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HESI l Med l Surg l Version l 2 | l Questions l
and l 100% l Correct l Verified l Answers| 2025 / l
2026 l NEW l Update
QUESTION
l Al clientl takingl furosemidel (Lasix),l reportsl difficultyl sleeping.l Whatl questionl isl importantl forl thel nursel tol askl thel client? A)l Whatl dosel ofl medicationl arel youl taking?l B)l Arel youl eatingl foodsl richl inl potassium?l C)l Havel youl lostl weightl recently?l D)l Atl whatl timel dol youl takel yourl medication? Answer: D)l Atl whatl timel dol youl takel yourl medication? Thel nursel needsl tol firstl determinel atl whatl timel ofl dayl thel clientl takesl thel Lasixl (D).l Becausel ofl thel diureticl effectl ofl Lasix,l clientsl shouldl takel thel medicationl inl thel morningl tol preventl nocturia.l Thel actuall dosel ofl medicationl (A)l isl ofl lessl importancel thanl thel timel taken.l (B)l isl notl relatedl tol thel insomnia.l (C)l isl valuablel informationl aboutl thel effectl ofl thel diuretic,l butl isl notl likelyl tol bel relatedl tol insomnia.
QUESTION
l Thel nursel workingl inl al postoperativel surgicall clinicl isl assessingl al womanl whol hadl al leftl radicall mastectomyl forl breastl cancer.l Whichl factorl putsl thisl clientl atl greatestl riskl forl developingl lymphedema? A)l Shel sustainedl anl insectl bitel tol herl leftl arml yesterday.l B)l Shel hasl lostl twentyl poundsl sincel thel surgery.l C)l Herl healthcarel providerl nowl prescribesl al calciuml channell blockerl forl hypertension.l D)l Herl hobbyl isl playingl classicall musicl onl thel piano. Answer: A)l Shel sustainedl anl insectl bitel tol herl leftl arml yesterday.l Al radicall mastectomyl interruptsl lymphl flow,l andl thel increasedl lymphl flowl thatl occursl inl responsel tol thel insectl bitel increasesl thel riskl forl thel occurrencel ofl lymphedemal (A).l (B)l isl notl al factor.l Lymphedemal isl notl significantlyl relatedl tol vascularl circulationl (C).l
Onlyl overusel ofl thel arm,l suchl asl weight-lifting,l wouldl causel lymphedema--(D)l wouldl not.
QUESTION
l Thel nursel isl teachingl al femalel clientl whol usesl al contraceptivel diaphragml aboutl reducingl thel riskl forl toxicl shockl syndromel (TSS).l Whichl informationl shouldl thel nursel include?l (Selectl alll thatl apply.) A)l Removel thel diaphragml immediatelyl afterl intercourse.l B)l Washl thel diaphragml withl anl alcoholl solution.l C)l Usel thel diaphragml tol preventl conceptionl duringl thel menstruall cycle.l D)l Dol notl leavel thel diaphragml inl placel longerl thanl 8 l hoursl afterl intercourse.l E)l Contactl al healthcarel providerl al suddenl onsetl ofl feverl graterl thanl 101ºl Fl appears.l F)l Replacel thel oldl diaphragml everyl 3 l months. Answer: D)l Dol notl leavel thel diaphragml inl placel longerl thanl 8 l hoursl afterl intercourse.l E)l Contactl al healthcarel providerl al suddenl onsetl ofl feverl graterl thanl 101ºl Fl appears.l Correctl selectionsl arel (Dl andl E).l Thel diaphragml needsl tol remainl againstl thel cervixl forl 6 l tol 8 l hoursl tol preventl pregnancyl butl shouldl notl remainl forl longerl thanl 8 l hoursl (D)l tol avoidl thel riskl ofl TSS.l Ifl al suddenl feverl occurs,l thel clientl shouldl notifyl thel healthcarel providerl (E).l (A)l increasesl thel riskl ofl pregnancy,l andl (B)l canl reducel thel integrityl ofl thel barrierl contraceptivel butl neitherl preventsl thel riskl ofl TSS.l Thel diaphragml shouldl notl bel usedl duringl mensesl (C)l becausel itl obstructsl thel menstruall flowl andl isl notl indicatedl becausel conceptionl doesl notl occurl duringl thisl time.l (F)l isl notl necessary.
QUESTION
l Thel nursel isl assessingl al clientl whol hasl al historyl ofl Parkinson'sl diseasel forl thel pastl 5 l years.l Whatl symptomsl shouldl thisl clientl mostl likelyl exhibit? A)l Lossl ofl short-terml memory,l faciall ticsl andl grimaces,l andl constantl writhingl movements.l B)l Shufflingl gait,l masklikel faciall expression,l andl tremorsl ofl thel head.l C)l Extremel muscularl weakness,l easyl fatigability,l andl ptosis.l D)l Numbnessl ofl thel extremities,l lossl ofl balance,l andl visuall disturbances. Answer: B)l Shufflingl gait,l masklikel faciall expression,l andl tremorsl ofl thel head.l
QUESTION
l Inl preparingl tol administerl intravenousl albuminl tol al clientl followingl surgery,l whatl isl thel priorityl nursingl intervention?l (Selectl alll thatl apply.) A)l Setl thel infusionl pumpl tol infusel thel albuminl withinl fourl hours.l B)l Comparel thel client'sl bloodl typel withl thel labell onl thel albumin.l C)l Assignl al UAPl tol monitorl bloodl pressurel q15l minutes.l D)l Administerl throughl al largel gaugel catheter.l E)l Monitorl hemoglobinl andl hematocritl levels.l F)l Assessl forl increasedl bleedingl afterl administration. Answer: A)l Setl thel infusionl pumpl tol infusel thel albuminl withinl fourl hours.l D)l Administerl throughl al largel gaugel catheter.l E)l Monitorl hemoglobinl andl hematocritl levels.l F)l Assessl forl increasedl bleedingl afterl administration.l (A,l D,l E,l andl F)l arel thel correctl selections.l Albuminl shouldl bel infusedl withinl fourl hoursl becausel itl doesl notl containl anyl preservatives.l Anyl fluidl remainingl afterl fourl hoursl shouldl bel discardedl (A).l Albuminl administrationl doesl notl requirel bloodl typingl (B).l Vitall signsl shouldl bel monitoredl periodicallyl tol assessl forl fluidl volumel overload,l butl everyl 15 l minutesl isl notl necessaryl (C).l Thisl frequencyl isl oftenl usedl duringl thel firstl hourl ofl al bloodl transfusion.l Al largel gaugel catheterl (D)l allowsl forl fastl infusionl rate,l whichl mayl bel necessary.l Hemodilutionl mayl decreasel hemoglobinl andl hematocritl levelsl (E),l whilel increasedl bloodl volumel andl bloodl pressurel mayl causel bleedingl (F).
QUESTION
l Al clientl isl admittedl tol thel hospitall withl al diagnosisl ofl severel acutel diverticulitis.l Whichl assessmentl findingl shouldl thel nursel expectl thisl clientl tol exhibit? A)l Lowerl leftl quadrantl painl andl al low-gradel fever.l B)l Severel painl atl McBurney'sl pointl andl nausea.l C)l Abdominall painl andl intermittentl tenesmus.l D)l Exacerbationsl ofl severel diarrhea. Answer: A)l Lowerl leftl quadrantl painl andl al low-gradel fever.l Leftl lowerl quadrantl painl occursl withl diverticulitisl becausel thel sigmoidl colonl isl thel mostl commonl areal forl diverticula,l andl thel inflammationl ofl diverticulal causesl al low- gradel feverl (A).l (B)l wouldl bel indicativel ofl appendicitis.l (Cl andl D)l arel symptomsl exhibitedl withl ulcerativel colitis.
QUESTION
l Al clientl whol isl fullyl awakel afterl al gastroscopyl asksl thel nursel forl somethingl tol drink.l Afterl confirmingl thatl liquidsl arel allowed,l whichl assessmentl actionl shouldl thel nursel considerl al priority? A)l Listenl tol bilaterall lungl andl bowell sounds.l B)l Obtainl thel client'sl pulsel andl bloodl pressure.l C)l Assistl thel clientl tol thel bathrooml tol void.l D)l Checkl thel client'sl gagl andl swallowl reflexes. Answer: D)l Checkl thel client'sl gagl andl swallowl reflexes.l Followingl gastroscopy,l al clientl shouldl remainl nothingl byl mouthl untill thel effectsl ofl locall anesthesial havel dissipatedl andl thel airway'sl protectivel reflexes,l gagl andl swallowl reflexes,l havel returnedl (D).l (A,l B,l andl C)l arel notl thel priorityl beforel reintroducingl orall fluidsl afterl al gastroscopy.
QUESTION
l Al 49 - year-oldl femalel clientl arrivesl atl thel clinicl forl anl annuall examl andl asksl thel nursel whyl shel becomesl excessivelyl diaphoreticl andl feelsl warml duringl nighttime.l Whatl isl thel nurse'sl bestl response? A)l Explainl thel effectl ofl thel follicle-stimulatingl andl luteinizingl hormones.l B)l Discussl perimenopausel andl relatedl comfortl measures.l C)l Assessl lungl fieldsl andl forl al coughl productivel ofl blood-tingedl mucous.l D)l Askl ifl al feverl abovel 101ºl Fl hasl occurredl inl thel lastl 24 l hours. Answer: B)l Discussl perimenopausel andl relatedl comfortl measures.l Thel perimenopausall periodl beginsl aboutl 10 l yearsl beforel menopausel withl thel cessationl ofl menstruationl atl thel averagel agesl ofl 52 l tol 54.l Lowerl estrogenl levelsl causesl FSHl andl LHl secretionl inl burstsl (surges),l whichl triggersl vasomotorl instability,l nightl sweats,l andl hotl flashes,l sol discussionsl aboutl thel perimenopausall body'sl changes,l comfortl measuresl (B),l andl treatmentl optionsl shouldl bel provided.l In-depthl pathophysiologyl ofl thel symptomsl (A)l mayl onlyl confusel thel client.l Therel isl nol indicationl thatl thel clientl hasl tuberculosisl andl anl infection,l sol (Cl andl D)l arel notl indicated.
QUESTION
A)l Lymphl nodel involvementl isl notl significant.l B)l Smalll tumorsl arel aggressivel andl indicatel poorl prognosis.l C)l Thel tumor'sl estrogenl receptorl guidesl treatmentl options.l D)l Stagel Il indicatesl metastasis. Answer: C)l Thel tumor'sl estrogenl receptorl guidesl treatmentl options.l Treatmentl decisionsl (C)l andl predictionl ofl prognosisl arel relatedl tol thel tumor'sl receptorl status,l suchl asl estrogenl andl progesteronel receptorl statusl whichl commonlyl arel well- differentiated,l havel al lowerl chancel ofl recurrence,l andl arel receptivel tol hormonall therapy.l Tumorl stagingl designatesl tumorl sizel andl spreadl ofl breastl cancerl cellsl intol axillaryl lymphl nodes,l whichl isl onel ofl thel mostl importantl prognosticl factorsl inl early- stagel breastl cancer,l notl (A).l Largerl tumorsl arel morel likelyl tol indicatel poorl prognosis,l notl (B).l Stagel Il indicatesl thel cancerl isl localizedl andl hasl notl spreadl systemicallyl (D).
QUESTION
l Whichl healthcarel practicel isl mostl importantl forl thel nursel tol teachl al postmenopausall client? A)l Wearl layersl ofl clothesl ifl experiencingl hotl flashes.l B)l Usel al water-solublel lubricantl forl vaginall dryness.l C)l Consumel adequatel foodsl richl inl calcium.l D)l Participatel inl stimulatingl mentall exercises. Answer: C)l Consumel adequatel foodsl richl inl calcium.l Bonel densityl lossl associatedl withl osteoporosisl increasesl atl al morel rapidl ratel whenl estrogenl levelsl beginl tol fall,l sol thel mostl importantl healthcarel practicel duringl menopausel isl ensuringl anl adequatel calciuml (C)l intakel tol helpl maintainl bonel densityl andl preventl osteoporosis.l Althoughl practicesl suchl asl (Al andl B)l mayl reducel somel ofl thel discomfortsl forl al postmenopausall female,l calciuml intakel isl morel importantl thanl comfortl measures.l Althoughl sociall andl mentall exercisesl stimulatel thought,l therel isl nol scientificl evidencel thatl mentall exercisesl (D)l preventl demential orl commonl forgetfulnessl associatedl withl reducedl hormonall levels.
QUESTION
l Thel nursel isl preparingl al teachingl planl forl al clientl whol isl newlyl diagnosedl withl Typel 1 l diabetesl mellitus.l Whichl signsl andl symptomsl shouldl thel nursel describel whenl teachingl thel clientl aboutl hypoglycemia?
A)l Sweating,l trembling,l tachycardia.l B)l Polyuria,l polydipsia,l polyphagia.l C)l Nausea,l vomiting,l anorexia.l D)l Fruityl breath,l tachypnea,l chestl pain. Answer: A)l Sweating,l trembling,l tachycardia.l Sweating,l dizziness,l andl tremblingl arel signsl ofl hypoglycemicl reactionsl relatedl tol thel releasel ofl epinephrinel asl al compensatoryl responsel tol thel lowl bloodl sugarl (A).l (B,l C,l andl D)l dol notl describel commonl symptomsl ofl hypoglycemia.
QUESTION
l Whatl isl thel correctl procedurel forl performingl anl ophthalmoscopicl examinationl onl al client'sl rightl retina? A)l Instructl thel clientl tol lookl atl examiner'sl nosel andl notl movel his/herl eyesl duringl thel exam.l B)l Setl ophthalmoscopel onl thel plusl 2 l tol 3 l lensl andl holdl itl inl frontl ofl thel examiner'sl rightl eye.l C)l Froml al distancel ofl 8 l tol 12 l inchesl andl slightlyl tol thel side,l shinel thel lightl intol thel client'sl pupil.l D)l Forl optimuml visualization,l keepl thel ophthalmoscopel atl leastl 3 l inchesl froml thel client'sl eye. Answer: D)l Forl optimuml visualization,l keepl thel ophthalmoscopel atl leastl 3 l inchesl froml thel client'sl eye.l Thel clientl shouldl focusl onl al distantl objectl inl orderl tol promotel pupill dilation.l Thel ophthalmoscopel shouldl bel setl onl thel 0 l lensl tol beginl (createsl nol correctionl atl thel beginningl ofl thel exam),l andl shouldl bel heldl inl frontl ofl thel examiner'sl leftl eyel whenl examiningl thel client'sl rightl eye.l Forl optimuml visualization,l thel ophthalmoscopel shouldl bel keptl withinl onel tol threel inchesl ofl thel client'sl eyel (D).l (Al andl B)l describel incorrectl methodsl forl conductingl anl ophthalmoscopicl examination.l (C)l shouldl illicitl al redl reflexl asl thel lightl travelsl throughl thel crystallinel lensl tol thel retina.
QUESTION
l Thel nursel isl teachingl al femalel clientl aboutl thel bestl timel tol planl sexuall intercoursel inl orderl tol conceive.l Whichl informationl shouldl thel nursel provide? A)l Twol weeksl beforel menstruation.l
Answer: A)l Adenocarcinoma.l Adenocarcinomal isl thel onlyl lungl cancerl notl relatedl tol cigarettel smokingl (A).l Itl hasl beenl foundl tol bel directlyl relatedl tol lungl scarringl andl fibrosisl froml preexistingl pulmonaryl diseasel suchl asl TBl orl COPD.l Bothl (Bl andl D)l arel malignantl lungl cancersl relatedl tol cigarettel smoking.l (C)l isl al skinl cancerl andl isl relatedl tol exposurel tol sunlight,l notl tol lungl problems.
QUESTION
l Thel nursel assessesl al clientl withl advancedl cirrhosisl ofl thel liverl forl signsl ofl hepaticl encephalopathy.l Whichl findingl shouldl thel nursel considerl anl indicationl ofl progressivel hepaticl encephalopathy? A)l Anl increasel inl abdominall girth.l B)l Hypertensionl andl al boundingl pulse.l C)l Decreasedl bowell sounds.l D)l Difficultyl inl handwriting. Answer: D)l Difficultyl inl handwriting.l Al dailyl recordl inl handwritingl mayl providel evidencel ofl progressionl orl reversall ofl hepaticl encephalopathyl leadingl tol comal (D).l (A)l isl al signl ofl ascites.l (B)l arel notl seenl withl hepaticl encephalopathy.l (C)l doesl notl indicatel anl increasel inl seruml ammonial levell whichl isl thel primaryl causel ofl hepaticl encephalopathy.
QUESTION
l Al clientl whol hasl heartl failurel isl admittedl withl al seruml potassiuml levell ofl 2.9l mEq/L.l Whichl actionl isl mostl importantl forl thel nursel tol implement? A)l Givel 20 l mEql ofl potassiuml chloride.l B)l Initiatel continuousl cardiacl monitoring.l C)l Arrangel al consultationl withl thel dietician.l D)l Teachl aboutl thel sidel effectsl ofl diuretics. Answer: B)l Initiatel continuousl cardiacl monitoring.l
Hypokalemial (normall 3.5l tol 5 l mEq/L)l causesl changesl inl myocardiall irritabilityl andl ECGl waveform,l sol itl isl mostl importantl forl thel nursel tol initiatel continuousl cardiacl monitoringl (B)l tol identifyl ventricularl ectopyl orl otherl life-threateningl dysrhythmias.l Potassiuml chloridel (A)l shouldl bel givenl afterl cardiacl monitoringl isl initiatedl sol thatl thel effectsl ofl potassiuml replacementl onl thel cardiacl rhythml canl bel monitored.l (Cl andl D)l shouldl bel implementedl whenl thel clientl isl stable.
QUESTION
l Thel nursel isl planningl carel tol preventl complicationl forl al clientl withl multiplel myeloma.l Whichl interventionl isl mostl importantl forl thel nursel tol include? A)l Safetyl precautionsl duringl activity.l B)l Assessl forl changesl inl sizel ofl lymphl nodes.l C)l Maintainl al fluidl intakel ofl 3 l tol 4 l Ll perl day.l D)l Administerl narcoticl analgesicl aroundl thel clock. Answer: C)l Maintainl al fluidl intakel ofl 3 l tol 4 l Ll perl day.l Multiplel myelomal isl al malignancyl ofl plasmal cellsl thatl infiltratel bonel causingl demineralizationl andl hypercalcemia,l sol maintainingl al urinaryl outputl ofl 1.5l tol 2 l Ll perl dayl requiresl anl intakel ofl 3 l tol 4 l Ll (C)l tol promotel excretionl ofl seruml calcium.l Althoughl thel clientl isl atl riskl forl pathologicl fracturesl duel tol diffusel osteoporosis,l mobilizationl andl weightl bearingl (A)l shouldl bel encouragedl tol promotel bonel reabsorptionl ofl circulatingl calcium,l whichl canl causel renall complications.l (B)l isl al componentl ofl ongoingl assessment.l Chronicl painl managementl (D)l shouldl bel includedl inl thel planl ofl care,l butl preventionl ofl complicationsl relatedl tol hypercalcemial isl mostl important.
QUESTION
l Al clientl hasl al stagingl procedurel forl cancerl ofl thel breastl andl askl thel nursel whichl typel ofl breastl cancerl hasl thel poorestl prognosis.l Whichl informationl shouldl thel nursel offerl thel client? A)l Stagel II.l B)l Invasivel infiltratingl ductall carcinoma.l C)l T1N0M0.l D)l Inflammatoryl withl peaul d'orange. Answer: D)l Inflammatoryl withl peaul d'orange.l
Answer: D)l 6 l tol 12 l weeks.l Althoughl thel HIVl antigenl isl detectablel approximatelyl 2 l weeksl afterl exposure,l seroconversionl tol HIVl positivel mayl takel upl tol 6 l tol 12 l weeksl (D)l afterl exposure,l sol thel clientl shouldl returnl tol repeatl thel seruml screenl forl thel presencel ofl HIVl antibodiesl duringl thatl timel frame.l (A)l willl delayl treatmentl ifl thel clientl testsl positive.l (Bl andl C)l mayl providel inaccuratel resultsl becausel thel timel framel maybel tool earlyl tol reevaluatel thel client.
QUESTION
l Al 32 - year-oldl femalel clientl complainsl ofl severel abdominall painl eachl monthl beforel herl menstruall period,l painfull intercourse,l andl painfull defecation.l Whichl additionall historyl shouldl thel nursel obtainl thatl isl consistentl withl thel client'sl complaints? A)l Frequentl urinaryl tractl infections.l B)l Inabilityl tol getl pregnant.l C)l Premenstruall syndrome.l D)l Chronicl usel ofl laxatives. Answer: B)l Inabilityl tol getl pregnant.l Dysmenorrhea,l dyspareunia,l andl difficultyl orl painfull defecationl arel commonl symptomsl ofl endometriosis,l whichl isl thel abnormall displacementl ofl endometriall tissuel inl thel dependentl areasl ofl thel pelvicl peritoneum.l Al historyl ofl infertilityl (B)l isl anotherl commonl findingl associatedl withl endometriosis.l Althoughl (A,l C,l andl D)l arel common,l nonspecificl gynecologicall complaints,l thel mostl commonl complaintsl ofl thel clientl withl endometriosisl arel painl andl infertility.
QUESTION
l Thel nursel isl completingl anl admissionl interviewl andl assessmentl onl al clientl withl al historyl ofl Parkinson'sl disease.l Whichl questionl shouldl providel informationl relevantl tol thel client'sl planl ofl care? A)l Havel youl everl experiencedl anyl paralysisl ofl yourl armsl orl legs?l B)l Havel youl everl sustainedl al severel headl injury?l C)l Havel youl everl beenl 'frozen'l inl onel spot,l unablel tol move?l D)l Dol youl havel headaches,l especiallyl onesl withl throbbingl pain?
Answer: C)l Havel youl everl beenl 'frozen'l inl onel spot,l unablel tol move?l Clientsl withl Parkinson'sl diseasel frequentlyl experiencel difficultyl inl initiating,l maintaining,l andl performingl motorl activities.l Theyl mayl evenl experiencel beingl rootedl tol thel spotl andl unablel tol movel (C).l Parkinson'sl diseasel doesl notl causel (A).l Parkinson'sl diseasel isl notl usuallyl associatedl withl (B),l norl doesl itl typicallyl causel (D).
QUESTION
l Al femalel clientl requestsl informationl aboutl usingl thel calendarl methodl ofl contraception.l Whichl assessmentl isl mostl importantl forl thel nursel tol obtain? A)l Amountl ofl weightl gainl orl weightl lossl duringl thel previousl year.l B)l Anl accuratel menstruall cyclel diaryl forl thel pastl 6 l tol 12 l months.l C)l Skinl pigmentationl andl hairl texturel forl evidencel ofl hormonall changes.l D)l Previousl birth-controll methodsl andl beliefsl aboutl thel calendarl method. Answer: B)l Anl accuratel menstruall cyclel diaryl forl thel pastl 6 l tol 12 l months.l Thel fertilel period,l whichl occursl 2 l weeksl priorl tol thel onsetl ofl menses,l isl determinedl usingl anl accuratel recordl ofl thel numberl ofl daysl ofl thel menstruall cyclesl forl thel pastl 6 l months,l sol itl isl mostl importantl tol emphasizel tol thel clientl thatl accuracyl andl compliancyl ofl al menstruall diaryl (B)l isl thel basisl ofl thel calendarl method.l (Al andl C)l mayl bel partiallyl relatedl tol hormonall fluctuationsl butl arel notl indicatorsl forl usingl thel calendarl method.l (D)l mayl demonstratel clientl understandingl andl compliancyl butl isl notl thel mostl importantl aspect.
QUESTION
l Thel nursel isl caringl forl al clientl withl syndromel ofl inappropriatel antidiureticl hormonel (SIADH),l whichl isl manifestedl byl whichl symptoms? A)l Lossl ofl thirst,l weightl gain.l B)l Dependentl edema,l fever.l C)l Polydipsia,l polyuria.l D)l Hypernatremia,l tachypnea. Answer: A)l Lossl ofl thirst,l weightl gain.l SIADHl occursl whenl thel posteriorl pituitaryl glandl releasesl tool muchl ADH,l causingl waterl retention,l al urinel outputl ofl lessl thanl 20 l ml/hour,l andl dilutionall hyponatremia.l
dependingl onl sexuall stimulationl orl hormonall levels,l andl isl nol longerl recommendedl asl al reportablel symptoml whenl discoveredl duringl breastl self-examl (BSE).l Thel clientl mayl needl furtherl teachingl concerningl (D),l al disturbingl symptom,l butl itl isl notl asl importantl asl (C).
QUESTION
l Dysrhythmiasl arel al concernl forl anyl client.l However,l thel presencel ofl al dysrhythmial isl morel seriousl inl anl elderlyl personl because A)l elderlyl personsl usuallyl livel alonel andl cannotl summonl helpl whenl symptomsl appear.l B)l elderlyl personsl arel morel likelyl tol eatl high-fatl dietsl whichl makel theml susceptiblel tol heartl disease.l C)l cardiacl symptoms,l suchl asl confusion,l arel morel difficultl tol recognizel inl thel elderly.l D)l elderlyl personsl arel intolerantl ofl decreasedl cardiacl outputl whichl mayl resultl inl dizzinessl andl falls. Answer: D)l elderlyl personsl arel intolerantl ofl decreasedl cardiacl outputl whichl mayl resultl inl dizzinessl andl falls.l Cardiacl outputl isl decreasedl withl agingl (D).l Becausel ofl lossl ofl contractilityl andl elasticity,l bloodl flowl isl decreasedl andl tachycardial isl poorlyl tolerated.l Therefore,l ifl anl elderlyl personl experiencesl dysrhythmial (tachycardial orl bradycardia),l furtherl compromisingl theirl cardiacl output,l theyl arel morel likelyl tol experiencel syncope,l falls,l transientl ischemicl attacks,l andl possiblyl dementia.l Mostl elderlyl personsl dol notl eatl high- fatl dietsl (B)l andl mostl arel notl confusedl (C).l Althoughl manyl elderlyl personsl dol livel alone,l inabilityl tol summonl helpl (A)l cannotl bel assumed.
QUESTION
l Whichl reactionl shouldl thel nursel identifyl inl al clientl whol isl respondingl tol stimulationl ofl thel sympatheticl nervousl system? A)l Pupill constriction.l B)l Increasedl heartl rate.l C)l Bronchiall constriction.l D)l Decreasedl bloodl pressure. Answer: B)l Increasedl heartl rate.l Anyl stressorl thatl isl perceivedl asl threateningl tol homeostasisl actsl tol stimulatel thel sympatheticl nervousl systeml andl manifestsl asl al flight-or-fightl response,l whichl includesl
anl increasel inl heartl ratel (B).l (A,l C,l andl D)l arel responsesl ofl thel parasympatheticl nervousl system.
QUESTION
l Al clientl receivingl cholestyraminel (Questran)l forl hyperlipidemial shouldl bel evaluatedl forl whatl vitaminl deficiency? A)l K.l B)l B12.l C)l B6.l D)l C. Answer: A)l K.l Clientsl shouldl bel monitoredl forl anl increasedl prothrombinl timel andl prolongedl bleedingl timesl whichl wouldl alertl thel nursel tol al vitaminl Kl deficiencyl (A).l Thesel drugsl reducel absorptionl ofl thel fatl solublel (lipid)l vitaminsl A,l D,l E,l andl K.l (B,l C,l andl D)l arel notl fatl solublel vitamins.
QUESTION
l Al clientl experiencingl uncontrolledl atriall fibrillationl isl admittedl tol thel telemetryl unit.l Whatl initiall medicationl shouldl thel nursel anticipatel administeringl tol thel client? A)l Xylocainel (Lidocaine).l B)l Procainamidel (Pronestyl).l C)l Phenytoinl (Dilantin).l D)l Digoxinl (Lanoxin). Answer: D)l Digoxinl (Lanoxin).l Digoxinl (Lanoxin)l (D)l isl administeredl forl uncontrolled,l symptomaticl atriall fibrillationl resultingl inl al decreasedl cardiacl output.l Digoxinl slowsl thel ratel ofl conductionl byl prolongingl thel refractoryl periodl ofl thel AVl node,l thusl slowingl thel ventricularl response,l decreasingl thel heartl rate,l andl effectingl cardiacl output.l (A,l B,l andl C)l arel notl indicatedl inl thel initiall treatmentl ofl uncontrolledl atriall fibrillation.
QUESTION
A)l Faciall flushing.l B)l Fever.l C)l Poundingl headache.l D)l Feelingsl ofl dizziness. Answer: D)l Feelingsl ofl dizziness.l Feelingsl ofl dizzinessl mayl occurl asl thel resultl ofl al decreasedl heartl rate,l leadingl tol decreasedl cardiacl outputl (D).l (Al andl C)l willl notl occurl asl thel resultl ofl pacemakerl failure.l (B)l mayl bel anl indicationl ofl infectionl postoperatively,l butl isl notl anl indicationl ofl pacemakerl failure.
QUESTION
l Al clientl takingl al thiazidel diureticl forl thel pastl sixl monthsl hasl al seruml potassiuml levell ofl 3.l Thel nursel anticipatesl whichl changel inl prescriptionl forl thel client? A)l Thel dosagel ofl thel diureticl willl bel decreased.l B)l Thel diureticl willl bel discontinued.l C)l Al potassiuml supplementl willl bel prescribed.l D)l Thel dosagel ofl thel diureticl willl bel increased. Answer: C)l Al potassiuml supplementl willl bel prescribed.l Thisl client'sl potassiuml levell isl tool lowl (normall isl 3.5l tol 5).l Takingl al thiazidel diureticl oftenl resultsl inl al lossl ofl potassium,l sol al potassiuml supplementl needsl tol bel prescribedl tol restorel al normall seruml potassiuml levell (C).l (A,l B,l andl D)l arel notl recommendedl actionsl forl restoringl al normall seruml potassiuml level.
QUESTION
l Al 77 - year-oldl femalel clientl isl admittedl tol thel hospital.l Shel isl confused,l hasl nol appetite,l isl nauseatedl andl vomiting,l andl isl complainingl ofl al headache.l Herl pulsel ratel isl 43 l beatsl perl minute.l Whichl questionl isl al priorityl forl thel nursel tol askl thisl clientl orl herl familyl onl admission?l "Doesl thel client A)l havel herl ownl teethl orl dentures?"l B)l takel aspirinl andl ifl so,l howl much?"l C)l takel nitroglycerin?"l D)l takel digitalis?"
Answer: D)l takel digitalis?"l Elderlyl personsl arel particularlyl susceptiblel tol digitalisl intoxicationl (D)l whichl manifestsl itselfl inl suchl symptomsl asl anorexia,l nausea,l vomiting,l diarrhea,l headache,l andl fatigue.l Althoughl itl isl importantl tol obtainl al completel medicationl historyl (Bl andl C),l thel symptomsl describedl arel classicl forl digitalisl toxicity,l andl assessmentl ofl thisl probleml shouldl bel madel promptly.l (A)l isl irrelevant.
QUESTION
l Thel nursel isl caringl forl al clientl withl al continuousl feedingl throughl al percutaneousl endoscopicl gastrostomyl (PEG)l tube.l Whichl interventionl shouldl thel nursel includel inl thel planl ofl care? A)l Flushl thel tubel withl 50 l mll ofl waterl ql 8 l hours.l B)l Checkl forl tubel placementl andl residuall volumel q4l hours.l C)l Obtainl al dailyl x-l rayl tol verifyl tubel placement.l D)l Positionl onl leftl sidel withl headl ofl bedl elevatedl 45 l degrees. Answer: B)l Checkl forl tubel placementl andl residuall volumel q4l hours.l Tubel placementl andl residuall volumel shouldl bel checkedl beforel eachl feedingl (B).l Tubel placementl isl checkedl byl aspirationl ofl stomachl contentsl andl measurementl ofl pH.l Itl isl importantl tol checkl forl residuall volumel becausel gastricl emptyingl isl oftenl delayedl duringl illness.l Therel isl anl increasedl riskl forl aspirationl ofl thel feedingl withl increasedl residuall volume.l (A,l C,l andl D)l arel notl correctl proceduresl tol follow.
QUESTION
l Thel nursel isl takingl al historyl ofl al newlyl diagnosedl Typel 2 l diabeticl whol isl beginningl treatment.l Whichl subjectivel informationl isl mostl importantl forl thel nursel tol note? A)l Al historyl ofl obesity.l B)l Anl allergyl tol sulfal drugs.l C)l Cessationl ofl smokingl threel yearsl ago.l D)l Numbnessl inl thel solesl ofl thel feet. Answer: B)l Anl allergyl tol sulfal drugs.l Anl allergyl tol sulfal drugsl mayl makel thel clientl unablel tol usel somel ofl thel mostl commonl antihyperglycemicl agentsl (sulfonylureas).l Thel nursel needsl tol highlightl thisl
