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MEDSurg hesi - HESI hints for exam
Medical Surgical nursing (NURS 1341)
Houston Community College
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MED-SURG HESI practice questions from the Saunders book
The nurse is preparing to assist a client with a cuffed tracheostomy tube to eat. What intervention is the priority before the client is permitted to drink or eat? Inflate the cuff
Rationale: If a client with a tracheostomy is allowed to eat and the tracheostomy has a cuff, the nurse should inflate the cuff to prevent aspiration of food or fluids. The cuff would not be deflated because of the risk of aspiration.
The nurse has implemented a bowel maintenance program for an unconscious client. The nurse would evaluate the plan as best meeting the needs of the client if which method was successful in stimulating a bowel movement? Glycerin suppository
Rationale: The least amount of invasiveness needed to produce a bowel movement is best. Use of glycerin suppositories is the least invasive method and usually stimulates bowel evacuation within a half-hour.
A client is readmitted to the hospital with dehydration after surgery for creation of an ileostomy. The nurse assesses that the client has lost 3 lb of weight, has poor skin turgor, and has concentrated urine. The nurse interprets the client's clinical picture as correlating most closely with recent intake of which medication, which is contraindicated for the ileostomy client? Biscodyl
Rationale: The client with an ileostomy is prone to dehydration because of the location of the ostomy in the gastrointestinal tract and should not take laxatives.
The client is complaining of skin irritation from the edges of a cast applied the previous day. Which action should the nurse take? The nurse petals the edges of the cast with tape Rationale: minimize skin irritation.
The nurse is taking a health history for a client with hyperparathyroidism. Which question would elicit information about this client's condition? "Are you experiencing pain in your joints?"
Rationale: Hyperparathyroidism is associated with over secretion of parathyroid hormone (PTH), which causes excessive osteoblast growth and activity within the bones. When bone reabsorption is increased, calcium is released from the bones into the blood, causing hypercalcemia. The bones suffer demineralization as a result of calcium loss, leading to bone and joint pain
A client with type 2 diabetes mellitus has a blood glucose level greater than 600 mg/dL (34 mmol/L) and is complaining of polydipsia, polyuria, weight loss, and weakness. The nurse reviews the health care provider's documentation and expects to note which diagnosis? Hyperosmolar hyperglycemic syndrome (HHS)
Rationale: HHS is seen primarily in clients with type 2 diabetes mellitus, who experience a relative deficiency of insulin. The onset of signs and symptoms may be gradual. Manifestations may include polyuria, polydipsia, dehydration, mental status alterations, weight loss, and weakness.
The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse develops the plan, expecting that the health care provider (HCP) will most likely prescribe which option? ---Maintain activity level as prescribed.
Rationale: Standard management for the client with DVT includes maintaining the activity level as prescribed by the health care provider; limb elevation; relief of discomfort with warm, moist heat; and analgesics as needed. Recent research is showing that ambulation, as previously thought, does not cause pulmonary embolism and does not cause the existing DVT to worsen. Therefore, the nurse should maintain the prescribed activity level, which could be bed rest or ambulation. Opioid analgesics are not required to relieve pain, and pain normally is relieved with acetaminophen provider (HCP) will most likely prescribe which option? Maintain activity level as prescribed.
A client has had surgery to repair a fractured left hip. When repositioning the client from side to side in the bed, what should the nurse plan to use as the most important item for this maneuver? ----- Abductor splint
Rationale: After surgery to repair a fractured hip, an abductor splint is used to maintain the affected extremity in good alignment. A bed pillow and an overhead trapeze also are used, but neither is the priority item to be used in repositioning the client from side to side.
The nurse is preparing to care for a client who had a supratentorial craniotomy. The nurse should plan to place the client in which po sition? Semi Fowler's
Rationale: you know why
The nurse is developing a plan of care for a client with Cushing's syndrome. The nurse documents a client problem of excess fluid volume. Which nursing actions should be included in the care plan for this client? Select all that apply.
Monitor daily weight. Monitor intake and output. Assess extremities for edema
Rationale: The client with Cushing's syndrome and a problem of excess fluid volume should be on daily weights and intake and output and have extremities assessed for edema. He or she should be maintained on a high-potassium, low-sodium diet.
A client with a history of ear problems is going on vacation by aircraft. The nurse advises the client to include which activities to prevent barotrauma during ascent and descent of the airplane? Select all that apply:
Yawning- Swallowing - Chewing gum - Sucking on a hard c ( its not what your thinking )
Rationale:
Clients who are prone to barotrauma should perform any of a variety of mouth movements to equalize pressure between the ear and the atmosphere, particularly during ascent and descent of an aircraft. These can include yawning, swallowing, drinking, chewing, and sucking on hard candy. Valsalva maneuver also may be helpful. The client should avoid sitting with the mouth motionless during this time because the resulting lack of pressure change in the ear will contribute to pressure buildup behind the tympanic membrane.
The nurse is assessing a client with an abdominal aortic aneurysm. Which assessment finding by the nurse is unrelated to the aneurysm? B
A. Pulsatile abdominal mass
B. Hyperactive bowel sounds in the area
C. Systolic bruit over the area of the mass
D. Subjective sensation of "heart beating" in the abdomen
Rationale: Hyperactive bowel sounds are not related specifically to an abdominal aortic aneurysm. Not all clients with abdominal aortic aneurysm exhibit symptoms. Those who do may describe a feeling of the "heart beating" in the abdomen when supine or being able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be auscultated over the mass.
The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective?
A rise in blood pressure
Following pericardiocentesis, the client usually expresses immediate relief. Heart sounds are no longer muffled or distant and blood pressure increases.
The nurse is creating a plan of care for a client with a diagnosis of nephrotic syndrome whose glomerular filtration rate (GFR) is normal. Which interventions should the nurse include in the plan of care? Select all that apply. All of these
Monitor daily weight.
Maintain sodium restrictions.
Monitor intake and output (I&O).
Maintain bed rest when edema is severe.
Rationale:Controlling edema is a critical aspect of therapeutic management of nephrotic syndrome. If the GFR is normal, dietary intake of proteins is needed to restore normal plasma oncotic pressure and thereby decrease edema. Daily measurement of weight and abdominal girth, and careful monitoring of I&O will determine whether weight loss is caused by diuresis or protein loss. Dietary modifications may include salt restriction and fluid restriction and are based on the client's symptoms. Bed rest is prescribed to promote diuresis when edema is severe.
The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal compartment. Which is the most appropriate action? Document the findings
Rationale: Bubbling in the water seal compartment is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. Therefore, it is unnecessary to call the HCP or change the chest tube drainage system. Continuous bubbling during inspiration and expiration indicat es an air leak. If this occurs, it must be corrected.
The nurse is planning discharge teaching for a client diagnosed and treated for compartment syndrome. Which information should the nurse include in the teaching?
"Bleeding and swelling caused increased pressure in an area that couldn't expand."
Rationale: Compartment syndrome is caused by bleeding and swelling within a tissue compartment that is lined by fascia, which does not expand. The bleeding and swelling put pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms.
The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply.
Head midline
Neck in neutral position
Head of bed elevated 30 to 45 degrees
Rationale:Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure from elevating. The head of the client at risk for or with increased intracranial pressure should be positioned so that it is in a neutral, midline position. The head of the bed should be raised to 30 to 45 degrees. The nurse should avoid flexing or extending the client's neck or turning the client's head from side to side.
The nurse is caring for a postoperative pneumonectomy client. Which finding on assessment of the client is an adverse sign or symptom indicating pulmonary edema? Lung crackles in the remaining lung
Rationale: The client with pulmonary edema that developed after pneumonectomy demonstrates dyspnea, cough, frothy sputum, crackles, and possibly cyanosis.
A client is scheduled for surgical creation of an internal arteriovenous (AV) fistula on the following day. The client says to the nurse, "I'll be so happy when the fistula is made tomorrow. This means I can have that other hemodialysis catheter pulled right out." Which interpretation should the nurse make based on the client's statement?
The client does not understand that the site needs to mature or develop for 1 to 2 weeks before use.
Rationale: An AV fistula is the internal creation of an arterial-to-venous anastomosis. This causes engorgement of the vein, allowing both the artery and the vein to be easily cannulated for hemodialysis. Fistulas take 1 to 2 weeks to mature (engorgement) or develop before they can be used for dialysis, so the current method of access must remain in place to be used during that period.
A client is admitted with suspected diabetic ketoacidosis (DKA). Which clinical manifestations best support a diagnosis of DKA?
1 glucose 500 mg/dL (27 mmol/L); arterial blood gases: pH 7, PaCo2 50, HCO3– 26.
2 glucose 400 mg/dL (22 mmol/L); arterial blood gases: pH 7, PaCo2 40, HCO3– 22.
3 glucose 450 mg/dL (25 mmol/L); arterial blood gases: pH 7, PaCo2 39, HCO3– 29.
4 glucose 350 mg/dL (19 mmol/L); arterial blood gases: pH 7, PaCo2 30, HCO3– 14.
Rationale: DKA is caused by a profound deficiency of insulin and is characterized by hyperglycemia (blood glucose level greater than or equal to 250 mg/dL [13 mmol/L]), ketosis (ketones in urine or serum), metabolic acidosis, and dehydration. The correct option is 4, as it represents an elevated blood glucose and the arterial blood gases (ABGs) indicate metabolic acidosis. Option 1 is incorrect, as the ABGs indicate respiratory acidosis; option 2 is incorrect, as the ABG values are within normal; and option 3 is incorrect, as the ABGs indicate metabolic alkalosis.
A client with ulcerative colitis has a prescription to begin a salicylate compound medication to reduce inflammation. What instruction should the nurse give the client regarding when to take this medication? After meals
Rationale: The medication needs to be taken after meals to reduce gastrointestinal irritation
A client with chronic kidney disease who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril. When should the nurse plan to administer this medication? On return from dialysis
Rationale: Antihypertensive medications such as enalapril are given to the client following hemodialysis. This prevents the client from becoming hypotensive during dialysis and from having the medication removed from the bloodstream by dialysis.
The nurse is monitoring the function of a client's chest tube that is attached to a drainage system. The nurse notes that the fluid in the water seal chamber rises
A client who has undergone gastric surgery has a nasogastric (NG) tube connected to low intermittent suction that is not draining properly. Which action should the nurse take initially? (3)
1 the surgeon to report the problem.
2 the NG tube to the proper location.
3 the suction device to make sure it is working.
4 the NG tube with saline to remove the obstruction.
Rationale:
After gastric surgery, the client will have an NG tube in place until bowel function returns. It is important for the NG tube to drain properly to prevent abdominal distention and vomiting. The nurse must ensure that the NG tube is attached to suction at the level prescribed and that the suction device is working correctly. The tip of the NG tube may be placed near the suture line. Because of this possibility, the nurse should never reposition the NG tube or irrigate it. If the NG tube needs to be repositioned, the nurse should call the surgeon, who would do this repositioning under fluoroscopy
The community health nurse is visiting a homeless shelter and is assessing the clients in the shelter for the presence of scabies. Which assessment finding should the nurse expect to note if scabies is present?
Brown-red macules with scales
Pustules on the trunk of the body
White patches noted on the elbows and knees
Multiple straight or wavy threadlike lines underneath the skin
Rationale:
Scabies can be identified by the multiple straight or wavy threadlike lines beneath the skin. The skin lesions are caused by the female, which burrows beneath the skin to lay its eggs. The eggs hatch in a few days, and the baby mites find their way to the skin surface, where they mate and complete the life cycle. Options 1, 2, and 3 are not characteristics of scabies.
The registered nurse is precepting a new nurse who is caring for a client with pernicious anemia as a result of gastrectomy. Which statement made by the new nurse indicates understanding of this diagnosis? "Decreased production of intrinsic factor by the stomach affects absorption of vitamin B12 in the small intestine." Rationale:
Intrinsic factor is produced in the stomach but is used to aid in the absorption of vitamin B12 in the small intestine.
The nurse has a prescription to obtain a urinalysis specimen from a client with an indwelling urinary catheter. Which actions should the nurse include in performing this procedure? Select all that apply. (1,2,3,5)
1 the procedure to the client
2 the tubing of the drainage bag
3 a sample from the port on the drainage tubing
4 the specimen from the urinary drainage bag
5 the port with an alcohol swab before inserting the syringe
Rationale:
A urine specimen is not taken from the urinary drainage bag. Urine undergoes chemical changes while sitting in the bag, so its properties do not necessarily reflect current client status. In addition, it may become contaminated with bacteria from opening the system. The remaining options are correct interventions for obtaining the specimen.
MEDSurg hesi - HESI hints for exam
Course: Medical Surgical nursing (NURS 1341)
University: Houston Community College
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