) Decreased consciousness E.) Numbness and tingling in extremities
Answer: A, B, C, D, E
49. A nurse is preparing a list of home care instructions for a client with peripheral artery disease (PAD). Which instructions should the nurse include on the list? Select all that apply. A.) Avoid crossing the legs. B.) Report signs of skin breakdown. C.) Avoid ambulation to help prevent pain. D.) Inspect the skin of the extremities daily. E.) Elevate the legs above the level of the heart when in bed or in a chair. F.) Avoid exposure to cold and place a heating pad on the legs to improve blood flow.
Answer: A, B, D
54. Which statement made by a client with rheumatoid arthritis about precautions to be taken during the intake of methotrexate indicates understanding? Select all that apply. One, some, or all responses may be correct A.) "I need to drink lots of water." B.) "I will take the drug with food." C.) "I should not plan to become pregnant." D.) "I need to get an eye test every 6 months." E.) "I will rinse out my mouth thoroughly after eating."
Answer: A, C
42. Who is experiencing a loss of appetite and complains of feeling "too full to eat." What does the nurse encourage the client to do? Select all that apply. A.) Avoid drinking fluids before and during meals. B.) Eat a variety of dark-green vegetables, such as broccoli. C.) Have snacks, such as crackers and cheese, between meals. D.) Select foods that are easy to chew and are not gas forming.
Answer: A, D
15. A nurse caring for a client with a diagnosis of peptic ulcer is monitoring the client for signs of perforation. Which findings would cause the nurse to suspect perforation? A.) Bradycardia B.) Abdominal rigidity C.) A sudden bout of diarrhea D.) Projectile vomiting of bile
Answer: B
17. A nurse is assisting with data collection of a client with angina pectoris. The client reports that the anginal pain is triggered by exercise and relieved by rest or nitroglycerin. In the client's record, the nurse notes that the client is experiencing which situation? A.) Stable angina B.) Variant angina C.) Unstable angina D.) Nonanginal pain
Answer: A
21. The nurse provides discharge instructions to a client who has undergone mechanical valve replacement. Which statement by the client indicates an understanding of the instructions? A.) "I'll have to take a blood thinner for the rest of my life." B.) "If I hear a clicking sound I need to call the surgeon immediately." C.) "I need to avoid lifting anything heavier than 30 lb for at least 6 weeks." D.) "I shouldn't worry if I see redness at the incision site or clear drainage, because it's normal
Answer: A
22. A nurse provides self-care instructions to a client with hypertension who will be taking an antihypertensive medication daily. Which statement by the client indicates a need for further instruction? A.) "I need to cut down on my smoking." B.) "I'm going to have to take this medicine for the rest of my life." C.) "I can use relaxation techniques to help control my blood pressure." D.) "I need to check food labels for the sodium content when I'm shopping."
Answer: A
25. A client is brought to the emergency department after sustaining a fall, complaining of severe pain in the right arm. The nurse carefully cuts off the clothing that is covering the arm and notes an open wound with bone protruding from it. Which action should the nurse take immediately? A.) Covering the open area with a sterile dressing B.) Obtaining a prescription for pain medication C.) Placing the cut-off shirt sleeve over the open area D.) Irrigating the open area with half strength hydrogen peroxide
Answer: A
29. Which preoperative teaching is most important for the nurse to include when completing laryngectomy education? A.) Establishing a means for communicating postoperatively B.) Explaining that there will be a feeding tube postoperatively C.) Demonstrating how to care for a permanent laryngeal stoma D.) Teaching how to cough to expectorate bronchial secretions effectively
Answer: A
7. A hospitalized client has just been found to have acute renal failure (ARF). The laboratory calls the nursing unit and reports that the client has a serum potassium level of 6.4 mEq/L. On the basis of this laboratory finding, the nurse should first take which action? A.) Call the health care provider B.) Check the client's sodium level C.) Encourage the client to increase fluid intake D.) Have the client decrease intake of potassium-rich foods
Answer: A
50. A client with sepsis has been receiving intravenous antibiotics, and acute kidney injury has developed as a result. The nurse assesses the client and reviews the laboratory results. Which findings should the nurse expect to note during the oliguric stage of acute kidney injury? Select all that apply. A.) A calcium level of 8.0 mg/dL B.) A creatinine level of 2.0 mg/dL C.) A serum sodium level of 159 mEq/L D.) A serum potassium level of 3.1 mEq/L
Answer: A, B
5. A nurse provides instructions to a client who is taking allopurinol for the treatment of gout. Which statements by the client indicate an understanding of the medication? A.) "I need to take the medication 1 hour before I eat." B.) "I need to drink at least 8 glasses of fluid every day." C. "I'll start taking a vitamin C supplement each morning." D.) "I can use an antihistamine lotion if I get an itchy rash."
Answer: B
9. On the first day after undergoing total knee arthroplasty, the client tells the nurse that he is experiencing pain when he extends his leg. The nurse should take which action? A.) Notify the health care provider immediately B.) Administer an analgesic and evaluate the response C.) Immobilize the knee temporarily and contact the health care provider to report pain D.) Put the client's knee through full passive range of motion to assess tolerance
Answer: B
52. Which assessment finding would the nurse assess for that could suggest a pulmonary embolus? Select all that apply. One, some, or all responses may be correct. A.) Apathy B.) Dyspnea C.) Hemoptysis D.) Bronchial wheezes E.) Feeling of impending doom
Answer: B, C, E
14. A nurse has taught a client with chronic obstructive pulmonary disease (COPD) about positions that will ease breathing during dyspneic episodes. Which statement by the client indicates a need for further instruction? A.) "I should sit up and lean on a table." B.) "I should stand and lean against a wall." C.) "I should lie flat on my side in a fetal position." D.) "I should sit up with my elbows resting on my knees."
Answer: C
1. A nurse is visiting a client who is receiving home health care, focusing on medication and dietary instructions and management of heart failure. The nurse should reinforce which instruction? A.) If you feel tired and short of breath, lie down flat and prop up your feet. B.) Eating liver several times a week will help build up your strength. C.) Your daily dose of furosemide should be taken first thing in the morning. D.) The dose of enalapril will help prevent vasodilation from occurring.
Answer: C
12. A nurse reinforces dietary instructions to a client with viral hepatitis whose laboratory results indicate liver impairment. The nurse provides the client with which information? A.) To increase intake of foods high in protein to promote healing B.) To consume mainly high-fat foods because they are better tolerated C.) That most calorie intake should consist of foods high in carbohydrates D.) That snacks, particularly those that are salty, are an important part of the diet
Answer: C
13. A nurse is checking a client's closed chest drainage system and notes rapid bubbling in the water seal chamber. The nurse checks the system for an air leak but does not find one. The nurse interprets this in which way? A.) The pneumothorax is resolving. B.) The degree of suction needs to be decreased. C.) There is an incision or tear in the pulmonary pleura. D.) The suction applied to the system is not working correctly.
Answer: C
45. Which of the following risk factors for MI are modifiable? Select all that apply. A.) The client smokes four or five cigarettes a day B.) The client reports a sedentary lifestyle. C.) The client is 5 feet 1 inch tall and weighs 232 lb. D.) The client's blood pressure consistently ranges between 148/88 and 170/96 mm Hg. E.) The client reports that her mother has a history of severely increased cholesterol levels that cannot be controlled with diet or medication.
Answer: A, B, C, D
18. A client who was exposed to cold for a prolonged period is brought to the emergency department. The nurse, conducting an assessment of the client, notes acute frostbite of the fingers of the left hand. Which action should the nurse take immediately? A.) Placing the client's fingers in cold water for 15 to 20 minutes B.) Placing the client's fingers in warm water for 15 to 20 minutes C.) Placing the client's fingers in warm water for 5 minutes, then debriding any obvious blisters D.) Placing the client's fingers in cold water for 10 minutes and then warm water for 10 minutes and continuing this pattern for 1 hour
Answer: B
30. Which intervention would the nurse implement to help prevent atelectasis in a client with fractured ribs as a result of chest trauma? A.) Apply a thoracic binder for support. B.) Encourage coughing and deep breathing. C.) Defer pain medication the first day after injury. D.) Position the client face down on a soft mattress.
Answer: B
31. Which action would the nurse determine is needed for a client who has undergone gastric bypass surgery? A.) Ensure that the client eats three large meals a day. B.) Teach the client how to avoid dumping syndrome. C.) Weigh the client twice daily. D.) Encourage a full glass of water with every meal.
Answer: B
34. A hospitalized client develops an infection at a catheter insertion site. The nurse uses the term iatrogenic when describing this infection because it resulted from what? A.) Poor personal hygiene B.) A procedure performed at the hospital C.) Inadequate dietary intake D.) The client's developmental level
Answer: B
39. Which statement would cause the nurse to conclude that teaching was effective after providing discharge instructions to a client who received a prescription for digoxin after a myocardial infarction? A.) "I should avoid foods high in potassium." B.) "I should check my radial pulse rate daily." C.) "I should increase my intake of vitamin K." D.) "I should adjust the dosage according to my activities."
Answer: B
19. A client who is experiencing chest pain is brought to the emergency department by a family member. Assessing the client, the nurse obtains a description of the client's chest pain. Which information from the client causes the nurse to determine that the client's pain is most likely angina? A.) The pain is unrelieved by rest. B.) The pain is unrelieved by nitroglycerin. C.) The pain was precipitated by a stressful event. D.) The pain is accompanied by nausea, vomiting, diaphoresis, and dyspnea
Answer: C
23. A client undergoes transplantation of a kidney from her brother. Which information should the nurse, in home care instructions to the client about graft rejection, provide to the client? A.) Rejection always occurs during the 48 hours after surgery. B.) Rejection is not a problem when the donor is a direct family member. C.) The client should contact the healthcare provider if she notices weight gain or edema. D.) The client should not be concerned about rejection, because immunosuppressive medications prevent its occurrence.
Answer: C
6. A client with phantom limb pain has decided to use transcutaneous electrical nerve stimulation (TENS) as prescribed by the health care provider. The nurse reinforces instructions regarding the use of the TENS unit. Which statements by the client indicate a need for further instruction regarding this pain-relief measure? A.) "I'm so glad this will help relieve the pain." B.) "Now I won't need to take so many pain medications." C.) "I need to put the electrodes on the areas that you marked." D.) "I'm not sure I'm going to like having those electrodes attached to my skin."
Answer: C
11. A client who sustained an extensive full-thickness burn injury is being admitted to the nursing unit. Which prescription by the health care provider would the nurse question? A.) Insert Foley catheter and check urine output each hour. B.) Maintain nasogastric tube with low intermittent suction. C.) Assess vital signs, oxygen saturation, and level of consciousness each hour. D. Administer morphine sulfate 6 mg intramuscularly every 3 hours as needed.
Answer: D
16. A nurse is caring for a client with a diagnosis of chronic renal failure (CRF). Which early sign of CRF does the nurse expect to note during data collection? A.) Restlessness B.) Temperature of 99.8°F C.) Pulse of 110 beats/min D.) Blood pressure of 168/94 mm Hg
Answer: D
20. A nurse provides home care instructions to a client with bacterial infective endocarditis. Which statement by the client indicates a need for further instruction? A.) "I need to let my dentist know that I had this infection." B.) "I need to take antibiotics before I have any invasive procedures." C.) "I should check my temperature every day and call the doctor if I have a fever." D.) "I need to be sure to floss my teeth and use an electric toothbrush."
Answer: D