2021 HESI PN Medical surigical Proctored Exam Versions 2 With Answers (73 Solved Questions)
Learn from past test-takers with 2021 HESI PN Medical surigical Proctored Exam Versions 2 With Answers, an extensive collection of past exams.
Max Martinez
Contributor
4.9
56
28 days ago
Preview (15 of 49)
Sign in to access the full document!
VERSION 2
ATI MED-SURG PROCTORED EXAM PRACTICE QUESTIONS WITH ANSWERS (73
Q/A)
1. A nurse is collecting data from a client who has emphysema. Which of the following findings
should the nurse expect? (Select all that apply.)
1) Dyspnea
2) Barrel chest
3) Clubbing of the fingers
4) Shallow respirations
INCORRECT
5) Bradycardia
Answer Rationale:
Dyspnea is correct. Dyspnea is experienced by clients who have emphysema due to inadequate
oxygen exchange in the lungs.
Barrel chest is correct. The lungs of clients who have emphysema lose their elasticity, and the
diaphragm becomes permanently flattened by overdistention of the lungs. The muscles of the rib
cage also become rigid, and the ribs flare outward. This produces the barrel chest typical of
emphysema clients.
ATI MED-SURG PROCTORED EXAM PRACTICE QUESTIONS WITH ANSWERS (73
Q/A)
1. A nurse is collecting data from a client who has emphysema. Which of the following findings
should the nurse expect? (Select all that apply.)
1) Dyspnea
2) Barrel chest
3) Clubbing of the fingers
4) Shallow respirations
INCORRECT
5) Bradycardia
Answer Rationale:
Dyspnea is correct. Dyspnea is experienced by clients who have emphysema due to inadequate
oxygen exchange in the lungs.
Barrel chest is correct. The lungs of clients who have emphysema lose their elasticity, and the
diaphragm becomes permanently flattened by overdistention of the lungs. The muscles of the rib
cage also become rigid, and the ribs flare outward. This produces the barrel chest typical of
emphysema clients.
VERSION 2
ATI MED-SURG PROCTORED EXAM PRACTICE QUESTIONS WITH ANSWERS (73
Q/A)
1. A nurse is collecting data from a client who has emphysema. Which of the following findings
should the nurse expect? (Select all that apply.)
1) Dyspnea
2) Barrel chest
3) Clubbing of the fingers
4) Shallow respirations
INCORRECT
5) Bradycardia
Answer Rationale:
Dyspnea is correct. Dyspnea is experienced by clients who have emphysema due to inadequate
oxygen exchange in the lungs.
Barrel chest is correct. The lungs of clients who have emphysema lose their elasticity, and the
diaphragm becomes permanently flattened by overdistention of the lungs. The muscles of the rib
cage also become rigid, and the ribs flare outward. This produces the barrel chest typical of
emphysema clients.
ATI MED-SURG PROCTORED EXAM PRACTICE QUESTIONS WITH ANSWERS (73
Q/A)
1. A nurse is collecting data from a client who has emphysema. Which of the following findings
should the nurse expect? (Select all that apply.)
1) Dyspnea
2) Barrel chest
3) Clubbing of the fingers
4) Shallow respirations
INCORRECT
5) Bradycardia
Answer Rationale:
Dyspnea is correct. Dyspnea is experienced by clients who have emphysema due to inadequate
oxygen exchange in the lungs.
Barrel chest is correct. The lungs of clients who have emphysema lose their elasticity, and the
diaphragm becomes permanently flattened by overdistention of the lungs. The muscles of the rib
cage also become rigid, and the ribs flare outward. This produces the barrel chest typical of
emphysema clients.
Clubbing of the fingers is correct. Air is trapped in the lungs due to their lack of elasticity,
which decreases oxygenation. Clubbing results from these chronic low blood-oxygen levels.
Shallow respirations is correct. Clients who have emphysema lose lung elasticity;
consequently, respirations become increasingly shallow and more rapid.
Bradycardia is incorrect. The heart rate will increase as the heart tries to compensate for less
oxygen being delivered to the tissues.
2. A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical
manifestations should the nurse expect to observe? (Select all that apply.)
1) Buffalo hump
2) Purple striations
3) Moon face
INCORRECT
4) Tremors
INCORRECT
5) Obese extremities
Answer Rationale:
Buffalo hump is correct. Cushing's syndrome is a disease caused by an increased production of
cortisol or by excessive use of corticosteroids. Buffalo hump, a collection of fat between the
shoulders, is a common manifestation of Cushing's syndrome.Purple striations is
correct. Purple striations on the skin of the abdomen, thighs, and breasts are a common
manifestation of Cushing's syndrome. This is due to the collection of body fat in these
areas.Moon face is correct. Moon face is a common manifestation of Cushing's syndrome.
Clients who have this manifestation present with a round, red, full face.Tremors is
incorrect. Tremors are not a common finding of Cushing's syndrome.Obese extremities is
incorrect. Clients who have Cushing's syndrome have truncal obesity, a protuberant abdomen,
with thin extremities, which is due to an alteration in protein metabolism.
3. A nurse is assisting with the care of a client immediately following a lumbar puncture. Which
of the following actions should the nurse take? (Select all that apply.)
1) Encourage fluid intake.
2) Monitor the puncture site for hematoma.
INCORRECT
3) Insert a urinary catheter.
INCORRECT
4) Elevate the client’s head of bed.
INCORRECT
5) Apply a cervical collar to the client.
which decreases oxygenation. Clubbing results from these chronic low blood-oxygen levels.
Shallow respirations is correct. Clients who have emphysema lose lung elasticity;
consequently, respirations become increasingly shallow and more rapid.
Bradycardia is incorrect. The heart rate will increase as the heart tries to compensate for less
oxygen being delivered to the tissues.
2. A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical
manifestations should the nurse expect to observe? (Select all that apply.)
1) Buffalo hump
2) Purple striations
3) Moon face
INCORRECT
4) Tremors
INCORRECT
5) Obese extremities
Answer Rationale:
Buffalo hump is correct. Cushing's syndrome is a disease caused by an increased production of
cortisol or by excessive use of corticosteroids. Buffalo hump, a collection of fat between the
shoulders, is a common manifestation of Cushing's syndrome.Purple striations is
correct. Purple striations on the skin of the abdomen, thighs, and breasts are a common
manifestation of Cushing's syndrome. This is due to the collection of body fat in these
areas.Moon face is correct. Moon face is a common manifestation of Cushing's syndrome.
Clients who have this manifestation present with a round, red, full face.Tremors is
incorrect. Tremors are not a common finding of Cushing's syndrome.Obese extremities is
incorrect. Clients who have Cushing's syndrome have truncal obesity, a protuberant abdomen,
with thin extremities, which is due to an alteration in protein metabolism.
3. A nurse is assisting with the care of a client immediately following a lumbar puncture. Which
of the following actions should the nurse take? (Select all that apply.)
1) Encourage fluid intake.
2) Monitor the puncture site for hematoma.
INCORRECT
3) Insert a urinary catheter.
INCORRECT
4) Elevate the client’s head of bed.
INCORRECT
5) Apply a cervical collar to the client.
Answer Rationale:
Encourage fluid intake is correct. The nurse should encourage fluids, unless contraindicated, to
replace the cerebrospinal fluid that was removed during the procedure and reduce the risk for a
headache.
Monitor the puncture site for a hematoma is correct. The nurse should monitor and report a
hematoma at the insertion site because this can indicate bleeding.
Insert a urinary catheter is incorrect. There is no indication for a urinary catheter insertion.
Elevate the client’s head of bed is incorrect. The client should remain flat in bed for 1 hr or
more to reduce the risk for a headache.
Apply a cervical collar to the client is incorrect. There is no indication for a cervical collar for
this client.
4. A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is to
take hydroxyzine preoperatively. Which of the following effects of the medication should the
nurse include in the teaching? (Select all that apply.)
1) Decreasing anxiety
2) Controlling emesis
INCORRECT
3) Relaxing skeletal muscles
INCORRECT
4) Preventing surgical site infections
5) Reducing the amount of narcotics needed for pain relief
Answer Rationale:
Decreasing anxiety is correct. The nurse should include that hydroxyzine is an effective
antianxiety agent and is used to decrease anxiety in surgical clients as well as in persons with
moderate anxiety.
Controlling emesis is correct. The nurse should include that hydroxyzine is an effective
antiemetic and is used to control nausea and vomiting in pre- and postoperative clients.
Relaxing skeletal muscles is incorrect. The nurse should recognize benzodiazepines, such as
diazepam (Valium), are used to produce skeletal muscle relaxation.
Preventing surgical site infections is incorrect. The nurse should instruct the client that
antibiotics administered prior to surgery are used to diminish the risk of surgical site infections;
hydroxyzine, an antiemetic, does not have any effect on bacteria.
Reducing the amount of narcotics needed for pain relief is correct. Hydroxyzine increases the
Encourage fluid intake is correct. The nurse should encourage fluids, unless contraindicated, to
replace the cerebrospinal fluid that was removed during the procedure and reduce the risk for a
headache.
Monitor the puncture site for a hematoma is correct. The nurse should monitor and report a
hematoma at the insertion site because this can indicate bleeding.
Insert a urinary catheter is incorrect. There is no indication for a urinary catheter insertion.
Elevate the client’s head of bed is incorrect. The client should remain flat in bed for 1 hr or
more to reduce the risk for a headache.
Apply a cervical collar to the client is incorrect. There is no indication for a cervical collar for
this client.
4. A nurse is reinforcing pre-operative teaching for a client who is scheduled for surgery and is to
take hydroxyzine preoperatively. Which of the following effects of the medication should the
nurse include in the teaching? (Select all that apply.)
1) Decreasing anxiety
2) Controlling emesis
INCORRECT
3) Relaxing skeletal muscles
INCORRECT
4) Preventing surgical site infections
5) Reducing the amount of narcotics needed for pain relief
Answer Rationale:
Decreasing anxiety is correct. The nurse should include that hydroxyzine is an effective
antianxiety agent and is used to decrease anxiety in surgical clients as well as in persons with
moderate anxiety.
Controlling emesis is correct. The nurse should include that hydroxyzine is an effective
antiemetic and is used to control nausea and vomiting in pre- and postoperative clients.
Relaxing skeletal muscles is incorrect. The nurse should recognize benzodiazepines, such as
diazepam (Valium), are used to produce skeletal muscle relaxation.
Preventing surgical site infections is incorrect. The nurse should instruct the client that
antibiotics administered prior to surgery are used to diminish the risk of surgical site infections;
hydroxyzine, an antiemetic, does not have any effect on bacteria.
Reducing the amount of narcotics needed for pain relief is correct. Hydroxyzine increases the
effects of narcotic pain medications. The nurse should instruct the client that when it is used for
surgical clients, narcotic requirements may be significantly reduced.
5. A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse
determines that teaching has been effective when the client identifies which of the following
manifestations of hypoglycemia? (Select all that apply.)
INCORRECT
1) Polyuria
2) Blurry vision
3) Tachycardia
INCORRECT
4) Polydipsia
5) Sweating
Answer Rationale:
Polyuria is incorrect. Hyperglycemia causes polyuria.
Blurry vision is correct. Manifestations of hypoglycemia include blurry vision, tremors, anxiety,
irritability, headache, and hypotension.
Tachycardia is correct. Manifestations of hypoglycemia include tachycardia, tremors, anxiety,
irritability, headache, and hypotension.
Polydipsia is incorrect. Hyperglycemia causes polydipsia.
Sweating is correct. Manifestations of hypoglycemia include sweating, tremors, anxiety,
irritability, headache, and hypotension.
6. A nurse is collecting data from a client who has an exacerbation of gout. Which of the
following findings should the nurse expect? (Select all that apply.)
1) Edema
2) Erythema
3) Tophi
4) Tight skin
INCORRECT
5) Symmetrical joint pain
Answer Rationale:
Edema is correct. Swelling over the affected joints is a classic manifestation of gout.
Erythema is correct. Redness over the affected joints is a classic manifestation of gout.
surgical clients, narcotic requirements may be significantly reduced.
5. A nurse is reinforcing teaching with a client who has type 2 diabetes mellitus. The nurse
determines that teaching has been effective when the client identifies which of the following
manifestations of hypoglycemia? (Select all that apply.)
INCORRECT
1) Polyuria
2) Blurry vision
3) Tachycardia
INCORRECT
4) Polydipsia
5) Sweating
Answer Rationale:
Polyuria is incorrect. Hyperglycemia causes polyuria.
Blurry vision is correct. Manifestations of hypoglycemia include blurry vision, tremors, anxiety,
irritability, headache, and hypotension.
Tachycardia is correct. Manifestations of hypoglycemia include tachycardia, tremors, anxiety,
irritability, headache, and hypotension.
Polydipsia is incorrect. Hyperglycemia causes polydipsia.
Sweating is correct. Manifestations of hypoglycemia include sweating, tremors, anxiety,
irritability, headache, and hypotension.
6. A nurse is collecting data from a client who has an exacerbation of gout. Which of the
following findings should the nurse expect? (Select all that apply.)
1) Edema
2) Erythema
3) Tophi
4) Tight skin
INCORRECT
5) Symmetrical joint pain
Answer Rationale:
Edema is correct. Swelling over the affected joints is a classic manifestation of gout.
Erythema is correct. Redness over the affected joints is a classic manifestation of gout.
Tophi is correct. Tophi are a classic manifestation of gout. They are nodules that form in
subcutaneous tissue due to the accumulation of urate crystals.
Tight skin is correct. Tight skin over the affected joints is a classic manifestation of gout.
Symmetrical joint pain is incorrect. Symmetrical joint pain is a manifestation of rheumatoid
arthritis, not gout.
7. A nurse is assisting in the plan of care for a client who had surgery for a bowel obstruction.
The client has a nasogastric tube in place. Which of the following actions should the nurse
include in the client's plan of care? (Select all that apply.)
1) Perform leg exercises every 2 hr.
2) Encourage hourly use of an incentive spirometer while awake.
3) Document the color, consistency, and amount of nasogastric drainage.
INCORRECT
4) Irrigate the nasogastric tube every 4 to 8 hr.
INCORRECT
5) Maintain bed rest for 48 hr following surgery.
Answer Rationale:
Perform leg exercises every 2 hr is correct. Postoperative clients should frequently perform leg
exercises, independently or with assistance, to prevent skin breakdown.Encourage hourly use of
an incentive spirometer while awake is correct. Postoperative clients should be encouraged to
use the incentive spirometer ten times each hour while awake to prevent atelectasis.Document
the color, consistency, and amount of nasogastric drainage is correct. Documenting the color,
consistency, and amount of nasogastric drainage is appropriate to include in the client's plan of
care.Irrigate the nasogastric tube every 4 to 8 hr is incorrect. Following abdominal surgery,
the NG tube should not be moved or irrigated unless prescribed by the provider.Maintain bed
rest for 48 hr following surgery is incorrect. Maintaining bed rest following surgery should not
be included in the plan of care. Early ambulation prevents distention and improves intestinal
mobility.
8. A nurse is assisting with discharge teaching for a client who is postoperative following a
laryngectomy. Which of the following instructions should the nurse include in the teaching?
(Select all that apply.)
1) To aid in swallowing food, tip the chin before swallowing.
INCORRECT
2) Avoid using liquid supplements.
INCORRECT
3) Include warm foods in your diet because they are easier to swallow.
4) Swallow twice after each bite.
subcutaneous tissue due to the accumulation of urate crystals.
Tight skin is correct. Tight skin over the affected joints is a classic manifestation of gout.
Symmetrical joint pain is incorrect. Symmetrical joint pain is a manifestation of rheumatoid
arthritis, not gout.
7. A nurse is assisting in the plan of care for a client who had surgery for a bowel obstruction.
The client has a nasogastric tube in place. Which of the following actions should the nurse
include in the client's plan of care? (Select all that apply.)
1) Perform leg exercises every 2 hr.
2) Encourage hourly use of an incentive spirometer while awake.
3) Document the color, consistency, and amount of nasogastric drainage.
INCORRECT
4) Irrigate the nasogastric tube every 4 to 8 hr.
INCORRECT
5) Maintain bed rest for 48 hr following surgery.
Answer Rationale:
Perform leg exercises every 2 hr is correct. Postoperative clients should frequently perform leg
exercises, independently or with assistance, to prevent skin breakdown.Encourage hourly use of
an incentive spirometer while awake is correct. Postoperative clients should be encouraged to
use the incentive spirometer ten times each hour while awake to prevent atelectasis.Document
the color, consistency, and amount of nasogastric drainage is correct. Documenting the color,
consistency, and amount of nasogastric drainage is appropriate to include in the client's plan of
care.Irrigate the nasogastric tube every 4 to 8 hr is incorrect. Following abdominal surgery,
the NG tube should not be moved or irrigated unless prescribed by the provider.Maintain bed
rest for 48 hr following surgery is incorrect. Maintaining bed rest following surgery should not
be included in the plan of care. Early ambulation prevents distention and improves intestinal
mobility.
8. A nurse is assisting with discharge teaching for a client who is postoperative following a
laryngectomy. Which of the following instructions should the nurse include in the teaching?
(Select all that apply.)
1) To aid in swallowing food, tip the chin before swallowing.
INCORRECT
2) Avoid using liquid supplements.
INCORRECT
3) Include warm foods in your diet because they are easier to swallow.
4) Swallow twice after each bite.
Loading page 6...
INCORRECT
5) Take a sip of water with each bite of food.
Answer Rationale:
To aid in swallowing food, tip the chin before swallowing is correct. This action decreases the
risk of aspiration.
Avoid using liquid supplements is incorrect. Following a laryngectomy, the client is at risk for
malnutrition. Liquid supplements provide needed protein and calories.
Include warm foods in your diet because they are easier to swallow is incorrect.The client
should include cold foods in her diet because they are easier to swallow.
Swallow twice after each bite is correct. Swallowing once when initially propelling food down
the esophagus and a second time (dry swallowing) to fully clear the esophagus of food will
decrease the risk of aspirating food left in the esophagus.
Take a sip of water with each bite of food is incorrect. This action places the client at risk for
aspiration.
9. A nurse is assisting with discharge teaching for a client who is postoperative from a
mastectomy including the removal of axillary lymph nodes. Which of the following instructions
should the nurse include? (Select all that apply.)
INCORRECT
1) Use talcum powder instead of deodorant on the affected side for the first two weeks after
surgery.
2) Perform range-of-motion exercises of the affected arm.
INCORRECT
3) Avoid lifting arm above shoulder level on the affected side.
INCORRECT
4) Wait 72 hr before consuming a regular diet.
5) Elevated the affected arm on a pillow when resting in bed.
Answer Rationale:
Use talcum powder instead of deodorant on the affected side for the first two weeks after
surgery is incorrect. The client should avoid the use of talcum powder and deodorant until the
incision is healed.
Perform range-of-motion exercises of the affected arm is correct. The client should perform
range-of-motion exercises on the affected arm to improve circulation and reduce the risk of
lymphedema.
Avoid lifting arm above shoulder level on the affected side is incorrect. The client should face
5) Take a sip of water with each bite of food.
Answer Rationale:
To aid in swallowing food, tip the chin before swallowing is correct. This action decreases the
risk of aspiration.
Avoid using liquid supplements is incorrect. Following a laryngectomy, the client is at risk for
malnutrition. Liquid supplements provide needed protein and calories.
Include warm foods in your diet because they are easier to swallow is incorrect.The client
should include cold foods in her diet because they are easier to swallow.
Swallow twice after each bite is correct. Swallowing once when initially propelling food down
the esophagus and a second time (dry swallowing) to fully clear the esophagus of food will
decrease the risk of aspirating food left in the esophagus.
Take a sip of water with each bite of food is incorrect. This action places the client at risk for
aspiration.
9. A nurse is assisting with discharge teaching for a client who is postoperative from a
mastectomy including the removal of axillary lymph nodes. Which of the following instructions
should the nurse include? (Select all that apply.)
INCORRECT
1) Use talcum powder instead of deodorant on the affected side for the first two weeks after
surgery.
2) Perform range-of-motion exercises of the affected arm.
INCORRECT
3) Avoid lifting arm above shoulder level on the affected side.
INCORRECT
4) Wait 72 hr before consuming a regular diet.
5) Elevated the affected arm on a pillow when resting in bed.
Answer Rationale:
Use talcum powder instead of deodorant on the affected side for the first two weeks after
surgery is incorrect. The client should avoid the use of talcum powder and deodorant until the
incision is healed.
Perform range-of-motion exercises of the affected arm is correct. The client should perform
range-of-motion exercises on the affected arm to improve circulation and reduce the risk of
lymphedema.
Avoid lifting arm above shoulder level on the affected side is incorrect. The client should face
Loading page 7...
a wall with the arms slightly bent and “walk” both arms up the wall as high as possible.
Wait 72 hr before consuming a regular diet is incorrect. The client can eat a regular diet 24 hr
after surgery.
Elevated the affected arm on a pillow when resting in bed is correct. The client should
elevate the affected arm to increase circulation and reduce the risk of lymphedema.
10. A client who is postoperative returns to the unit in skeletal traction. When collecting data
from the client, the nurse should expect which of the following findings? (Select all that apply.)
1) Redness at the pin sites
2) Warmth at the pin sites
INCORRECT
3) Movement of the pins at the insertion sites
INCORRECT
4) No drainage from the pin sites
INCORRECT
5) Tenting of the skin around the pin sites
Answer Rationale:
Redness at the pin sites is correct. The nurse should expect the client to have redness at the pin
sites, as it is a manifestation of the expected reaction after insertion.
Warmth at the pin sites is correct. The nurse should expect the client to have warmth at the pin
sites, as it is a manifestation of the expected reaction after insertion.
Movement of the pins at the insertion sites is incorrect. The nurse should report movement of
the pins to the surgeon immediately, as it is a manifestation of infection.
No drainage from the pin sites is incorrect. Up to 72 hr after surgery, serosanguineous drainage
from the pin sites can be heavy; therefore, it is important to clean the pin sites daily.
Tenting of the skin around the pin sites is incorrect. The nurse should report tenting to the
surgeon immediately, as it is a manifestation of infection.
11. A nurse is reinforcing teaching about dietary recommendations for a client who has a hiatal
hernia. Which of the following client statements indicate understanding of the teaching? (Select
all that apply.)
INCORRECT
1) "I will lie down for one half hour after meals."
2) "I will consume less caffeine and spicy foods."
Wait 72 hr before consuming a regular diet is incorrect. The client can eat a regular diet 24 hr
after surgery.
Elevated the affected arm on a pillow when resting in bed is correct. The client should
elevate the affected arm to increase circulation and reduce the risk of lymphedema.
10. A client who is postoperative returns to the unit in skeletal traction. When collecting data
from the client, the nurse should expect which of the following findings? (Select all that apply.)
1) Redness at the pin sites
2) Warmth at the pin sites
INCORRECT
3) Movement of the pins at the insertion sites
INCORRECT
4) No drainage from the pin sites
INCORRECT
5) Tenting of the skin around the pin sites
Answer Rationale:
Redness at the pin sites is correct. The nurse should expect the client to have redness at the pin
sites, as it is a manifestation of the expected reaction after insertion.
Warmth at the pin sites is correct. The nurse should expect the client to have warmth at the pin
sites, as it is a manifestation of the expected reaction after insertion.
Movement of the pins at the insertion sites is incorrect. The nurse should report movement of
the pins to the surgeon immediately, as it is a manifestation of infection.
No drainage from the pin sites is incorrect. Up to 72 hr after surgery, serosanguineous drainage
from the pin sites can be heavy; therefore, it is important to clean the pin sites daily.
Tenting of the skin around the pin sites is incorrect. The nurse should report tenting to the
surgeon immediately, as it is a manifestation of infection.
11. A nurse is reinforcing teaching about dietary recommendations for a client who has a hiatal
hernia. Which of the following client statements indicate understanding of the teaching? (Select
all that apply.)
INCORRECT
1) "I will lie down for one half hour after meals."
2) "I will consume less caffeine and spicy foods."
Loading page 8...
3) "I will sleep with the head of my bed elevated."
4) "I will try not to gain weight."
INCORRECT
5) "I will drink less fluid."
Answer Rationale:
“I will lie down for one half hour after meals.” is incorrect. A client who has a hiatal hernia
should remain upright for at least 1 hr after meals and preferably for several hours.
“I will consume less caffeine and spicy foods.” is correct. These foods and beverages can
worsen the symptoms of a hiatal hernia.
“I will sleep with the head of my bed elevated.” is correct. The client should raise the head of
the bed on blocks to avoid lying flat when sleeping.
“I will try not to gain weight.” is correct. Obesity raises intra-abdominal pressure and makes
the hernia worse.
“I will drink less fluid.” is incorrect. Clients should consume adequate and appropriate amounts
of fluid, whether or not they have a hiatal hernia.
12. A nurse is collecting data from a client who has an acute myocardial infarction (MI). Which
of the following clinical manifestations should the nurse expect to find? (Select all that apply.)
INCORRECT
1) Orthopnea
INCORRECT
2) Headache
3) Nausea
4) Tachycardia
5) Diaphoresis
Answer Rationale:
Orthopnea is incorrect. Orthopnea is a manifestation of heart failure, which can develop from a
myocardial infarction, but it is not a common manifestation of acute MI.
Headache is incorrect. Chest pain and sometimes jaw and shoulder pain, not headache, are
classic manifestations of acute MI.
Nausea is correct. Nausea and vomiting are classic manifestations of acute MI.
Tachycardia is correct. Tachycardia and dysrhythmias are classic manifestations of acute MI.
4) "I will try not to gain weight."
INCORRECT
5) "I will drink less fluid."
Answer Rationale:
“I will lie down for one half hour after meals.” is incorrect. A client who has a hiatal hernia
should remain upright for at least 1 hr after meals and preferably for several hours.
“I will consume less caffeine and spicy foods.” is correct. These foods and beverages can
worsen the symptoms of a hiatal hernia.
“I will sleep with the head of my bed elevated.” is correct. The client should raise the head of
the bed on blocks to avoid lying flat when sleeping.
“I will try not to gain weight.” is correct. Obesity raises intra-abdominal pressure and makes
the hernia worse.
“I will drink less fluid.” is incorrect. Clients should consume adequate and appropriate amounts
of fluid, whether or not they have a hiatal hernia.
12. A nurse is collecting data from a client who has an acute myocardial infarction (MI). Which
of the following clinical manifestations should the nurse expect to find? (Select all that apply.)
INCORRECT
1) Orthopnea
INCORRECT
2) Headache
3) Nausea
4) Tachycardia
5) Diaphoresis
Answer Rationale:
Orthopnea is incorrect. Orthopnea is a manifestation of heart failure, which can develop from a
myocardial infarction, but it is not a common manifestation of acute MI.
Headache is incorrect. Chest pain and sometimes jaw and shoulder pain, not headache, are
classic manifestations of acute MI.
Nausea is correct. Nausea and vomiting are classic manifestations of acute MI.
Tachycardia is correct. Tachycardia and dysrhythmias are classic manifestations of acute MI.
Loading page 9...
Diaphoresis is correct. Profuse sweating and anxiety are classic manifestations of acute MI.
13.A nurse is reinforcing nutrition teaching for a client who has chronic kidney disease about
limiting foods high in potassium. Which of the following foods should the nurse instruct the
client to avoid? (Select all that apply).
1) Orange juice
INCORRECT
2) Watermelon
3) Bananas
INCORRECT
4) Corn flakes cereal
INCORRECT
5) White rice
Answer Rationale:
Orange juice is correct. Orange juice is high in potassium; 240 mL (8 oz) contains 496 mg of
potassium
Watermelon is incorrect. Watermelon is low in potassium; 152 g (1 cup) of diced watermelon
contains 170 mg of potassium.
Bananas is correct. Bananas are high in potassium; one medium banana contains 422 mg of
potassium.
Corn flakes cereal is incorrect.Corn flakes cereal is low in potassium; 34 g (1 cup) of corn
flakes cereal contains 60 mg of potassium.
White rice is incorrect. White rice is low in potassium; 158 g (1 cup) of cooked white rice
contains 55 mg of potassium.
14.A nurse is reinforcing nutrition teaching to a client who has chronic kidney disease about
limiting foods high in phosphorus. Which of the following foods should the nurse instruct the
client to avoid? (Select all that apply).
1) Milk
2) Sunflower seeds
INCORRECT
3) Orange juice
INCORRECT
4) Frozen kale
5) Poultry
13.A nurse is reinforcing nutrition teaching for a client who has chronic kidney disease about
limiting foods high in potassium. Which of the following foods should the nurse instruct the
client to avoid? (Select all that apply).
1) Orange juice
INCORRECT
2) Watermelon
3) Bananas
INCORRECT
4) Corn flakes cereal
INCORRECT
5) White rice
Answer Rationale:
Orange juice is correct. Orange juice is high in potassium; 240 mL (8 oz) contains 496 mg of
potassium
Watermelon is incorrect. Watermelon is low in potassium; 152 g (1 cup) of diced watermelon
contains 170 mg of potassium.
Bananas is correct. Bananas are high in potassium; one medium banana contains 422 mg of
potassium.
Corn flakes cereal is incorrect.Corn flakes cereal is low in potassium; 34 g (1 cup) of corn
flakes cereal contains 60 mg of potassium.
White rice is incorrect. White rice is low in potassium; 158 g (1 cup) of cooked white rice
contains 55 mg of potassium.
14.A nurse is reinforcing nutrition teaching to a client who has chronic kidney disease about
limiting foods high in phosphorus. Which of the following foods should the nurse instruct the
client to avoid? (Select all that apply).
1) Milk
2) Sunflower seeds
INCORRECT
3) Orange juice
INCORRECT
4) Frozen kale
5) Poultry
Loading page 10...
Answer Rationale:
Milk is correct. All animal products, including dairy, are a source of phosphorus and should be
avoided by a client who is on a phosphorus restricted diet.
Sunflower seeds is correct. Sunflower seeds are a food source high in phosphorus and should be
avoided by a client who is on a phosphorus restricted diet.
Orange juice is incorrect. Orange juice is not a food source high in phosphorus and is safe for
clients on a phosphorus restricted diet.
Frozen kale is incorrect. Frozen kale is not a food source high in phosphorus and is safe for
clients on a phosphorus restricted diet.
Poultry is correct. All animal products, including poultry, are a source of phosphorus and should
be avoided by a client who is on a phosphorus restricted diet.
15.A nurse is assisting in the plan of care for a client who is scheduled to have a renal biopsy.
Which of the following actions should the nurse include in the plan? (Select all that apply).
1) Collect a urine specimen prior to the procedure.
2) Obtain an informed consent prior to the procedure.
INCORRECT
3) Administer diphenhydramine prior to the procedure.
INCORRECT
4) Maintain a clear liquid diet 4 hr prior to the procedure.
5) Complete coagulation studies prior to the procedure.
Answer Rationale:
Collect a urine specimen prior to the procedure is correct. A urine specimen is needed prior
to the procedure to allow for postprocedure comparison.
Obtain an informed consent is correct. Because the procedure is invasive it requires written,
informed consent.
Administer diphenhydramine prior to the procedure is incorrect. Benadryl is sometimes
used prior to a procedure that uses dye, but not for a renal biopsy.
Maintain a clear liquid diet 4 hr prior to the procedure is incorrect. NPO for 6 to 8 hr prior
to the procedure is usually required.
Complete coagulation studies prior to the procedure is correct. Coagulation studies are
obtained prior to the procedure to evaluate the risk for bleeding from the biopsy site.
16. A nurse is caring for a client following a renal biopsy. Which of the following actions should
the nurse take? (Select all that apply).
Milk is correct. All animal products, including dairy, are a source of phosphorus and should be
avoided by a client who is on a phosphorus restricted diet.
Sunflower seeds is correct. Sunflower seeds are a food source high in phosphorus and should be
avoided by a client who is on a phosphorus restricted diet.
Orange juice is incorrect. Orange juice is not a food source high in phosphorus and is safe for
clients on a phosphorus restricted diet.
Frozen kale is incorrect. Frozen kale is not a food source high in phosphorus and is safe for
clients on a phosphorus restricted diet.
Poultry is correct. All animal products, including poultry, are a source of phosphorus and should
be avoided by a client who is on a phosphorus restricted diet.
15.A nurse is assisting in the plan of care for a client who is scheduled to have a renal biopsy.
Which of the following actions should the nurse include in the plan? (Select all that apply).
1) Collect a urine specimen prior to the procedure.
2) Obtain an informed consent prior to the procedure.
INCORRECT
3) Administer diphenhydramine prior to the procedure.
INCORRECT
4) Maintain a clear liquid diet 4 hr prior to the procedure.
5) Complete coagulation studies prior to the procedure.
Answer Rationale:
Collect a urine specimen prior to the procedure is correct. A urine specimen is needed prior
to the procedure to allow for postprocedure comparison.
Obtain an informed consent is correct. Because the procedure is invasive it requires written,
informed consent.
Administer diphenhydramine prior to the procedure is incorrect. Benadryl is sometimes
used prior to a procedure that uses dye, but not for a renal biopsy.
Maintain a clear liquid diet 4 hr prior to the procedure is incorrect. NPO for 6 to 8 hr prior
to the procedure is usually required.
Complete coagulation studies prior to the procedure is correct. Coagulation studies are
obtained prior to the procedure to evaluate the risk for bleeding from the biopsy site.
16. A nurse is caring for a client following a renal biopsy. Which of the following actions should
the nurse take? (Select all that apply).
Loading page 11...
1) Monitor for hematuria.
2) Check for flank pain.
INCORRECT
3) Observe for extravasation of tissue surrounding the biopsy site.
INCORRECT
4) Encourage ambulation.
INCORRECT
5) Administer aspirin PRN for pain.
Answer Rationale:
Monitor for hematuria is correct. The nurse should monitor the client for bleeding, such as
hematuria, tachycardia, hypotension, or bleeding at the biopsy site.
Check for flank pain is correct. Flank pain is a manifestation of internal bleeding from the renal
biopsy.
Observe for extravasation of tissue surrounding the biopsy site is incorrect. Extravasation is
associated with the infiltration of dye or medication around an IV site and is not a risk following
a renal biopsy.
Encourage ambulation is incorrect. The client should be on strict bedrest following a renal
biopsy.
Administer aspirin PRN for pain is incorrect. Aspirin is contraindicated for a client who is
postoperative renal biopsy due to the increased risk for bleeding.
17.A nurse is reinforcing preoperative teaching to a client who is to undergo a radical
prostatectomy. Which of the following statements should the nurse include in the teaching?
(Select all that apply).
1) "You may feel the need to urinate even though a catheter is in place."
2) "Performing Kegel exercises following the surgery will help you to manage
incontinence."
INCORRECT
3) "There is very little postoperative pain with this procedure."
INCORRECT
4) "You will be on a low-fiber diet following the surgery."
5) "You should expect your urine to be blood-tinged for a few days following the surgery."
Answer Rationale:
”You may feel the need to urinate even though a catheter is in place.” is correct. Pressure
from the taping of the catheter to the thigh or abdomen may cause the sensation of the need to
void.
2) Check for flank pain.
INCORRECT
3) Observe for extravasation of tissue surrounding the biopsy site.
INCORRECT
4) Encourage ambulation.
INCORRECT
5) Administer aspirin PRN for pain.
Answer Rationale:
Monitor for hematuria is correct. The nurse should monitor the client for bleeding, such as
hematuria, tachycardia, hypotension, or bleeding at the biopsy site.
Check for flank pain is correct. Flank pain is a manifestation of internal bleeding from the renal
biopsy.
Observe for extravasation of tissue surrounding the biopsy site is incorrect. Extravasation is
associated with the infiltration of dye or medication around an IV site and is not a risk following
a renal biopsy.
Encourage ambulation is incorrect. The client should be on strict bedrest following a renal
biopsy.
Administer aspirin PRN for pain is incorrect. Aspirin is contraindicated for a client who is
postoperative renal biopsy due to the increased risk for bleeding.
17.A nurse is reinforcing preoperative teaching to a client who is to undergo a radical
prostatectomy. Which of the following statements should the nurse include in the teaching?
(Select all that apply).
1) "You may feel the need to urinate even though a catheter is in place."
2) "Performing Kegel exercises following the surgery will help you to manage
incontinence."
INCORRECT
3) "There is very little postoperative pain with this procedure."
INCORRECT
4) "You will be on a low-fiber diet following the surgery."
5) "You should expect your urine to be blood-tinged for a few days following the surgery."
Answer Rationale:
”You may feel the need to urinate even though a catheter is in place.” is correct. Pressure
from the taping of the catheter to the thigh or abdomen may cause the sensation of the need to
void.
Loading page 12...
“Performing Kegel exercises following the surgery will help you to manage incontinence.” is
correct. Urinary incontinence is a common complication following a radical prostatectomy.
Kegel exercises can reduce the severity of the incontinence.
“There is very little postoperative pain with this procedure.” is incorrect. Along with
incisional pain, the client may also experience pain from bladder spasms. Clients are often
provided a patient-controlled analgesia pump for the first 24 hr postoperative period.
“You will be on a low-fiber diet following the surgery.” is incorrect. Straining with defecation
can lead to postoperative bleeding. A high-fiber diet and a stool softener are often prescribed.
“You should expect your urine to be blood-tinged for a few days following the surgery.” is
correct. The flow of bladder irrigation is maintained to keep the urine a reddish pink, which
should clear to a pink tinge within 48 hr following surgery. Urine which turns bright red indicates
bleeding and should be reported immediately.
18. A nurse is reinforcing teaching about possible treatments with a client who has psoriasis.
Which of the following treatment options should the nurse include in the teaching? (Select all that
apply.)
1) Tar preparations
2) Corticosteroids
3) Ultraviolet light therapy
INCORRECT
4) Laser therapy
INCORRECT
5) Topical antibiotics
Answer Rationale:
Tar preparations is correct. Tar preparations help to impede the proliferation of skin cells and
are effective to remove scales as well as increase remission.
Corticosteroids is correct. Corticosteroids help reduce the inflammation and pruritus associated
with psoriasis.
Ultraviolet light therapy is correct. Ultraviolet light therapy is effective in the treatment of
psoriasis by decreasing the growth rate of epidermal cells.
Laser therapy is incorrect. Laser therapy is appropriate for the removal of skin lesions rather
than for the treatment of psoriasis.
Topical antibiotics is incorrect. Antibiotics are not appropriate for the treatment of psoriasis, as
it is not a bacterial condition.
correct. Urinary incontinence is a common complication following a radical prostatectomy.
Kegel exercises can reduce the severity of the incontinence.
“There is very little postoperative pain with this procedure.” is incorrect. Along with
incisional pain, the client may also experience pain from bladder spasms. Clients are often
provided a patient-controlled analgesia pump for the first 24 hr postoperative period.
“You will be on a low-fiber diet following the surgery.” is incorrect. Straining with defecation
can lead to postoperative bleeding. A high-fiber diet and a stool softener are often prescribed.
“You should expect your urine to be blood-tinged for a few days following the surgery.” is
correct. The flow of bladder irrigation is maintained to keep the urine a reddish pink, which
should clear to a pink tinge within 48 hr following surgery. Urine which turns bright red indicates
bleeding and should be reported immediately.
18. A nurse is reinforcing teaching about possible treatments with a client who has psoriasis.
Which of the following treatment options should the nurse include in the teaching? (Select all that
apply.)
1) Tar preparations
2) Corticosteroids
3) Ultraviolet light therapy
INCORRECT
4) Laser therapy
INCORRECT
5) Topical antibiotics
Answer Rationale:
Tar preparations is correct. Tar preparations help to impede the proliferation of skin cells and
are effective to remove scales as well as increase remission.
Corticosteroids is correct. Corticosteroids help reduce the inflammation and pruritus associated
with psoriasis.
Ultraviolet light therapy is correct. Ultraviolet light therapy is effective in the treatment of
psoriasis by decreasing the growth rate of epidermal cells.
Laser therapy is incorrect. Laser therapy is appropriate for the removal of skin lesions rather
than for the treatment of psoriasis.
Topical antibiotics is incorrect. Antibiotics are not appropriate for the treatment of psoriasis, as
it is not a bacterial condition.
Loading page 13...
19. A nurse is assisting in planning an educational session regarding risk factors for skin cancer
to a group of clients. Which of the following information should the nurse plan to include in the
session? (Select all that apply.)
INCORRECT
1) Being dark-skinned
INCORRECT
2) Age under 40 years
3) Overexposure to ultraviolet light
4) Chronic skin irritations
5) Genetic predisposition
Answer Rationale:
Being dark-skinned is incorrect. Light-skinned individuals are at greater risk for developing
skin cancer.
Age under 40 years is incorrect. Individuals between the ages of 30 and 60 are at the greatest
risk for developing nonmelanoma skin cancers.
Overexposure to ultraviolet light is correct. Overexposure to ultraviolet light is a risk factor for
developing skin cancer. Rays from the sun are known to be carcinogenic and can result in
malignant changes.
Chronic skin lesions is correct. Chronic skin lesions are a risk factor for developing skin cancer.
Clients are taught to monitor for a change in these chronic lesions as a precursor to a malignancy.
Genetic predisposition is correct.Genetic predisposition is a risk factor for developing skin
cancer, particularly malignant melanoma.
20.A nurse is reinforcing teaching with a client who has questions concerning the various
treatment options for his new diagnosis of basal cell carcinoma (BCC). Which of the following
treatments should she include in the teaching? (Select all that apply).
1) Cryosurgery
2) Electrodessication
3) Radiation therapy
INCORRECT
to a group of clients. Which of the following information should the nurse plan to include in the
session? (Select all that apply.)
INCORRECT
1) Being dark-skinned
INCORRECT
2) Age under 40 years
3) Overexposure to ultraviolet light
4) Chronic skin irritations
5) Genetic predisposition
Answer Rationale:
Being dark-skinned is incorrect. Light-skinned individuals are at greater risk for developing
skin cancer.
Age under 40 years is incorrect. Individuals between the ages of 30 and 60 are at the greatest
risk for developing nonmelanoma skin cancers.
Overexposure to ultraviolet light is correct. Overexposure to ultraviolet light is a risk factor for
developing skin cancer. Rays from the sun are known to be carcinogenic and can result in
malignant changes.
Chronic skin lesions is correct. Chronic skin lesions are a risk factor for developing skin cancer.
Clients are taught to monitor for a change in these chronic lesions as a precursor to a malignancy.
Genetic predisposition is correct.Genetic predisposition is a risk factor for developing skin
cancer, particularly malignant melanoma.
20.A nurse is reinforcing teaching with a client who has questions concerning the various
treatment options for his new diagnosis of basal cell carcinoma (BCC). Which of the following
treatments should she include in the teaching? (Select all that apply).
1) Cryosurgery
2) Electrodessication
3) Radiation therapy
INCORRECT
Loading page 14...
4) Photochemotherapy
5) Mohs surgery
Answer Rationale:
Cryosurgery is correct. Cryosurgery freezes the cancerous tissue and is used in the treatment of
BCC.
Electrodessication is correct. Electrodessication uses electrical energy to destroy and remove
cancerous tissue and is used in the treatment of BCC.
Radiation therapy is correct. Radiation therapy can be used in the treatment of BCC depending
on client age and the location of the tumor.
Photochemotherapy is incorrect. Photochemotherapy is used in the treatment of psoriasis rather
than BCC.
Mohs surgery is correct. Mohs micrographic surgery is used in the treatment of BCC as the
most accurate method of removing the tumor while preserving healthy tissue.
21. A nurse is collecting data for a client who has giant cell arteritis. Which of the following
findings should the nurse expect? (Select all that apply.)
1) Chest pain
2) Loss of vision
INCORRECT
3) Weight gain
4) Dyspnea
5) Headache
Answer Rationale:
Chest pain is correct. Chest pain is a finding associated with giant cell arteritis because of the
inflammation of the coronary arteries that can occur. Loss of vision is correct. Loss of vision is a
finding associated with giant cell arteritis because of the inflammation that can occur with the
vessels of the eyes. Weight gain is incorrect. Weight loss can occur because of the inflammatory
process and metabolic process. Dyspnea is correct. Dyspnea is a finding associated with giant
cell arteritis that may occur with inflammation of the pulmonary arteries.Headache is
correct. Headache is a finding associated with giant cell arteritis that may occur with
inflammation of the cranial arteries.
22. A nurse is collecting data from a client who has a herniated intervertebral cervical disc.
Which of the following findings should the nurse expect? (Select all that apply.)
1) Tingling in the arms
INCORRECT
2) Low back pain
5) Mohs surgery
Answer Rationale:
Cryosurgery is correct. Cryosurgery freezes the cancerous tissue and is used in the treatment of
BCC.
Electrodessication is correct. Electrodessication uses electrical energy to destroy and remove
cancerous tissue and is used in the treatment of BCC.
Radiation therapy is correct. Radiation therapy can be used in the treatment of BCC depending
on client age and the location of the tumor.
Photochemotherapy is incorrect. Photochemotherapy is used in the treatment of psoriasis rather
than BCC.
Mohs surgery is correct. Mohs micrographic surgery is used in the treatment of BCC as the
most accurate method of removing the tumor while preserving healthy tissue.
21. A nurse is collecting data for a client who has giant cell arteritis. Which of the following
findings should the nurse expect? (Select all that apply.)
1) Chest pain
2) Loss of vision
INCORRECT
3) Weight gain
4) Dyspnea
5) Headache
Answer Rationale:
Chest pain is correct. Chest pain is a finding associated with giant cell arteritis because of the
inflammation of the coronary arteries that can occur. Loss of vision is correct. Loss of vision is a
finding associated with giant cell arteritis because of the inflammation that can occur with the
vessels of the eyes. Weight gain is incorrect. Weight loss can occur because of the inflammatory
process and metabolic process. Dyspnea is correct. Dyspnea is a finding associated with giant
cell arteritis that may occur with inflammation of the pulmonary arteries.Headache is
correct. Headache is a finding associated with giant cell arteritis that may occur with
inflammation of the cranial arteries.
22. A nurse is collecting data from a client who has a herniated intervertebral cervical disc.
Which of the following findings should the nurse expect? (Select all that apply.)
1) Tingling in the arms
INCORRECT
2) Low back pain
Loading page 15...
14 more pages available. Scroll down to load them.
Preview Mode
Sign in to access the full document!
100%
Study Now!
XY-Copilot AI
Unlimited Access
Secure Payment
Instant Access
24/7 Support
Document Chat
Document Details
Subject
Health Education Systems, Inc.