MED SURG II HESI EXAM (3 NEWEST VERSIONS) 2024 ACTUAL EXAM 450 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |ALREADY GRADED A+

1 | P a g e

MED SURG II HESI EXAM (3 NEWEST VERSIONS) 2024

ACTUAL EXAM 450 QUESTIONS AND CORRECT

DETAILED ANSWERS WITH RATIONALES (VERIFIED

ANSWERS) |ALREADY GRADED A+

MED SURG II HESI EXAM VERSION A

A client receiving cholestyramine (Questran) for hyperlipidemia should

be evaluated for what vitamin deficiency?

A) K.

B) B12.

C) B6.

D) C. - ANSWER- A) K.

Rationale: Clients should be monitored for an increased

prothrombin time and prolonged bleeding times which would alert

the nurse to a vitamin K deficiency (A). These drugs reduce

absorption of the fat soluble (lipid) vitamins A, D, E, and K. (B, C,

and D) are not fat soluble vitamins.

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?

2 | P a g e

A) Situational low self-esteem related to functional impairment and

change in role function.

B) Disabled family coping related to dissonant coping style of

significant person.

C) Interrupted family processes related to shift in health status of family

member.

D) Risk for ineffective therapeutic regimen management related to

complexity of care. - ANSWER- B) Disabled family coping related to

dissonant coping style of significant person.

Rationale: A stroke affects the whole family and in this case the

spouse probably thinks that she is helping and needs to feel that she

is contributing to the client's care. Her help is noted as being

incongruent with attempts of self-care by the client thereby

disabling family coping (B). The scenario does not discuss the

client's self-esteem (A), interrupted family processes (C) or the risk

for ineffective therapeutic regimen (D).

When teaching diaphragmatic breathing to a client with chronic

obstructive pulmonary disease (COPD), which information should the

nurse provide?

A) Place a small book or magazine on the abdomen and make it rise

while inhaling deeply.

B) Purse the lips while inhaling as deeply as possible and then exhale

through the nose.

C) Wrap a towel around the abdomen and push against the towel while

forcefully exhaling.

3 | P a g e

D) Place one hand on the chest, one hand the abdomen and make both

hands move outward. - ANSWER- A) Place a small book or magazine

on the abdomen and make it rise while inhaling deeply.

Rationale: Diaphragmatic or abdominal breathing uses the

diaphragm instead of accessory muscles to achieve maximum

inhalation and to slow the respiratory rate. The client should

protrude the abdomen on inhalation and contract it with exhalation,

so (A) helps the client visualize the rise and fall of the abdomen. The

client should purse the lips while exhaling, not (B). (C and D) are

ineffective.

A middle-aged male client with diabetes continues to eat an abundance

of foods that are high in sugar and fat. According to the Health Belief

Model, which event is most likely to increase the client's willingness to

become compliant with the prescribed diet?

A) He visits his diabetic brother who just had surgery to amputate an

infected foot.

B) He is provided with the most current information about the dangers

of untreated diabetes.

C) He comments on the community service announcements about

preventing complications associated with diabetes.

D) His wife expresses a sincere willingness to prepare meals that are

within his prescribed diet. - ANSWER- A) He visits his diabetic brother

who just had surgery to amputate an infected foot.

Rationale: The loss of a limb by a family member (A) will be the

strongest event or "cue to action" and is most likely to increase the

4 | P a g e

perceived seriousness of the disease. (B, C, and D) may influence his

behavior but do not have the personal impact of (A).

After the fourth dose of gentamicin sulfate (Garamycin) IV, the nurse

plans to draw blood samples to determine peak and trough levels. When

are the best times to draw these samples?

A) 15 minutes before and 15 minutes after the next dose.

B) One hour before and one hour after the next dose.

C) 5 minutes before and 30 minutes after the next dose.

D) 30 minutes before and 30 minutes after the next dose. - ANSWERC) 5 minutes before and 30 minutes after the next dose.

Rationale: Peak drug serum levels are achieved 30 minutes after IV

administration of aminoglycosides. The best time to draw a trough is

the closest time to the next administration (C). (A, B, and D) are not

as good a time to draw the trough as (C). (B and D) are not the best

times to draw the peak of an aminoglycoside that has been

administered IV.

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?

A) Racing pulse with exertion.

B) Clubbing of the fingers.

C) An increased chest diameter.