MED-SURG II HESI TEST BANK 2023-2024 ACTUAL EXAM 350 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS) |AGRADE

MED-SURG II HESI TEST BANK 2023-2024 ACTUAL EXAM 350

QUESTIONS AND CORRECT DETAILED ANSWERS WITH

RATIONALES (VERIFIED ANSWERS) |AGRADE

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. - ANSWER- A, D

A nurse is caring for a client scheduled for a bone marrow biopsy. The client

expresses fear about the procedure and asks the nurse if the biopsy will hurt.

Which of the following responses should the nurse make?

1) "You must be very worried about what the biopsy will show."

2) "You'll be asleep for the whole biopsy procedure and won't be aware of what's

happening."

3) "Your provider scheduled this, so she will want to know you still have questions

about the procedure."

4) "The biopsy can be uncomfortable, but we will try to keep you as comfortable as

possible." - ANSWER- D.

A nurse is assisting with planning care for a client who is recovering from a lefthemispheric stroke. Which of the following interventions should the nurse include

in the plan?

1) Control impulsive behavior.

2) Compensate for left visual field deficits.

3) Re-establish communication.

4) Improve left-side motor function. - ANSWER- C.

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 - ANSWER- A.

A nurse is reviewing the laboratory results of a client who is postoperative and has

a respiratory rate of 7/min. The arterial blood gas (ABG) values include:

pH 7.22

PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg

Oxygen saturation 80%

Bicarbonate 28 mEq/L

Which of the following interpretations of the ABG values should the nurse make?

1) Metabolic acidosis

2) Respiratory acidosis

3) Metabolic alkalosis

4) Respiratory alkalosis - ANSWER- B.

A nurse is reinforcing teaching with a client who has peripheral vascular disease

(PVD). The nurse should recognize that which of the following statements by the

client indicates a need for further teaching?

1) "I will avoid crossing my legs at the knees."

2) "I will use a thermometer to check the temperature of my bath water."

3) "I will not go barefoot."

4) "I will wear stockings with elastic tops." - ANSWER- D.

A nurse is preparing to provide morning hygiene care for a client who has

Alzheimer's disease. The client becomes agitated and combative when the nurse

approaches him. Which of the following actions should the nurse plan to take?

1) Turn the water on and ask the client to test the temperature.

2) Obtain assistance to place mitten restraints on the client.

3) Firmly tell the client that good hygiene is important.

4) Calmly ask the client if he would like to listen to some music. - ANSWER- D.

A nurse is collecting data on a client's wound. The nurse observes that the wound

surface is covered with soft, red tissue that bleeds easily. The nurse should

recognize this is a manifestation of which of the following?

1) Decreased perfusion

2) Infection

3) Granulation tissue

4) An inflammatory response - ANSWER- C.

A nurse is caring for a client who has multiple myeloma and has a WBC count of

2,200/mm3. Which of the following food items brought by the family should the

nurse prohibit from being given to the client?

1) Baked chicken

2) Bagels

3) A factory-sealed box of chocolates

4) Fresh fruit basket - ANSWER- D.

A nurse is contributing to the plan of care for an older adult client who is

postoperative following a right hip arthroplasty. Which of the following

interventions should the nurse include in the plan?

1) Perform the client's personal care activities for her.

2) Limit the client's fluid intake.

3) Monitor the Homan's sign.

4) Maintain abduction of the right hip. - ANSWER- D.

A nurse is caring for a client who has heart failure and respiratory arrest. Which of

the following actions should the nurse take first?

1) Establish IV access.

2) Feel for a carotid pulse.

3) Establish an open airway.

4) Auscultate for breath sounds. - ANSWER- B.

A nurse is caring for a client scheduled for coronary artery bypass grafting who

reports he is no longer certain he wants to have the procedure. Which of the

following responses should the nurse make?

1) "Why have you changed your mind about the surgery?"

2) "Bypass surgery must be very frightening for you."

3) "Your provider would not have scheduled the surgery unless you needed it."

4) "I will call your doctor and have him discuss your surgery with you." -

ANSWER- B.

A nurse is caring for a client who is postoperative following foot surgery and is not

to bear weight on the operative foot. The nurse enters the room to discover the