HESI Medical Surgical Review Questions With Answers (244 Solved Questions)

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A client who has undergone abdominal surgery calls the nurse and reports that she just felt“something give way” in the abdominal incision. The nurse checks the incision and notes thepresence of wound dehiscence. The nurse immediately:Contacts the physicianDocuments the findingsPlaces the client in a supine position with the legs flatCovers the abdominal wound with a sterile dressing moistened with sterile saline solutionRationale: Wound dehiscence is the disruption of a surgical incision or wound. Whendehiscence occurs,the nurse immediately places the client in a low Fowler’s position or supinewith the knees bent and instructs the client to lie quietly. These actions will minimize protrusionof the underlying tissues. The nurse then covers the wound with a sterile dressing moistenedwith sterile saline. The physician is notified, and the nurse documents the occurrence and thenursing actions that were implemented in response.Test-Taking Strategy: Use the process of elimination and note the strategic word “immediately.”Visualize this occurrence and recall that the primary concern when wound dehiscence occurs isthe protrusion of underlying tissues. This will direct you to the correct option. Review the nursingactions to be taken immediately in the event of wound dehiscence if you had difficulty with thisquestion.A client who just returned from the recovery room after a tonsillectomy and adenoidectomy isrestless and her pulse rate is increased. As the nurse continues the assessment, the clientbegins to vomit a copious amount of bright-red blood. The immediate nursing action is to:Notify the surgeonContinue the assessmentCheck the client’s blood pressureObtain a flashlight, gauze, and a curved hemostatRationale: Hemorrhage is a potential complication after tonsillectomy and adenoidectomy. If theclient vomits a large amount of bright-red blood or the pulse rate increases and the patient isrestless, the nurse must notify the surgeon immediately. The nurse should obtain a light, mirror,gauze, curved hemostat, and waste basin to facilitate examination of the surgical site. Thenurse should also gather additional assessment data, but the surgeon must be contactedimmediately.Test-Taking Strategy: Focus on the data in the question. Noting the words “bright-red blood” willassist in directing you to the correct option. Remember that the presence of bright-red bloodindicates active bleeding. Review the nursing actions to be taken immediately when bleedingoccurs after a tonsillectomy and adenoidectomy if you had difficulty with this question.

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A client who has just undergone surgery suddenly experiences chest pain, dyspnea, andtachypnea. The nurse suspects that the client has a pulmonary embolism and immediately setsabout:Preparing the client for a perfusion scanAttaching the client to a cardiac monitorAdministering oxygen by way of nasal cannula CorrectEnsuring that the intravenous (IV) line is patentRationale: Pulmonary embolism is a life-threatening emergency. Oxygen is immediatelyadministered nasally to relieve hypoxemia, respiratory distress, and central cyanosis, and thephysician is notified. IV infusion lines are needed to administer medications or fluids. Aperfusion scan, among other tests, may be performed. The electrocardiogram is monitored forthe presence of dysrhythmias. Additionally, a urinary catheter may be inserted and blood forarterial blood gas determinations drawn. The immediate priority, however, is the administrationof oxygen.Test-Taking Strategy: Focus on the client’s diagnosis and use the skills of prioritizing. Apply theABCs (airway, breathing, and circulation) to find the correct option. Review the nursing actionsto be taken immediately in the event of pulmonary embolism if you had difficulty with thisquestion.A nurse is assessing a client who has a closed chest tube drainage system. The nurse notesconstant bubbling in the water seal chamber. What actions should the nurse take? (Select allthat apply).Clamping the chest tubeChanging the drainage systemAssessing the system for an external air leakReducing the degree of suction being appliedDocumenting assessment findings, actions taken, and client responseRationale: Constant bubbling in the water seal chamber of a closed chest tube drainage systemmay indicate the presence of an air leak. The nurse would assess the chest tube system for thepresence of an external air leak if constant bubbling were noted in this chamber. If an externalair leak is not present and the air leak is a new occurrence, the physician is notified immediately,because an air leak may be present in the pleural space. Leakage and trapping of air in thepleural space can result in a tension pneumothorax. Clamping the chest tube is incorrect.Additionally, a chest tube is not clamped unless this has been specifically prescribed in theagency’s policies and procedures. Changing the drainage system will not alleviate the problem.Reducing the degree of suction being applied will not affect the bubbling in the water sealchamber and could be harmful. The nurse would document the assessment findings andinterventions taken in the client’s medical record.Test-Taking Strategy: Use the process of elimination and your knowledge regarding the priorityactions in the care of a closed chest tube drainage system. Focus on the data in the question,

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noting that there is bubbling in the water seal chamber. Recalling that this may indicate an airleak will direct you to the correct options. Review the nursing actions to be taken immediately inthe event that complications of a closed chest tube drainage system occur if you had difficultywith this question.A nurse is helping a client with a closed chest tube drainage system get out of bed and into achair. During the transfer, the chest tube is caught on the leg of the chair and dislodged from theinsertion site. The immediate priority on the part of the nurse is:Contacting the physicianReinserting the chest tubeTransferring the client back to bedCovering the insertion site with a sterile occlusive dressingRationale: If a chest tube is dislodged from the insertion site, the nurse immediately covers thesite with sterile occlusive dressing. The nurse then performs a respiratory assessment, helps theclient back into bed, and contacts the physician. The nurse does not reinsert the chest tube. Thephysician will reinsert the chest tube as necessary.Test-Taking Strategy: Use the process of elimination, noting the strategic word “immediate.”Eliminate the option that involves reinsertion of the chest tube first, because a nurse is nottrained to insert a chest tube. To select from the remaining options, focus on the subject,dislodgment of a chest tube from its insertion site, and recall the complications associated withthis occurrence; this will direct you to the correct option. Review the nursing actions to be takenimmediately in the event of complications associated with a closed chest tube drainage systemif you had difficulty with this question.A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloodysecretions. The nurse would first:Continue suctioning to remove the bloodCheck the degree of suction being appliedEncourage the client to cough out the bloody secretionsRemove the suction catheter from the client’s nose and begin vigorous suctioning through themouthRationale: The return of bloody secretions is an unexpected outcome of suctioning. If it occurs,the nurse should first assess the client and then determine the degree of suction being applied.The degree of suction pressure may need to be decreased. The nurse must also remember toapply intermittent suction and perform catheter rotation during suctioning. Continuing thesuctioning or performing vigorous suctioning through the mouth will result in increased traumaand therefore increased bleeding. Suctioning is normally performed on clients who are unable toexpectorate secretions. It is therefore unlikely that the client will be able to cough out the bloodysecretions.

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Test-Taking Strategy: Use the process of elimination. Eliminate the options of continuing thesuctioning to remove the blood and removing the suction catheter from the nose to beginvigorous suctioning through the mouth, because they are comparable or alike. Next eliminatethe option that involves encouraging the client to cough out the bloody secretions, because it isunlikely that the client will be able to do so. Review the nursing actions to be taken immediatelyin the event of a complication during suctioning if you had difficulty with this question.A nurse is suctioning a client through a tracheostomy tube. During the procedure, the clientbegins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction catheterfrom the client’s trachea but is unable to do so. The nurse would first:Call a codeContact the physicianAdminister a bronchodilatorDisconnect the suction source from the catheterRationale: Inability to remove a suction catheter is a critical situation. This finding, along with theclient’s symptoms presented in the question, indicates the presence of bronchospasm andbronchoconstriction. The nurse immediately disconnects the suction source from the catheterbut leave the catheter in the trachea. The nurse then connects the oxygen source to thecatheter. The physician is notified and will most likely prescribe an inhaled bronchodilator. Thenurse also prepares for emergency resuscitation if the bronchospasm is not relieved.Test-Taking Strategy: Use the process of elimination, noting the strategic word “first.” Eliminatethe option of administering a bronchodilator, because this action requires a physician’sprescription. To select from the remaining options, visualize the situation presented in thequestion. Noting that the nurse is unable to remove the suction catheter from the client’s tracheawill direct you to the correct option. Review the nursing actions to be taken immediately in theevent of a complication during suctioning if you had difficulty with this question.A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour.The nurse first:Contacts the physicianChecks for kinks in the drainage systemChecks the client’s blood pressure and heart rateConnects a new drainage system to the client’s chest tubeRationale: If a chest tube is not draining, the nurse must first check for a kink or clot in the chestdrainage system. The nurse also observes the client for signs of respiratory distress ormediastinal shift; and if such signs are noted, the physician is notified. Checking the heart rateand blood pressure is not directly related to the lack of chest tube drainage. Connecting a newdrainage system to the client’s chest tube is done once the fluid drainage chamber is full. Aspecific procedure is followed when a new drainage system is connected to a client’s chesttube.

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Test-Taking Strategy: Use the process of elimination, noting the strategic word “first.” Focusingon the subject, a lack of chest tube drainage, will direct you to the correct option. Reviewunexpected outcomes and related interventions in the care of a chest tube drainage system ifyou had difficulty with this question.A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the client’surine output for the past hour was 25 mL. On the basis of this finding, the nurse first:Calls the physicianIncreases the rate of the IV infusionChecks the client’s overall intake and output recordAdministers a 250-mL bolus of normal saline solution (0.9%)Rationale: Clients are at risk for becoming hypovolemic after surgery, and often the first sign ofhypovolemia is decreasing urine output. However, the nurse needs additional data to make anaccurate interpretation. Neither an increase in the rate of the IV infusion nor administration of a250-mL bolus of normal saline (0.9%) would be implemented without a prescription from thephysician. The physician is called once the nurse has gathered all necessary assessment data,including the overall fluid status and vital signs.Test-Taking Strategy: Note the strategic word “first.” Try to visualize the situation and use thesteps of the nursing process to answer the question. The correct option addresses the processof assessment. Eliminate increasing the rate of the IV infusion and administering a 250-mLbolus of normal saline (0.9%), because each requires a physician’s prescription. In this situation,the nurse needs to gather additional information before contacting the physician. Reviewunexpected outcomes after surgery and priority nursing interventions in the event of suchoutcomes if you had difficulty with this question.A nurse is getting a client out of bed for the first time since surgery. The nurse raises the head ofthe bed, and the client complains of dizziness. Which of the following actions should the nursetake first?Checking the client’s blood pressureChecking the oxygen saturation levelHaving the client take some deep breathsLowering the head of the bed slowly until the dizziness is relievedRationale: Dizziness or a feeling of faintness is not uncommon when a client is positionedupright for the first time after surgery. If this occurs, the nurse lowers the head of the bed slowlyuntil the dizziness is relieved. The nurse then checks the client’s pulse and blood pressure.Because the problem is circulatory, not respiratory, checking the oxygen saturation level andhaving the client take some deep breaths are not the first actions to be taken.Test-Taking Strategy: Use the process of elimination, noting the strategic word “first.” Note therelationship between the subject of the question (the client becomes dizzy) and the correct

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answer. Review unexpected outcomes after surgery and the priority nursing interventions in theevent of such outcomes if you had difficulty with this question.A nurse is preparing for intershift report when a nurse’s aide pulls an emergency call light in aclient’s room. Upon answering the light, the nurse finds a client who returned from surgeryearlier in the day experiencing tachycardia and tachypnea. The client’s blood pressure is 88/60mm Hg. Which action should the nurse take first?Calling the physicianChecking the hourly urine outputChecking the IV site for infiltrationPlacing the client in a modified Trendelenburg positionRationale: The client is exhibiting signs of shock and requires emergency intervention. The firstaction is to place the client in a modified Trendelenburg position to increase blood return fromthe legs, which in turn increases venous return and subsequently the blood pressure. The nursecalls the physician, verifies the client’s blood volume status by assessing urine output, andensures that the IV infusion is proceeding without complications.Test-Taking Strategy: Note the strategic word “first.” Use your knowledge of the ABCs (airway,breathing, circulation). The correct option addresses the client’s circulatory status. Review thenursing interventions to be taken immediately in the event of postoperative shock if you haddifficulty with this question.A nurse is assessing the chest tube drainage system of a postoperative client who hasundergone a right upper lobectomy. The closed drainage system contains 300 mL of bloodydrainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour afterthe initial assessment, the nurse notes that the bubbling in the water seal chamber is nowconstant, and the client appears dyspneic. On the basis of these findings, the nurse should firstassess:The client’s vital signsThe amount of drainageThe client’s lung soundsThe chest tube connectionsRationale: The client’s dyspnea is most likely related to an air leak caused by a looseconnection. Other causes might be a tear or incision in the pulmonary pleura, which requiresphysician intervention. Although the interventions identified in the other options should also betaken in this situation, they should be performed only after the nurse has tried to locate andcorrect the air leak. It only takes a moment to check the connections, and if a leak is found andcorrected, the client’s symptoms should resolve.Test-Taking Strategy: Note the strategic word “first” and focus on the data in the question.Recalling that a constant bubbling in the water seal chamber could indicate a leak in the system

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will direct you to the correct option. Review care of the client with a closed chest tube drainagesystem if you had difficulty with this question.A client recovering from surgery has a large abdominal wound. Which of the following foods,high in vitamin C, should the nurse encourage the client to eat as a means of promoting woundhealing?SteakVealCheeseOrangesRationale: Citrus fruits and juices are especially high in vitamin C. Other sources are potatoes,tomatoes, and other fruits and vegetables. Meats and dairy products are not especially high invitamin C. Meats are high in protein. Dairy products are high in calcium.Test-Taking Strategy: Note the strategic word "high" in the question. Eliminate steak and vealfirst because they are comparable or alike in that they are meats. To select from the remainingoptions, recall that cheese is high in calcium, not vitamin C; this will direct you to the correctoption. If you are unfamiliar with foods high in vitamin C, review this content.A nurse is caring for a client who has just regained bowel sounds after undergoing surgery. Thephysician has prescribed a clear liquid diet for the client. Which of the following items does thenurse ensure is available in the client’s room before allowing the client to drink?StrawNapkinSuction equipmentOxygen saturation monitorRationale: Aspiration is a concern when fluids are offered to a client who has just undergonesurgery. It is possible that the swallow reflex is still impaired as an effect of anesthesia. Thenurse checks the gag and swallow reflexes before offering fluids to the client, but suctionequipment still must be available. An oxygen saturation monitor is unnecessary when fluids arebeing administered, nor is a napkin or straw necessary; in fact, the straw could contribute to theformation of flatus, resulting in gastrointestinal discomfort.Test-Taking Strategy: The subject of the question is protecting the client’s gag and swallowreflexes. Use your knowledge of the ABCs (airway, breathing, and circulation) to answer thisquestion. The correct option helps maintain airway clearance. If you had difficulty with thisquestion, review care of the client who has recently undergone surgery.A client in the postanesthesia care unit has an as-needed prescription for ondansetron (Zofran).Which of the following occurrences would prompt the nurse to administer this medication to theclient?Paralytic ileus

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Incisional painUrine retentionNausea and vomitingRationale: Ondansetron is an antiemetic that is used in the treatment of postoperative nauseaand vomiting, as well as nausea and vomiting associated with chemotherapy. This medication isnot used to treat any of the problems identified in the other options.Test-Taking Strategy: To answer this question accurately, it is necessary to know theclassification of this medication. Focusing on the clinical setting identified in the question shouldnarrow your choices to nausea and vomiting and incisional pain. To correctly select from thesetwo options, it is necessary to know that ondansetron is an antiemetic. Review the action of thismedication if you had difficulty with this question.A nurse administers scopolamine as prescribed to a client in preparation for surgery. For whichside effect of this medication does the nurse monitor the client?Pupil constrictionIncreased urine outputComplaints of dry mouthComplaints of feeling sweatyRationale: Scopolamine, an anticholinergic medication, often causes the side effects of drymouth, urine retention, decreased sweating, and pupil dilation. The other options are incorrect.Test-Taking Strategy: Note the words “in preparation for surgery” and use the process ofelimination. Recalling that this medication dries body secretions will direct you to the correctoption. Review the expected side effects of this medication if this question was difficult for you.A nurse is preparing a client for transfer to the operating room. Which of the following actionsshould the take in the care of this client at this time?Ensuring that the client has voidedAdministering all daily medicationsPracticing postoperative breathing exercisesVerifying that the client has not eaten for the last 24 hoursRationale: The nurse should ensure that the client has voided if a Foley catheter is not in place.The nurse does not administer all daily medications just before sending a client to the operatingroom. Rather, the physician writes a specific prescription outlining which medications may begiven with a sip of water. The client is usually prescribed to have nothing by mouth for 8 hoursbefore surgery, not 24 hours. The time of transfer to the operating room is not the time topractice breathing exercises. This should have been done earlier.Test-Taking Strategy: Note the words “at this time.” Eliminate the option that involvesadministering all daily medications because of the close-ended word “all.” Eliminate the optionthat involves verifying that the client has not eaten for the last 24 hours because of the words

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“last 24 hours.” To select from the remaining options, focus on the words “at this time”; this willdirect you to the correct option. Remember that the client is likely to be anxious at this time,meaning that it would be inappropriate to practice breathing exercises. Review preoperativeclient care measures if you had difficulty with this question.A nurse receives a telephone call from a nurse on the post-anesthesia care unit, who reportsthat a client is being transferred to the surgical unit. What should the nurse plan to do first onarrival of the client?Assess the patency of the airwayCheck tubes and drains for patencyCheck the dressing for bleedingAssess the vital signs to compare them with preoperative measurementsRationale: The first action of the nurse is to assess the patency of the airway. The nurse thenperforms an assessment of cardiovascular function, the condition of the surgical site, thepatency of tubes and drains for patency, and the function of the central nervous system. If theairway is not patent, immediate measures must be taken to help ensure the survival of theclient.Test-Taking Strategy: Use your knowledge of the ABCs (airway, breathing, and circulation).Airway patency is the priority. The incorrect options are all nursing actions that should beperformed after a patent airway has been established. Review priority nursing assessments inthe client who has undergone surgery if you had difficulty with this question.A client without a history of respiratory disease has a pulse oximeter in place after surgery. Thenurse monitors the pulse oximeter readings to ensure that oxygen saturation remains above:85%89%95%100%Rationale: Pulse oximetry is a noninvasive method of continuously monitoring the oxygensaturation of hemoglobin (SaO2). In the absence of underlying respiratory disease, theexpected reading is at least 95%. Therefore the other options are incorrect. Readings of 85%and 89% are lower than what is desired in the postoperative period. A level of 100% is mostdesirable, but the level should remain at least 95%Test-Taking Strategy: Familiarity with the pulse oximeter and normal readings is needed toanswer this question. Noting the strategic word “above” in the question will help you answercorrectly. If you had difficulty with this question, review the purpose and expected results ofpulse oximetry.

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A client who underwent preadmission testing 1 week before surgery had blood drawn forseveral serum laboratory studies. Which abnormal laboratory results should the nurse report tothe surgeon’s office? Select all that apply.Hematocrit 30%Sodium 141 mEq/LHemoglobin 8.9 g/dLPlatelets 210,000 cells/mm3Serum creatinine 0.8 mg/dLRationale: Routine screening tests include complete blood cell count, serum electrolyteanalysis, coagulation studies, and serum creatinine tests. The complete blood cell countincludes the hemoglobin and hematocrit analysis. All of these values are within their normalranges except the hemoglobin and hematocrit. If a client has low hemoglobin and hematocritlevels, the surgery may be postponed by the surgeon. The normal hemoglobin level ranges from12 to 16.5 g/dL, and the hematocrit ranges from 35% to 52%.Test-Taking Strategy: Note the strategic word “abnormal” in the question and focus on thesubject, laboratory results that could necessitate the postponement of surgery. Recalling thenormal values for the laboratory studies identified in the options will direct you to the correctones. Review these normal laboratory values if you had difficulty answering this question.A client has been scheduled for magnetic resonance imaging (MRI). For which of the followingconditions, a contraindication to MRI, does the nurse check the client’s medical history?PancreatitisPacemaker insertionType 1 diabetes mellitusChronic airway limitationRationale: The candidate for MRI must be free of metal devices or implants. A careful history isconducted to determine whether any such metal objects, such as orthopedic hardware,pacemakers, artificial heart valves, aneurysm clips, and intrauterine devices, are inside theclient. These may heat up in the magnetic field generated by the MRI device, becomedislodged, or malfunction during the procedure. The other medical problems listed do not pose arisk or contraindication for this procedure.Test-Taking Strategy: Use the process of elimination. Note that each of the incorrect options is amedical disorder. The correct option is the name of a procedure in which a device is implantedinto the client. Remember that it is crucial to ensure that there are no metal objects in the vicinityof the MRI machine. Review contraindications to MRI if you had difficulty with this question.A client has just undergone lumbar puncture. Into which position does the nurse assist the clientafter the procedure?FlatSemi-Fowler

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Side-lying, with the head of the bed elevatedSitting up in a recliner with the feet elevatedRationale: After lumbar puncture, the client must remain flat for as long as 12 hours to helpprevent post-procedure spinal headache and leakage of cerebrospinal fluid. Therefore the otheroptions are incorrect.Test-Taking Strategy: Use the process of elimination. Note that the incorrect options arecomparable or alike in that they all involve elevation of the client’s head. Review care of theclient after lumbar puncture if you had difficulty with this question.A client has just returned to the nursing unit after computerized tomography (CT) with contrastmedium. Which of the following actions should the nurse plan to take as part of routineafter-care for this client?Administering a laxativeEncouraging fluid intakeMaintaining the client on strict bed restHolding all medications for at least 2 hoursRationale: After CT scanning, the client may resume all usual activities. The client should beencouraged to consume extra fluids to replace those lost during diuresis of the contrast dye.Medications do not have to be withheld. There is no reason to administer a laxative; also, aphysician’s prescription is needed for this intervention.Test-Taking Strategy: Use the process of elimination and note the strategic words “contrastmedium” in the question. Recalling the importance of flushing the dye from the system after thisprocedure will direct you to the correct option. Review care after a CT scan if you had difficultywith this question.A client reports for a scheduled electroencephalogram (EEG). Which statement by the clientindicates a need for additional preparation for the test?“I didn’t shampoo my hair.”“I ate breakfast this morning.”“I didn’t take my anticonvulsant today.”“It was hard not to drink coffee this morning, but I knew that I couldn’t, so I didn’t.”Rationale: Preprocedure care for EEG involves client teaching about the procedure, ensuringthat the client’s hair has been freshly shampooed, and providing a light meal and fluids toprevent hypoglycemia, which could alter brain waves. Medications such as antidepressants,tranquilizers, and anticonvulsants are withheld for 24 to 48 hours before the procedure asprescribed. Stimulants such as coffee, tea, cola, alcohol, and cigarettes are also withheld.Test-Taking Strategy: Use your knowledge of the EEG procedure to answer the question andnote the strategic words “needs additional preparation.” Recalling the purpose of an EEG and

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the anatomical location of this test will direct you to the correct option. Review preparation for anEEG if you had difficulty with this question.Blood is drawn from a client with suspected uric acid calculi for a serum uric acid determination.Which value does the nurse recognize as a normal uric acid level?1.7 mg/dL5.8 mg/dL8.9 mg/dL12.8 mg/dLRationale: The normal range for uric acid is 4.5 to 8 mg/dL for males and 2.5 to 6.2 mg/dL forfemales. Therefore the other options are incorrect.Test-Taking Strategy: To answer this question correctly, you must be familiar with the normalrange of values for serum uric acid. Review this reference range if you had difficulty with thisquestion.A nurse is providing post-procedure instructions to a client returning home after arthroscopy ofthe shoulder. The nurse should tell the client:To resume full activity the next dayNot to eat or drink anything until the next morningTo keep the shoulder completely immobilized for the rest of the dayTo report to the physician the development of fever or redness and heat at the siteRationale: After arthroscopy, signs and symptoms of infection such as fever or redness and heatat the site should be reported to the physician. The client may resume the usual dietimmediately. The arm does not have to be completely immobilized once sensation has returned,but the client is usually encouraged to refrain from strenuous activity for at least a few days.Test-Taking Strategy: Use the process of elimination. Eliminate keeping the shoulder completelyimmobilized for the rest of the day and resuming full activity the next day, because theyrepresent extremes of activity variations. To select from the remaining options, remember thatthe client is always taught to report signs and symptoms of infection to the physician. Reviewclient instructions after arthroscopy if you had difficulty with this question.A client is tested for HIV with the use of an enzyme-linked immunosorbent assay (ELISA), andthe test result is positive. The nurse should tell the client that:HIV infection has been confirmedThe client probably has an opportunistic infectionThe test will need to be confirmed with the use of a Western blotA positive test is a normal result and does not mean that the client is infected with HIVRationale: The normal value for an ELISA test is negative. A positive ELISA test must beconfirmed with the use of the Western Blot. The other options are incorrect.

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Test-Taking Strategy: Read each option carefully and note that the test result is positive.Recalling that an ELISA test is an HIV antibody-screening test and that a positive result must beconfirmed with the use of the Western blot will direct you to the correct option. Reviewinterpretations of the results of an ELISA test if you had difficulty with this question.A CD4+ lymphocyte count is performed on a client who is infected with HIV. The results of thetest indicate a CD4+ count of 450 cells/L. The nurse interprets this test result as indicating:Improvement in the clientThe need for antiretroviral therapyThe need to discontinue antiretroviral therapyAn effective response to the treatment for HIVRationale: The normal CD4+ count is between 500 and 1600 cells/mcL. Antiretroviral therapy isrecommended when the CD4+ count is less than 500 cells/mcL or below 25%, or when theclient shows symptoms of HIV. The other options are incorrect.Test-Taking Strategy: Use the process of elimination to answer the question. Eliminate theincorrect options because they are comparable or alike in that they indicate a positive responseto treatment. If you had difficulty with this question, review the CD4+ count and the interpretationof its results.A client has just undergone a renal biopsy. Which intervention should the nurse includeintervention in the post-procedure plan of care?Restricting fluid intake for the first 24 hoursPeriodically testing the urine for occult bloodAvoiding the administration of opioid analgesicsHaving the client ambulate in the room and hall for short distancesRationale: After renal biopsy, bed rest is maintained and the client’s vital signs and puncture siteare assessed frequently. Urine is tested periodically for occult blood to detect bleeding as acomplication.Fluids are encouraged to reduce the risk of clot formation at the biopsy site. Opioidanalgesics are often needed to manage the renal colic pain that some clients feel after thisprocedure.Test-Taking Strategy: Use the process of elimination. Recalling that pain and bleeding arepotential concerns after this procedure will direct you to the correct option. Review care of theclient after renal biopsy if you had difficulty with this question.A nurse has a prescription to collect a 24-hour urine specimen from a client. Which of thefollowing measures should the nurse take during this procedure?Keeping the specimen at room temperatureSaving the first urine specimen collected at the start timeDiscarding the last voided specimen at the end of the collection timeAsking the client to void, discarding the specimen, and noting the start time

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Rationale: Because the 24-hour urine collection is a timed quantitative determination, the testmust be started with an empty bladder. Therefore the first urine is discarded. Fifteen minutesbefore the end of the collection time, the client should be asked to void, and this specimen isadded to the collection. The collection should be refrigerated or placed on ice to help preventchanges in urine composition.Test-Taking Strategy: Use the process of elimination. Recalling that the 24-hour urine collectionis a timed quantitative determination will assist you in identifying the correct option. Review theprocedure for collecting a 24-hour urine specimen if you had difficulty with this question.A nurse is preparing a client for intravenous pyelography (IVP). Which action by the nurse ismost important?Administering a sedativeEncouraging fluid intakeAdministering an oral preparation of radiopaque dyeQuestioning the client about allergies to iodine or shellfishRationale: Some IVP dyes are iodine based; if the dye to be used in this procedure is one ofthem and the client has an allergy to iodine or shellfish, he may experience an allergic reaction,manifested as itching, hives, rash, a tight feeling in the throat, shortness of breath, orbronchospasm. For this reason, assessing the client for allergies is the priority. The dye isinjected intravenously. The client may or may not receive premedication. Nothing-by-mouthstatus is generally imposed after midnight on the day before the test.Test-Taking Strategy: Knowledge regarding preprocedure care for this diagnostic test isnecessary to answer this question. Noting the word “intravenous” in the name of the testindicates that a dye will be injected. This will help direct you to the correct option. Review thepriority assessments in preprocedure care for this diagnostic test if you had difficulty with thisquestion.A client who has undergone renal biopsy complains of pain, radiating to the front of theabdomen, at the biopsy site. For which of the following findings should the nurse assess theclient?BleedingRenal colicInfection at the siteIncreased temperatureRationale: Bleeding should be suspected if pain originates at the biopsy site and begins toradiate to the flank area and around to the front of the abdomen. Hypotension, a decreasinghematocrit, and gross or microscopic hematuria are also indicators of bleeding. Signs ofinfection would not appear immediately after a biopsy. There is no information in the question toindicate the presence of renal colic.

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HESI Medical Surgical Review Questions With Answers (244 Solved Questions) - Page 16 preview image

Test-Taking Strategy: Use the process of elimination. Eliminate the options of increasedtemperature and infection at the site first because they are comparable or alike. To choosebetween the remaining options, recall that the information in the question is not indicative ofrenal colic. Review the complications associated with renal biopsy if you had difficulty with thisquestion.A client has undergone renal angiography by way of the right femoral artery. The nursedetermines that the client is experiencing a complication of the procedure on noting:Urine output of 40 mL/hrBlood pressure of 118/76 mm HgRespiratory rate of 18 breaths/minPallor and coolness of the right legRationale: Complications of renal angiography include allergic reaction to the dye, dye-inducedrenal damage, and a number of vascular complications, including hemorrhage, thrombosis, andembolism. The nurse detects these complications by monitoring the client for signs andsymptoms of allergic reaction, decreased urine output, hematoma or hemorrhage at theinsertion site, and signs of diminished circulation to the affected leg. The incorrect options arenormal findings.Test-Taking Strategy: Use the process of elimination and note the words “a complication of theprocedure,” which should tell you that the correct option is an abnormal assessment finding.Eliminate the incorrect options, because they are normal findings. Pallor and coolness indicatethrombosis or hematoma and should be further assessed and reported. Review the signs ofcomplications after renal angiography if you had difficulty with this question.A nurse reviews a client’s urinalysis report. Which finding does the nurse recognize asabnormal?pH of 6.0An absence of proteinThe presence of ketonesSpecific gravity of 1.018Rationale: The normal pH range of urine is 4.5 to 7.8, and normal specific gravity ranges from1.016 to 1.022. The urine is typically screened for protein, glucose, ketones, bilirubin, casts,crystals, red blood cells, and white blood cells, none of which should be present.Test-Taking Strategy: Use the process of elimination and note the strategic word “abnormal” inthe query of the question. The words “the presence of” should direct you to the correct option.Review normal urinalysis findings if you had difficulty with this question.A nurse provides information to a client who is scheduled for cardiac catheterization to rule outcoronary occlusion. The nurse should tell the client that:The procedure is performed in the operating room

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