(Complete 275 Q&A) Med-Surg II HESI Test Bank

- A nurse is collecting data from a client who has a possible cataract. Which of the following manifestations should the nurse expect the client to report?

1) Decreased color perception

2) Loss of peripheral vision

3) Bright flashes of light

4) Eyestrain

- A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.)

1) Encourage fluid intake.

2) Monitor the puncture site for hematoma.

3) Insert a urinary catheter.

4) Elevate the client's head of bed.

5) Apply a cervical collar to the client.

- A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical manifestations should the nurse expect to observe? (Select all that apply.)

1) Buffalo hump

2) Purple striations

3) Moon face

4) Tremors

5) Obese extremities

- A nurse is collecting data from a client who has an exacerbation of gout. Which of the following findings should the nurse expect? (Select all that apply.)

1) Edema

2) Erythema

3) Tophi

4) Tight skin

5) Symmetrical joint pain

- A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.)

1) Dyspnea

2) Barrel chest

3) Clubbing of the fingers

4) Shallow respirations

5) Bradycardia

- A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is to take hydroxyzine preoperatively. Which of the following effects of the medication should the nurse include in the teaching? (Select all that apply.)

1) Decreasing anxiety 2) Controlling emesis

3) Relaxing skeletal muscles

4) Preventing surgical site infections

5) Reducing the amount of narcotics needed for pain relief

- A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse notes there has not been any urinary output in the last hour. Which of the following actions should the nurse perform first?

1) Notify the provider.

2) Administer a prescribed analgesic.

3) Offer oral fluids.

4) Determine the patency of the tubing.

- A nurse in a provider's office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include?

1) Take this medication between meals.

2) Limit intake of Vitamin C while taking this medication.

3) Take this medication with milk.

4) Limit intake of whole grains while taking this medication.

- A nurse in a provider's office is reinforcing teaching with a client who has anemia and has been taking ferrous gluconate for several weeks. Which of the following instructions should the nurse include?

1) Take this medication between meals.

2) Limit intake of Vitamin C while taking this medication.

3) Take this medication with milk.

4) Limit intake of whole grains while taking this medication.

- A nurse is assisting in the care of a client who is 2 hours postoperative following a wedge resection of the left lung and has a chest tube to suction. Which of the following is the priority finding the nurse should report to the provider?

1) Abdomen is distended

2) Chest tube drainage of 70 mL in the last hour

3) Subcutaneous emphysema is noted to the left chest wall

4) Pain level of 6 on a 0 to 10 scale

- A nurse is assisting with the care of a client who has diabetes insipidus. The nurse should monitor the client for which of the following manifestations?

1) Hypotension

2) Polyphagia

3) Hyperglycemia

4) Bradycardia

- A nurse is assisting with the care of a client who is postoperative and has a closed-wound drainage system in place. Which of the following actions should the nurse take?

1) Fully recollapse the reservoir after emptying it.

2) Empty the reservoir once per day.

3) Replace the drainage plug after releasing hand pressure on the device.

4) Irrigate the tubing with sterile normal saline solution at least once every 8 hr.

- A nurse is caring for a client during the immediate postoperative period following thoracic surgery. When administering an opioid analgesic for pain, the nurse should explain that the medication should have which of the following effects?

1) Reducing anxiety

2) Increasing blood pressure

3) Increasing coughing

4) Increasing the client's respiratory rate

- A nurse is caring for a client following an open reduction and internal fixation of a fractured femur. Which of the following findings is the nurse's priority?

1) Altered level of consciousness

2) Oral temperature of 37.7° C (100° C)

3) Muscle spasms

4) Headache

- A nurse is caring for a client immediately following a cardiac catheterization with a femoral artery approach. Which of the following actions should the nurse take?

1) Check pedal pulses every 15 min.

2) Perform passive range-of-motion for the affected extremity.

3) Remind the client not to turn from side to side.

4) Keep the client in high-Fowler's position for 6 hr.

- A nurse is caring for a client newly diagnosed with ovarian cancer. Which of the following reactions from the client should the nurse initially expect?

1) Denial

2) Bargaining

3) Acceptance

4) Anger

- A nurse is caring for a client who has a temperature of 39.7° C (103.5° F) and has a prescription for a hypothermia blanket. The nurse should monitor the client for which of the following adverse effects of the hypothermia blanket?

A. Shivering B. Infection C. Burns

D. Hypervolemia

- A nurse is caring for a client who has Alzheimer's disease. The nurse discovers the client entering the room of another client, who becomes upset and frightened. Which of the following actions should the nurse take?

1) Attempt to determine what the client was looking for.

2) Explain the client's Alzheimer's diagnosis to the frightened client.

3) Reprimand the client for invading the other client's privacy.

4) Ask the client to apologize for his behavior.

- A nurse is caring for a client who has COPD. Which of the following actions should the nurse take?

1) Encourage the client to drink 8 glasses of water a day.

2) Instruct the client to cough every 4 hr.

3) Provide the client with a low protein diet.

4) Advise the client to lie down after eating.

- A nurse is caring for a client who has myasthenia gravis (MG). Which of the following is a complication of MG for which the nurse should monitor?

1) Respiratory difficulty

2) Confusion

3) Increased intracranial pressure

4) Joint pain

- A nurse is caring for a client who has partial-thickness and full-thickness burns of his head, neck, and chest. The nurse should recognize which of the following is the priority risk to the client?

1) Airway obstruction

2) Infection

3) Fluid imbalance

4) Contractures

- A nurse is caring for a client who is postoperative following a tracheostomy, and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions?

A. Provide humidified oxygen.

B. Perform chest physiotherapy prior to suctioning.

C. Prelubricate the suction catheter tip with sterile saline when suctioning the airway. D. Hyperventilate the client with 100% oxygen before suctioning the airway..

- A nurse is caring for a client who is postoperative open reduction and internal fixation with placement of a wound drain to repair a hip fracture. Which of the following actions should the nurse take?

1) Empty the suction device every 4 hr.

2) Monitor circulation on the affected extremity every 2 hr for the first 12 hr.

3) Position the client's hip so that it is internally rotated.

4) Encourage foot exercises every 4 hr.

- A nurse is collecting data from a client who has Cushing's syndrome. Which of the following manifestations should the nurse expect?

1) Bruising

2) Weight loss

3) Hyperpigmentation

4) Double vision

- A nurse is collecting data from a client who has open-angle glaucoma. Which of the following findings should the nurse expect?

1) Loss of peripheral vision

2) Headache

3) Halos around lights

4) Discomfort in the eyes

- A nurse is collecting data from a client who is having an acute asthma exacerbation. When auscultating the client's chest, the nurse should expect to hear which of the following sounds?

1) Expiratory wheeze

2) Pleural friction rub

3) Fine rales

4) Rhonchi

- A nurse is collecting data from a client who was bitten by a tick one week ago. Which of the following client manifestations should the nurse identify as an indication of the development of Lyme disease?

1) An expanding circular rash

2) Swollen, painful joints

3) Decreased level of consciousness

4) Necrosis at the site of the bite

- A nurse is collecting data on a client who has hyperthyroidism. Which of the following manifestations should the nurse expect the client to report?

1) Frequent mood changes

2) Constipation

3) Sensitivity to cold

4) Weight gain

- A nurse is contribution to the plan of care for a client who is 12 hr postoperative following a right radical mastectomy with closed suction drains present. The nurse should expect that the client will be unable to perform which of the following activities with her right arm?

1) Combing her hair

2) Eating her breakfast

3) Buttoning her blouse

4) Tying her shoes

- A nurse is evaluating discharge instructions for a client following a right cataract extraction. Which of the following client statements indicates the teaching is effective?

1) "I will take a stool softener until my eye is healed."

2) "I will expect to have moderately severe pain for 1-2 days."

3) "I will refrain from cooking for 1 week."

4) "I will bend at the waist to tie my shoes."

- A nurse is reinforcing discharge teaching to a client following arthroscopic surgery. To prevent postoperative complications which of the following actions should be reinforced during the teaching?

1) Administer an opioid analgesic to the client 30 min prior to initiating CPM exercises.

2) Place the client's affected leg into the CPM machine with the machine in the flexed position.

3) Place the client into a high Fowler's position when initiating the CPM exercises.

4) Align the joints of the CPM machine with the knee gatch in the client's bed.

- A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching?

1) Change the ostomy pouch daily.

2) Empty the ostomy pouch when it is 2/3 full.

3) Trim the opening of the ostomy seal to be 1/2 in. wider than the stoma.

4) Apply lotion to the peristomal skin when changing the ostomy pouch.

- A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching?

A. Avoid bending at the waist.

B. Remove the eye shield at bedtime.

C. Limit the use of laxatives if constipated.

D. Seeing flashes of light is an expected finding following extraction.

- A nurse is reinforcing teaching about pernicious anemia with a client following a total gastrectomy. Which of the following dietary supplements should the nurse include in the teaching as the treatment for pernicious anemia?

1) Vitamin B12

2) Vitamin C

3) Iron

4) Folate

- A nurse is reinforcing teaching about rifampin with a female client who has active tuberculosis. Which of the following statements should the nurse include in the teaching?

1) "You should wear glasses instead of contacts while taking this medication."

2) "The medication causes amenorrhea if taken along with an oral contraceptive."

3) "A yellow tint to the skin is an expected reaction to the medication."

4) "Lifelong treatment with this medication is necessary."

- A nurse is reinforcing teaching with a client about how to prevent the onset of manifestations of Raynaud's phenomenon. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

1) "I will keep my house at a cool temperature."

2) "I will try to anticipate and avoid stressful situations."

3) "I will complete the smoking cessation program I started."

4) "I will wear gloves when removing food from the freezer."

- A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching?

A. Take temperature once a day.

B. Wash the armpits and genitals with a gentle cleanser daily. C. Change the litter boxes while wearing gloves.

D. Wash dishes in warm water.

- A nurse is reinforcing teaching with a client who has iron deficiency anemia and is to start taking ferrous sulfate twice a day. Which of the following statements by the client indicate an understanding of the teaching?

1) "I will take the medication with orange juice."

2) "I should expect to have loose stools while taking this medication."

3) "I will have clay colored stools while taking this medication."

4) "I should take the medication with milk."

- A nurse is reinforcing teaching with a client who is newly diagnosed with myasthenia gravis and is to start taking neostigmine. Which of the following instructions should the nurse include in the teaching?

1) Take the medication 45 minutes before eating.

2) Expect diaphoresis as a side effect of the neostigmine.

3) If a medication dose is missed, wait until the next scheduled dose to take the medication.

4) Treat nasal rhinitis with an over-the-counter antihistamine.