Hesi edition 6: Medical- Surgical Correct and Verified Answers Graded A

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Hesi edition 6: Medical- Surgical Correct

and Verified Answers Graded A

• The nurse assesses a postoperative client whose skin is cool, pale, and moist. The

client is very restless and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which action should the nurse take first?

• Measure the urine specific gravity.
• Obtain IV fluids for infusion per protocol.
• Prepare for insertion of a central venous catheter.
• Auscultate the client's breath sounds.

Correct Answer: B

• The client returns to the unit after abdominal surgery with a 5" x 9" absorbent

dressing in place to the mid abdomen. The nurse notes a spot of red staining centrally on the dressing. What is the nurse's next action?

• Note the size of the stain in the chart.
• Circle the stain with an ink pen.
• Remove the dressing to assess the source of the bleeding.
• Place a pressure dressing on the existing dressing.

Correct Answer: B

• The nurse notes for the client undergoing peritoneal dialysis during the outflow

phase the draining dialysate suddenly stops. The outflow is one liter less than the inflow at this time. What is the next nursing action?

• Take the client's blood pressure.
• Take the client's weight.
• Call the health care provider (HCP).
• Have the client change positions.

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Correct Answer: D

• When assigning clients on a medical-surgical floor to an RN and a PN, it is best for

the charge nurse to assign which client to the PN?

• A young adult with bacterial meningitis with recent seizures
• An older adult client with pneumonia and viral meningitis
• A female client in isolation with meningococcal meningitis
• A male client 1 day postoperative after drainage of a brain abscess

Correct Answer: B

• The clinic nurse is providing post-operative teaching for a client scheduled for a

myringoplasty. Which client statements indicate to the nurse that the teaching has been effective? (Select all that apply.)

• "I can wash my hair in the shower when I get home."
• "I will avoid forceful and deep coughing until my post- op checkup."
• "I must lay flat on my non-operative side for the first 12 hours after surgery."
• "My hearing may be less or muffled until the packing comes out."
• "I need to only take the first two doses of antibiotics and save the rest for another time."

Correct Answer: B, C, D

• The nurse is preparing teaching for nursing students who are participating in a flu

vaccine clinic at a local school. Who should receive the vaccine? (Select all that apply.)

• Health care personnel
• Those who are allergic to eggs
• Individuals who are over 50 years old
• Individuals with chronic health conditions
• Those who live in nursing homes
• Infants under 6 months of age

Correct Answer: A, C, D, E

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• The nurse is concerned about infection for a client after an esophagogastrostomy

for esophageal cancer. Which actions should the nurse include in the client's plan of care? (Select all that apply.)

• Frequent oral care every 2 hours while awake.
• Use incentive spirometer every 2 hours.
• Empty contents from NG tube every 8 hours.
• Ambulate within 1 hour of return from the PACU.
• Limit visitors until postoperative day 2.

Correct Answer: A, B, C

• Client census is often used to determine staffing needs. Which method of obtaining

census determination for a particular unit provides the best formula for determining long-range staffing patterns?

• Midnight census
• Oncoming shift census
• Average daily census
• Hourly census

Correct Answer: C

• A 58-year-old client who has no health problems asks the nurse about receiving the

pneumococcal vaccine. Which statement given by the nurse would offer the client accurate information about this vaccine?

• The vaccine is given annually before the flu season to those older than 50 years.
• The immunization is administered once to older adults or those at risk for illness.
• The vaccine is for all ages and is given primarily to those persons traveling overseas to

areas of infection.

• The vaccine will prevent the occurrence of pneumococcal pneumonia for up to 5 years.

Correct Answer: B

• A client with cirrhosis develops increasing pedal edema and ascites. Which dietary

modification is most important for the nurse to teach this client?

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• Avoid high-carbohydrate foods.
• Decrease intake of fat-soluble vitamins.
• Decrease caloric intake.
• Restrict salt and fluid intake.

Correct Answer: D

• When developing a discharge teaching plan for a client after the insertion of a

permanent pacemaker, the nurse writes a goal of "The client will verbalize symptoms of pacemaker failure." Which behavior indicates that the goal has been met?

• The client demonstrates the procedures to change the rate of the pacemaker using a

magnet.

• The client carries a card in his wallet stating the type and serial number of the

pacemaker.

• The client tells the nurse that it is important to report redness and tenderness at the

insertion site.

• The client states that changes in the pulse and feelings of dizziness are significant

changes.

Correct Answer: D

• The nurse is completing an admission interview for a client with Parkinson disease.

Which question will provide additional information about manifestations that the client is likely to experience?

• "Have you ever experienced any paralysis of your arms or legs?"
• "Do you have frequent blackout spells?"
• "Have you ever been frozen in one spot, unable to move?"
• "Do you have headaches, especially ones with throbbing pain?"

Correct Answer: C

• What is the correct location for placement of the hands for manual chest

compressions during cardiopulmonary resuscitation (CPR) on the adult client?

• Just above the xiphoid process, on the upper third of the sternum
• Below the xiphoid process, midway between the sternum and the umbilicus