Medical Surgical Hesi Correct and Verified Answers Graded A

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Medical Surgical Hesi Correct and Verified Answers Graded A

• Question: An adult client is admitted to the hospital burn unit with partial-thickness and

full-thickness burns over 40% of the body surface area. In assessing the potential for skin regeneration, what should the nurse remember about full-thickness burns?Correct Answer: Regenerative function of the skin is absent because the dermal layer has been destroyed

• Question: A client has been taking oral corticosteroids for the past 5 days because of

seasonal allergies. Which assessment finding is of most concern to the nurse?

Correct Answer: Purulent sputum (indication of infection)

• Question: The nurse is teaching a female client who uses a contraceptive diaphragm

about reducing the risk for toxic shock syndrome (TSS). Which information should the nurse include?Correct Answer: Do not leave the diaphragm in place longer than 8 hours after intercourse

• Question: A client with a 16 year hx of DM is having renal function tests because of

recent fatigue, weakness, elevated BUN, and serum creatinine levels. Which finding should the nurse conclude as an early symptom of renal insufficiency?Correct Answer: Nocturia (in early stages polyuria is present from the inability of the kidneys to concentrate urine and contributes to nocturia)

• Question: Which findings should the nurse identify as most significant for a client

diagnosed with polycystic kidney disease (PKD)?

Correct Answer: 3+ bacteria in urine

• Question: The nurse is planning to initiate a socialization group for older residents of a

long-term facility. Which information would be most useful to the nurse when planning activities for the group?

Correct Answer: The usual activity patterns of each member of the group

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• Question: A client is admitted to the medical ICU with a dx of myocardial infarction. The

clients history indicates the infarction occurred ten hours ago. Which laboratory test result would the nurse expect this client to exhibit?Correct Answer: Elevated CK-MB (peaks within 12-20 hours post MI. Indicates myocardial damage)

• Question: A male client receives a local anesthetic during surgery. During the post-

operative assessment, the nurse notices the client is slurring his speech. Which action should the nurse take?

Correct Answer: Evaluate his BP, pulse, and respiratory status

• Question: A client taking a thiazide diuretic for the past 6 months has a serum

potassium level of 3 (normal 3.5-5). The nurse anticipates which changes in prescription for the client?

Correct Answer: A potassium supplement will be prescribed

• Question: Healthcare workers must protect themselves against becoming infected

with HIV. The Center for Disease Control has issued guidelines for healthcare workers in relation to protection from HIV. These guidelines include which recommendation?Correct Answer: Wear gloves when coming in contact with the blood or body fluids of any pt.

• Question: A client is admitted to the hospital with a dx of severe acute diverticulitis.

Which assessment finding should the nurse expect this client to exhibit?Correct Answer: Lower left quadrant pain and a low grade fever (because the sigmoid colon is the most common area and inflammation causes the fever)

• Question: A client with DM is experiencing polyphagia. Which outcome statement is

the priority for this client?

Correct Answer: Adequate cellular nutrition

• Question: During a health fair, a 72-year-old male client tells the nurse that he is

experiencing shortness of breath. Auscultation reveals crackles and wheezing in both lungs. Suspecting that the client might have chronic bronchitis, which classic symptom should the nurse expect this client to have?

Correct Answer: Productive cough with grayish-white sputum

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• Question: How should the nurse position the electrodes for modified chest lead one

(MCL I) telemetry monitoring?Correct Answer: Negative polarity left shoulder, positive polarity right chest nipple line, ground left chest nipple line

• Question: Despite several eye surgeries, a 78-year-old client who lives alone has

persistent vision problems. The visiting nurse is discussing painting the house with the client. The nurse suggests that the edge of the steps should be painted which color?

Correct Answer: Medium yellow

• Question: Which postmenopausal client's complaint should the nurse refer to the

healthcare provider?

Correct Answer: Episodes of vaginal bleeding

• Question: Which description of symptoms is characteristic of a client diagnosed with

trigeminal neuralgia (tic douloureux)?

Correct Answer: Sudden, stabbing, severe pain over the lip and chin

• Question: A client has a staging procedure for cancer of the breast and ask the nurse

which type of breast cancer has the poorest prognosis. Which information should the nurse offer the client?

Correct Answer: Inflammatory with peau d'orange

• Question: The nurse is completing an admission interview and assessment on a client

with a hx of Parkinson's dz. Which question provides information relevant to the client's plan of care?Correct Answer: Have you ever been "frozen" in one spot, unable to move?

• Question: After checking the urinary drainage system for kinks in the tubing, the nurse

determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 ml for the last 2 hours. What priority nursing action should be implemented?

Correct Answer: Report the findings to the surgeon

• Question: When providing discharge teaching for a client with osteoporosis, the nurse

should reinforce which home care activity?

Correct Answer: Elimination of hazards to home safety

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• Question: A client's susceptibility to ulcerative colitis is most likely due to which

aspect in the clients hx?

Correct Answer: Jewish European ancestry

• Question: The nurse is caring for a client with a stroke resulting in right-sided paresis

and aphasia. The client attempts to use the left hand for feeding and other self-care activities. The spouse becomes frustrated and insists on doing everything for the client.Based on this data, which nursing diagnosis should the nurse document for this client?Correct Answer: Disabled family coping r/t dissonant coping style of significant person

• Question: In assessing cancer risk, the nurse identifies which woman as being at

greatest risk of developing breast cancer?

Correct Answer: A 50 year old whose mother had unilateral breast cancer

• Question: A client has taken steroids for 12 years to help manage COPD. When making

a home visit, which nursing function is of greatest importance to this client? Assess the client's...

Correct Answer: Temperature

• Question: When preparing a client who has had a total laryngectomy for discharge,

what instruction is most important for the nurse to include in the discharge teaching?Correct Answer: Tell the client to carry a medic alert card stating that he is a total neck breather

• Question: Two days postoperative, a male client reports aching pain in his left leg. The

nurse assesses redness and warmth on the lower left calf. What intervention should be most helpful to this client?

Correct Answer: Advise the client to remain in bed with the leg elevated

• Question: The nurse notes that the only ECG for a 55-year-old male client scheduled

for surgery in two hours is dated two years ago. The client reports that he has a history of "heart trouble," but has no problems at present. Hospital protocol requires that those over 50 years of age have a recent ECG prior to surgery. What nursing action is best for the nurse to implement?

Correct Answer: Call for an ECG to be performed immediately