HESI MED SURGE MAYO 11 2022

1. During spring break, a young adult presents at the urgent care clinic and reports a stiff neck, fever for
the past 6 hours, and a headache. Which intervention is most important for the nurse to implement?
(Suspect de meningitis)
Ans: Initiate isolation precautions.

2.Which food is most important for the nurse to encourage a client with osteomalacia to include in a daily
diet?
A. Fortified milk and cereals (Deficiency of vitamin D and Calcium)
B. Citrus fruits and juices
C. Red meats and eggs
D. Green leafy vegetables

3.Pt with petechiae and ecchymosis, which exam?

Ans: Platelet’s count

4.An older adult woman with a long history of chronic obstructive pulmonary disease (COPD) is admitted
with progressive shortness of breath and a persistent cough. She is anxious and is complaining of a dry
mouth. Which intervention should the nurse implement?

a. Assist her to an upright position.

b. Administer a prescribed sedative

c. Encourage client to drink water
d. Apply a high-flow venturi mask.

5.The nurse is planning care for an older adult male who experienced a cerebrovascular accident several
weeks ago. Because of his expressive aphasia, the client often becomes frustrated with the nursing staff.
Which intervention should the nurse implement?
a. speaks slowly to the pt
b. asks the pt simple questions
c. teach the pt use of basic sign language
d. encourage pt's use of picture charts.

6.The nurse is developing a plan of care for an adult client with cardiovascular disease who reports
blurred vision. Which outcome should the nurse include in the plan of care for this client?
A. The client's daily blood pressure will be less than 140/80 mmHg this month
B. The nurse will encourage the client to walk 30 minutes every day
C. The client's blood pressure readings will be less than 160/90. mmHg
D. The client will take up to 4 nitroglycerine tablets sublingually for chest pain.

7.The nurse observes an increased number of blood clots in the drainage tubing of a client with
continuous bladder irrigation following a transurethral resection of the prostate (TURP). What is the best
initial nursing action?
Ans: Provide additional oral fluid intake
8. An older female client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine
health assessment. To determine if the client is experiencing any long-term complication of DM, which
assessments should the nurse obtain? (Select all that apply)
a. Serum creatinine and blood urea nitrogen (BUN)
b. Sensation in feet and legs
c. Skin condition of lower extremities
d. Visual acuity
e. Signs of respiratory tract infection.

9.A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which
assessment finding warrants immediate intervention by the nurse?
A. Irregular apical pulse

B. Purple marks on the skin of the abdomen

C. Quarter size blood spot on dressing

D. Pitting ankle edema

10. A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath,
productive cough with thickened tenacious mucous, and the inability to walk up a flight of stairs without
experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-
care?
A. Increase the daily intake of oral fluids to liquefy secretions
B. Avoid crowded enclosed areas to reduce pathogen exposure
C. Call the clinic if undesirable side effects of mediations occur
D. Teach anxiety reduction methods for feelings of suffocation.
A. Increase the daily intake of oral fluids to liquefy secretions.

11. While caring for a client with a full-thickness burn covering 40% of the body, the nurse observes
purulent drainage at the wound. Before reporting this finding to the healthcare provides, the nurse should
review which of the client's laboratory values?
A. White blood cell count
B. Blood pH level
C. Platelet count
D. Hematocrit

12.A client with a chronic kidney disease is treated on hemodialysis. During the 1 treatment clients blood
pressure drops from 150/90 to 80/30. Which action should the nurse take first?
a. monitor bp q45 minutes
b. lowers the head of the chair and elevate feet (correct)
c. stops dialysis treatment
d. administers 5%albumin IV.

13.To reduce the risk for pulmonary complication for a client with amyotrophic lateral sclerosis (ALS),
what interventions should the nurse implement?
a. initiate passive range of motion
b. establish a regular routine
c. Teach the client breathing exercises
d. Perform chest physiotherapy
e. Encourage use of incentive spirometer

14. Paciente con diverticulosis Preguntaba de la dieta-

Ans: High-fiber and fluids

15. A female client who was involved in a motor vehicle collision is admitted with a fractured left femur
which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation
(ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions
should the nurse implement? (Select all that apply.)
B. Verify pedal pulses using a doppler pulse device.
C. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure
D. Evaluate the application of the splint to the left leg.

16.An adult female client is diagnosed with restless leg syndrome and is referred to the sleep clinic. The
healthcare provider prescribes ferrous sulfate (Feosol) 325 mg PO daily. Which laboratory values should
the nurse monitor?
a. Serum electrolytes
b. Neutrophils and eosinophils
c. Serum iron and ferritin
d. Platelet count and hematocrit

17. Patient with kidney stones has the infection as evidence that has complications risk. Who has more
risk?
R/ Patient who jog more than usual

18. Penicillin 500.000unit/1 ml, darle 200.000unit. Ans: 0.4 ml

19. A nurse is caring for a client with Diabetes Insipidus (DI). Which data warrants the most immediate
intervention by the nurse?
a. Serum sodium of 185 mEq/L
b. Dry skin with inelastic turgor
c. Apical rate of 110 beats/minute
d. Polyuria and excessive thirst

20. Video of a patient diagnosed with Diabetes Mellitus; the nurse teaches him how to apply
subcutaneous insulin. What should the nurse do?
R/ Continuous with the injection

21. Paciente con migraña y debilidad en las manos al examen neurológico y dolor en las articulaciones al
girar el doorknob. Que debe de hacer la enfermera?
Ans: Evitar caída por riesgo de injury
22. Paciente con cirrhosis hepática que tiene ascites y edema en los pies. Como se le explica el por qué
ocurre al paciente
Ans: Hypoalbuminemia

23. A client is admitted with a deep and productive cough, hemoptysis, and a low -grade fever and night
sweats. Which intervention should the nurse implement first?
A. Administer the initial dose of rifampin and isoniazid
B. Collect a sputum specimen for acid-fast bacillus
C. Provide a mask for the client to wear in public areas
D. Initiate airborne particulate isolation precautions.

24 An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the
priority nursing action?
A-Auscultate for presence of bowel sounds.
B-Monitor hemoglobin and hematocrit.
C-Encourage turning and Deep breathing.
D-Administer IV antibiotics as prescribed.

25.Taking prednisone PO 5 mg. What symptom (Corticosteroid)

Rapid weight gain

26.The family suspects that AIDS dementia is occurring in their son who is HIV positive. Which
symptom confirms their suspicions?
change has recently occurred in his handwriting.

27. Paciente con HIV y TB que se le realiza prueba de Mantoux y tiene 5mm'

Repetir en 2 meses
Positive test mean active tuberculosis
Multiple medication will need taken and over long time.

28.Paciente con lesion medular en C5 desde hace tiempo y que ahora presenta autonomic dysreflexia due
full bladder. Que sintomas responden a eso?? Buscar la respuesta donde aparecen estos sintomas
Elevated BP, Pounding headache ,sweating, nasal congestion, goose bumps, bradycardia

29. A male client with Herpes zoster (shingles) on his thorax tells the nurse that he is having difficulty
sleeping. What is the probable etiology of this problem?

A. Pain

B. Nocturia

C. Dyspnea
D. Frequent cough

30. The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD).
Which subjective data reported by the client supports this diagnosis?

upper mid abdominal gnawing and burning pain

31.Paciente con glaucoma, q empezo tratamiento y veia un túnel y estaba preocupado porque se iba a
quedar ciego , q debia hacer la enfermera
Decirle q siga con el tratamiento de las gotas.

32. Paciente que tiene un accidente y con una fractura tiene que ser operado y tiene tratamiento con
heparina 5000 unidades diarias Que debe hacer la enfermera??

R/ Avisar al medico about client’s medication list

33. A client with acute renal injury (AKI) who weighs 50 kg and has potassium level of 6.7 mEq/L (6.7
mmol/l) is admitted to the hospital. Which prescribed medication should the nurse administer first?
C. Sodium polystyrene (Kayexalate) 15 grams PO (ojo no decía Kayexalate)

34.The nurse is teaching a client who was recently diagnosed with gout how to manage the disease.
Which information should the nurse include in this client's teaching plan?

drink 6 – 8 cups of fluid every day

35. A male client tells the clinic nurse that he is experiencing burning on urination, and assessment
reveals that he had sexual intercourse four days ago with a woman he casually met. Which action should
the nurse implement?

A. Observe the perineal area for a chancroid-like lesion.

B. Obtain a specimen of urethral drainage for culture.
C. Assess for perineal itching, erythema and excoriation.
D. Identify all sexual partners in the last four days.

36. Which client has the highest risk for developing skin cancer?
A 65-year-old fair-skinned male who is a construction worker

37. Paciente con short of breath and difficult to arouse y con 4 parches de morfina colados en su piel. Lo
que a nurse debe hacer primero:
Quitar los parches de morfinas (esto fue lo q yo puse)
Usar antídoto
Colocar oxigeno
38. 43. Pneumonia con diagnostico por chest xray, que se le hace primero?

Cultivo de esputo

39. Paciente con ACV isquemico, que hace?

Cabeza a 30 grados/
Chequear historia medica sangrados y anticoagulantes/
Compresión alternada/
Chequear PT y plaquetas

40. After 3 days of persistent epigastric pain, a female patient presents to the clinic. She has been taking
oral antacids without relief. Her vital signs are 122 beats/min, respirations 16 breaths/min, O2 96% and
BP 116/70. The nurse obtains a 12-lead ECG. Which assessment finding is most critical?

ST elevation in three leads (PQRST) Is a medical emergency and it’s in 3 of the 12 leads)

41.The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy
two hours ago. The nurse observes the following vital sign: hear rate 140 beats/minute, respirations 26
breaths/minute, and blood pressure 140/90 mmHg. Which intervention is most important for the nurse to
implement?
Ans: Encourage the client to splint the incision with a pillow to cough and deep breathe.

42. The nurse is collecting information from a client with chronic pancreatitis who reports persistent
abdominal pain. To help client management, which assessment data is most important for the nurse to
obtain?
Ans: Eating pattern and dietary intake

43 Paciente con emphysema se va a la casa con oxigeno. Cual es el teaching mas importante?
How to use oxygen (correct)
Smoking sensation

44.Paciente que tiene orthopnea y le van a realizar una toracocentesis. Explicarle que es un procedimiento
se hace en up right position.

45 Diabetico con neuropatía recomendación?

Que los familiares ayuden con el chequeo de los pies/
Usar zapatos afuera y descalzo adentro

46 A client with cholelithiasis and jaundice has a gallstone lodged in the common bile duct and is unable
to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the
healthcare provider
A. Biliary emesis
B. Radiated right shoulder pain (correct)
C. Clay-colored stools
D. Distended, Hard, rigid abdomen

47. Paciente con fractura cerrada de tibia que lo operan y le colocan un tutor externo, Que debe incluir la
enfermera en el plan of care after surgery?

Impaiment of mobility

48.Paciente que es tratado en la emergencia por hipoglicemia, como sabe la enfermera si el paciente
entendio el teaching?

Usare salt, herbs and spices for food

Colocar la vacuna del flu todos los anos tan pronto este disponible

Lavarse los pies con agua caliente

Es la 4ta respuesta, la contestamos por descarte porque realmente todas las respuesta son raras

49.Enfermedad arterial periférica, recomendación?

Mirar los pies con un Espejo (por si tiene los pies rotos (break down))
poner calor
remojar en agua por 1hora

50. Infusion de 1000cc en 6 horas: Ans:167 ml/hora

51. Hypertiroidismo y exoftalmia?
Colocar gotas para lubricar el ojo