HESI Med Surg Questions And Correct Detailed Answers (Verified Answers) Already Graded A+

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HESI Med Surg Questions And Correct Detailed Answers (Verified Answers) Already Graded A+

• Question: Two clients ring their call bells simultaneously requesting pain medication.

What action should the nurse implement first?Correct Answer: Evaluate both clients’ pain using the standardized pain scale.

• Question: The nurse is caring for a client who is overweight and becoming diaphoretic.

What should the nurse include when assessing the client’s personal care and hygiene?Correct Answer: Assessment of skinfolds of the perineal area, observed skin under folds, and check the skin for unusual bruising.

• Question: When preparing to obtain a stool specimen for an occult blood test, the nurse

observes that the stool is tarry and black. Which action should the nurse implement?Correct Answer: Obtain the specimen from the patient’s current bowel movement.

• Question: The nurse observes a newly employed unlicensed assistive personnel (UAP)

checking the temperature of an adult using a tympanic thermometer. The UAP pulls the client’s auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?Correct Answer: Provide positive reinforcement to confirm that the procedure is being performed correctly.

• Question: The client is a 65-year-old woman who had an anteroposterior spinal fusion

two days ago. She tolerated the procedure well and has progressively increased her walking distance. Which action should the nurse take?Correct Answer: Consult with the surgeon, lead the client to guided imagery, and assess for sources of pain.

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• Question: A client who had an emergency gallbladder surgery yesterday is preparing for

discharge. When teaching wound care, which method should the nurse use to evaluate the client’s understanding of self-care at home?

Correct Answer: Have the client demonstrate the prescribed wound care.

• Question: The nurse is assisting a client who has a history of obstructive sleep apnea

with care. Which action should the nurse implement before leaving the client?

Correct Answer: Apply the client’s positive airway pressure device.

• Question: A client was involved in a multicar collision six days ago and sustained a liver

laceration, right rib fracture, and right femur fracture. The liver laceration was repaired.What are the recommended exercises and parameters to monitor?

Correct Answer:

• Exercise: Isometric.

• Actions: Support the extremity during the exercise routine, have the client contract the muscle group for 10 seconds then release.• Monitor: Number of muscle group contractions, relaxation repetitions, pain level.

• Question: A client is a 47-year-old female with a history of type 2 diabetes mellitus. She

is in the hospital recovering from pneumonia. During a sleep assessment, the client informs the nurse that she will never get eight hours of sleep because she wakes up several times at night to urinate. What are the potential conditions and actions to take?

Correct Answer:

• Potential Condition: Nocturia.

• Actions: Implement fall precautions, review home medication.

• Monitor: Diabetes, UTI.

• Question: A 75-year-old male presents to the emergency department with poorly

controlled diabetes. He has been experiencing polyuria, nausea, vomiting, confusion, and unstable blood sugars. What are the potential conditions and actions to take?

Correct Answer:

• Potential Condition: Diabetic complications, pressure injury.

• Actions: Offload coccyx and other bony prominences, cleanse and dress wounds.

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• Monitor: Wound status and documentation of skin prevention measures.

• Question: The client’s spouse has just learned of the client’s terminal illness. The

spouse is sitting in the corner and says to the nurse, "I feel as if I’m already so alone." Which action should the nurse take?

Correct Answer: Encourage the spouse to share their feelings.

• Question: The nurse is caring for a client with a history of neuropathy who reports

increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is a priority for promoting foot care at this time?

Correct Answer: Risk for impaired skin integrity.

• Question: A client is being admitted to the unit with a varicella zoster virus infection.

Which room should the nurse assign to the client?

Correct Answer: A private room with both contact and airborne precautions.

• Question: When assessing a client with a serum potassium level of 2.5 mEq, which

assessment is most important for the nurse to perform?

Correct Answer: Determine apical heart rate and rhythm.

• Question: A client in contact isolation due to a stage IV toxic wound infection with

MRSA requires multiple interventions. In which order should the nurse perform interventions?Correct Answer: Restart the IV line, perform tracheostomy care, change the coccyx dressing.

• Question: A client on a mechanical soft diet is experiencing constipation and asks the

nurse for a glass of prune juice. The nurse notes decreased bowel sounds. Which action should the nurse implement?

Correct Answer: Offer warm prune juice.

• Question: The nurse assesses a client who has a nasal cannula delivering oxygen to

determine if there is any skin irritation from the cannula. Which areas should the nurse observe?

Correct Answer: Top of the ears, around the nostrils, over the cheeks.

• Question: The nurse is caring for a client in isolation who requires wound care. The

nurse should perform actions in which order?

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Correct Answer: Wash hands, put on isolation gown, apply a surgical mask, don gloves.

• Question: The nurse is conducting an initial admission assessment for a woman

scheduled for a cesarean section within the next 24 hours. Which action should the nurse take?

Correct Answer: Determine the client’s decision about blood transfusion.

• Question: When administering a new medication to a client, the nurse logs into the

electronic medical health administration record. Which action should the nurse take next?Correct Answer: Verify the client’s identification by scanning the barcode on the armband.

• Question: A child has experienced several episodes of vomiting. After reviewing the

diet, the parent reports making clear liquid popsicles at a flavored gelatin for the child.What information should the nurse obtain about the popsicles?

Correct Answer: Whether they contain fruit or pulp.

• Question: A client with fluid overload is admitted to the hospital for diuresis. Which

assessment should the nurse use to evaluate fluid balance?

Correct Answer: Weight.

• Question: The palliative care nurse receives a consult for a terminally ill client in the

intensive care. The client is weak, mouth-breathing, and refusing to eat or drink. Which intervention should the nurse include in the plan of care?

Correct Answer: Keep mucous membranes moist.

• Question: While measuring vital signs, the nurse observes that the client is using

accessory neck muscles during respirations. Which follow-up action should the nurse take?

Correct Answer: Measure oxygen saturation.

• Question: To assess the quality of a client’s pain, which approach should the nurse

take?

Correct Answer: Ask the client to describe the pain.

• Question: The electronic medication system alerts the nurse that the medication dose

scanned for the client is two times higher than the prescribed dose. Which action should the nurse implement?

Correct Answer: Calculate the dose on hand to match the prescribed dose.