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Medical-Surgical HESI Practice Questions And Correct Detailed Answers (Verified Answers) Already Graded A+
- Which finding should the nurse identify as an indication of carbon monoxide
poisoning in a client who experienced a burn injury during a house fire?• Pulse oximetry reading of 80%.• Expiratory stridor and nasal flaring.• Cherry red color to the mucous membranes.• Presence of carbonaceous particles in sputum.
Correct Answer: Cherry red color to the mucous membranes.
Rationale: The saturation of hemoglobin molecules with carbon monoxide molecules, instead of oxygen molecules and the subsequent vasodilation induced cherry red color of the mucous membranes is an indication of carbon monoxide poisoning.
- A couple trying to cope with an infertility problem wants to know what can be done
to preserve emotional equilibrium. What is the best response for the nurse to provide?• "Tell your friends and family so that they can help you." • "Get involved with a support group. I will give you some names." • "Talk only to other friends who are infertile since only they can help." • "Start adoption proceedings immediately since obtaining an infant is very difficult." Correct Answer: "Get involved with a support group. I will give you some names." Rationale: A support group provides a safe haven for the couple to share their feelings and experience and gain insight from others dealing with the same experience and let's them know they are not alone in their situation.
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- The nurse is caring for a client with end stage liver disease who is being assessed for
the presence of asterixis. To assess the client for asterixis, what position should the nurse ask the client to demonstrate?• Extend the left arm laterally with the left palm upward.• Extend the arm, dorsiflex the wrist, and extend the fingers.• Extend the arms and hold this position for 30 seconds.• Extend arms with both legs adducted to shoulder width.
Correct Answer: Extend the arm, dorsiflex the wrist, and extend the fingers.
Rationale: Asterixis (flapping tremor, liver flap) is a hand-flapping tremor that is often seen frequently in hepatic encephalopathy. The tremor is induced by extending the arm and dorsiflexing the wrist causing rapid, non-rhythmic extension and flexion of the wrist while attempting to hold position.
- Which client is at highest risk for compromised psychological adjustment after a
- A man who smokes two packs of cigarettes a day wants to know if smoking is
hysterectomy?• A 46-year-old woman with three children and a recent promotion at work.• A 55-year-old woman with abnormal bleeding and pain for 3 years.• A 62-year-old widow who has three friends who had uncomplicated hysterectomies.• A 29-year-old woman whose uterus ruptured after giving birth to her first child.Correct Answer: A 29-year-old woman whose uterus ruptured after giving birth to her first child.Rationale: The client who is a primipara and is still in her childbearing years and is at highest risk for unresolved conflicts about the end of her childbearing opportunities.
contributing to the difficulty that he and his wife are having getting pregnant. What information is best for the nurse to provide? (Select all that apply.) • Only marijuana cigarettes affect sperm count.• Smoking can decrease the quantity and quality of sperm.• The first semen analysis should be repeated to confirm sperm counts.• Cessation of smoking improves general health and fertility.
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• Sperm specimens should be collected in 2 subsequent days.
Correct Answer:
• Smoking can decrease the quantity and quality of sperm.• The first semen analysis should be repeated to confirm sperm counts.• Cessation of smoking improves general health and fertility.Rationale: The use of tobacco, alcohol, and marijuana may affect a man's sperm counts.
- Which client should the nurse assess first?
• A 27-year-old complaining of severe back pain.• A 63-year-old complaining of foot and ankle pain.• A 49-year-old with pancreatitis complaining of unrelenting abdominal pain.• A 55-year-old newly admitted client complaining of jaw pain and indigestion.
Correct Answer: A 55-year-old newly admitted client complaining of jaw pain and
indigestion.Rationale: The 55-year-old client should be assessed first to rule out cardiac involvement because jaw pain and indigestion are common descriptors of myocardial injury.
- A client with rheumatoid arthritis is prescribed piroxicam (Feldene), a nonsteroidal
anti-inflammatory drug (NSAID). Which effect is characteristic of (NSAIDs) used for treating rheumatoid arthritis?• Production of replacement cartilage is stimulated.• Further destruction of the articular cartilage is prevented.• Inflammation is reduced by inhibiting prostaglandin synthesis.• Bradykinin is inhibited, thereby reducing acute and chronic pain.
Correct Answer: Inflammation is reduced by inhibiting prostaglandin synthesis.
Rationale: Nonsteroidal anti-inflammatory drugs (NSAIDs), used for treating rheumatoid arthritis, by inhibiting the synthesis of prostaglandins and providing relief from the associated pain.
- Which finding should the nurse report to the healthcare provider for a client with a
circumferential extremity burn?
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• Full thickness burns rather than partial thickness.• Supinates extremity but unable to fully pronate the extremity.• Slow capillary refill in the digits with absent distal pulse points.• Inability to distinguish sharp versus dull sensations in the extremity.Correct Answer: Slow capillary refill in the digits with absent distal pulse points.Rationale: A circumferential burn can form an eschar that results from burn exudate fluid that dries and acts as a tourniquet as fluid shifts occur in the interstitial tissue. As edema increases tissue pressure, blood flow to the distal extremity is compromised, which is manifested by slow capillary refill and absent distal pulses, so the healthcare provider should be notified about any compromised circulation that requires escharotomy.
- The unlicensed assistive personnel (UAP) reports that an 87-year-old female client
- A client who is admitted to the coronary care unit with a myocardial infarction (MI)
who is sitting in a chair at the bedside has an oral temperature of 97.2 F (36.4 C). Which intervention should the nurse implement?• Document the temperature reading on the vital sign graphic sheet.• Report the temperature to the healthcare provider immediately.• Instruct the UAP to take the client's temperature again in 30 minutes.• Advise the UAP to assist the client in returning to her bed.Correct Answer: Document the temperature reading on the vital sign graphic sheet.Rationale: A subnormal temperature of 97.2 F (36.4 C) (orally) is a common finding in elderly clients, so the nurse should document the findings and continue with the plan of care.
begins to develop increased pulmonary congestion, an increase in heart rate from 80 to 102 beats per minute, and cold, clammy skin. What action should the nurse implement?• Notify the healthcare provider.• Increase the IV flow rate.• Place the client in the supine position.• Prepare the client for an emergency echocardiography.
