HESI Med Surg V1 ,HESI Med Surg V2 Exam:
Questions & Answers
The nurse obtains a fingerstick glucose level utilizing bedside lancet/glucose meter equipment from a client with prescribed sliding scale insulin protocol. The meter indicates 56 mg/dl (3.12 mmol/l). At this time which intervention should the nurse implement first?
- Collect a blood specimen by venipuncture to send to the laboratory for
- Prepare the prescribed dose of rapid acting insulin from the sliding scale
- Give the client six ounces of non-diet carbonated soda and instruct to
- Document the glucose reading in the electronic medical record as the
serum glucose analysis.
instructions.
drink it entirely.
only action needed.(Ans- C
To achieve maximum mobility and independence for a client with multiple sclerosis (MS), which intervention is most important for the nurse to implement?
- Provide a walker for ambulation
- Frequently assist the client to the bathroom
- Apply alternating patches over eyes
- Teach strengthening exercises
(Ans- D
A client is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires immediate intervention by the nurse?
- Pupillary changes to ipsilateral dilation
- Orientation to person and place only 1 / 4
- Left- sided drooping and dysphagia
- Unequal bilateral hand grip strengths
(Ans- C
The nurse is teaching a client with glomerulonephritis about self care.Which dietary recommendations should the nurse encourage the client to follow?
- Limit oral fluid intake to 500 ml per day
- Restrict protein intake by limiting meats and other high-protein foods
- Increase intake of potassium-rich foods such as bananas and
- Increase intake of high fiber foods such as bran cereal
cantaloupe.
(Ans- B
The nurse is caring for a client with Herpes zoster who reports painful, red, blisters that align from the back along the chest's curvature to the anterior chest. Which intervention is the highest priority for the nurse?
- Place the client on contact precautions
- Administer antiviral medications
- Place wet compresses to ruptured vesicles
- Administer narcotic analgesics
(Ans- B
A young adult who suffered a severe brain injury in an automobile collision has been mechanically ventilated for the past three days and has no spontaneous respiratory effort. After serial electroencephalograms (EEG) reveal no brain activity, the healthcare provider discusses end-of-life options with the family who agree to discontinue life support. Which intervention should the nurse implement?
- Ask the family if they wish to remain at the bedside during withdrawal
- Request a living will be placed in the clients medical record
- Discuss the withdrawal procedure with the family and offer support 2 / 4
- Turn off mechanical ventilator and note time of death
(Ans- C
Following a transurethral resection of the prostate (TURP), a client is discharged from the hospital with an indwelling urinary catheter. which instruction is important for the nurse to include in the discharge teaching plan?
- Eliminate all spicy foods from your diet
- Drink 3 liters of water each day
- Clamp the catheter when taking a shower
- Avoid driving a car for 2 weeks
(Ans- B
On the first postoperative day, the nurse finds an older male client disoriented and trying to climb over the bed railing. Previously, he was oriented to person, place, and time on admission. Which intervention should the nurse implement first?
- Apply wrist restraints
- Determine the clients blood pressure
- Administer a mild sedative
- Assess the client for pain
(Ans- D
Acute soft tissue injuries ( ie sprains, strains) provide the nurse with a variety of teaching opportunities. Which instruction should the nurse provide to a client with a soft-tissue injury?
- Watch for shortness of breath which may indicate a fat embolus
- Begin range of motion exercises within the first 24 hours
- Apply ice intermittently for the first 24 hours
- After edema subsides, apply heat continuously
- / 4
(Ans- C
A client returns to the unit following a craniotomy for removal of a brain tumor and is obtunded, but arouses to painful stimuli. Which assessment is most important for the nurse to obtain?
- Drainage on dressing
- Last administration of analgesia
- Body Temperature
- Serial blood pressure and pulse
(Ans- B
A male client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of his right arm. When the nurse enters the room, he is struggling to put on a shirt, and he curses at the nurse. What is the best first response by the nurse?
- We will give you a class on dressing tomorrow
- This unit has a policy against staff harassment
- Dressing must be a frustrating experience for you
- It is important to dress the right arm first
(Ans- C
An older client who is agitated, dyspneic, orthopneic, and using accessory muscles to breathe is admitted for further treatment. Initial assessment includes a heart rate of 126 bpm and irregular, respirations 36 breaths per min, blood pressure 168/100 mmHg, wheezes and crackles in all lung fields. An hour after the administration of furosemide 60mg iv, which assessment should the nurse obtain to determine the clients response to the treatment? (Select all that apply)
- Skin elasticity
- Pain scale
- Lung sounds
- Urinary output
- Oxygen Saturation
- / 4
(Ans- C, D, E