Advanced Medsurg (Miami Dade College) Hesi Review. Questions and Answers With Rationale 100%.

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Advanced Medsurg (Miami Dade College)

Hesi Review
1. ID: 383740621
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 the
presence of wound dehiscence. The nurse immediately:
Contacts the physician

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Documents the findings
Places the client in a supine position with the legs flat
Covers the abdominal wound with a sterile dressing moistened with sterile saline solution
2. ID: 383740621
A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is
restless and her pulse rate is increased. As the nurse continues the assessment, the client begins to
vomit a copious amount of bright-red blood. The immediate nursing action is to:
Notify the surgeon Continue

the assessment
Check the client’s blood pressure
Obtain a flashlight, gauze, and a curved hemostat
3. ID: 383739348 Answers available

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A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and
tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets
about:
Preparing the client for a perfusion scan

Attaching the client to a cardiac monitor
Administering oxygen by way of nasal cannula
Ensuring that the intravenous (IV) line is patent

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4.ID: 383738703
A nurse is assessing a client who has a closed chest tube drainage system. The nurse notes
constant bubbling in the water seal chamber. What actions should the nurse take? (Select all that
apply).
Clamping the chest tube

https://bit.ly/2VkWqmTChang
ing the drainage system
Assessing the system for an external air leak

Reducing the degree of suction being applied
Documenting assessment findings, actions taken, and client response
5.ID: 383739392
A nurse is helping a client with a closed chest tube drainage system get out of bed and into a
chair. During the transfer, the chest tube is caught on the leg of the chair and dislodged from the
insertion site. The immediate priority on the part of the nurse is:
Contacting the physician

Reinserting the chest tube
Transferring the client back to
bed
Covering the insertion site with a sterile occlusive dressing
6.ID: 383737764
A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody
secretions. The nurse would first:
Continue suctioning to remove the blood
Check the degree of suction being applied

Encourage the client to cough out the bloody
secretions
Remove the suction catheter from the client’s nose and begin vigorous suctioning through
the mouth
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7. ID: 383737791
A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client
begins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction catheter
from the client’s trachea but is unable to do so. The nurse would first:
Call a code
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Contact the physician

Administer a
bronchodilator
Disconnect the suction source from the catheter
8. ID: 383739364
A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy 24
hours ago. The nurse notes that there has been no chest tube drainage for the past hour. The nurse
first:
Contacts the physician
Checks for kinks in the drainage system

Checks the client’s blood pressure and heart
rate
Connects a new drainage system to the client’s chest tube
9. ID: 383740435
A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the client’s
urine output for the past hour was 25 mL. On the basis of this finding, the nurse first:
Calls the physician
Increases the rate of the IV infusion

Checks the client’s overall intake and output record
Administers a 250-mL bolus of normal saline solution (0.9%)
10. ID: 383740623

A nurse is getting a client out of bed for the first time since surgery. The nurse raises the head of
the bed, and the client complains of dizziness. Which of the following actions should the nurse
take first?
Checking the client’s blood pressure

Checking the oxygen saturation level
Having the client take some deep
breaths
Lowering the head of the bed slowly until the dizziness is relieved
11. ID: 383738719

A nurse is preparing for intershift report when a nurse’s aide pulls an emergency call light in a
client’s room. Upon answering the light, the nurse finds a client who returned from surgery
earlier in the day experiencing tachycardia and tachypnea. The client’s blood pressure is 88/60
mm Hg. Which action should the nurse take first?
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Calling the physician
Checking the hourly urine

output Checking the IV site for
infiltration
Placing the client in a modified Trendelenburg position
12. ID: 383739342

A nurse is assessing the chest tube drainage system of a postoperative client who has undergone
a right upper lobectomy. The closed drainage system contains 300 mL of bloody drainage, and
the nurse notes intermittent bubbling in the water seal chamber. One hour after the initial
assessment, the nurse notes that the bubbling in the water seal chamber is now constant, and the
client appears dyspneic. On the basis of these findings, the nurse should first assess:
The client’s vital

signs The amount of
drainage The client’s
lung sounds
The chest tube connections
14. ID: 383739328

A nurse is caring for a client who has just regained bowel sounds after undergoing surgery. The
physician has prescribed a clear liquid diet for the client. Which of the following items does the
nurse ensure is available in the client’s room before allowing the client to drink?
Straw
Napki
n
Suction equipment
Oxygen saturation monitor

15.ID: 383737758
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 the
client?
Paralytic ileus
Incisional
pain Urine
retention
Nausea and vomiting
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16. ID: 383737778

A nurse administers scopolamine as prescribed to a client in preparation for surgery. For which
side effect of this medication does the nurse monitor the client?
Pupil constriction
Increased urine
output
Complaints of dry mouth
Complaints of feeling sweaty

17. ID: 383740631

A nurse is preparing a client for transfer to the operating room. Which of the following actions
should the take in the care of this client at this time?
Ensuring that the client has voided

Administering all daily medications
Practicing postoperative breathing
exercises
Verifying that the client has not eaten for the last 24 hours
18. ID: 383739360

A nurse receives a telephone call from a nurse on the post-anesthesia care unit, who reports that
a client is being transferred to the surgical unit. What should the nurse plan to do first on arrival
of the client?
Assess the patency of the airway

Check tubes and drains for patency
Check the dressing for bleeding
Assess the vital signs to compare them with preoperative measurements
19.ID: 383739322
A client without a history of respiratory disease has a pulse oximeter in place after surgery. The
nurse monitors the pulse oximeter readings to ensure that oxygen saturation remains above:
85%
89%
95%
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100%
20. ID: 383739350

A client who underwent preadmission testing 1 week before surgery had blood drawn for several
serum laboratory studies. Which abnormal laboratory results should the nurse report to the
surgeon’s office? Select all that apply.
Hematocrit 30%
Sodium 141 mEq/L
Hemoglobin 8.9 g/dL
Platelets 210,000
cells/mm3 Serum creatinine
0.8 mg/dL
21.ID: 383738794
A client has been scheduled for magnetic resonance imaging (MRI). For which of the following
conditions, a contraindication to MRI, does the nurse check the client’s medical history?
Pancreatitis
Pacemaker insertion Type
1 diabetes mellitus Chronic
airway limitation

. Into which position does the nurse assist the client after the procedure?
Flat Semi-
Fowler
Side-lying, with the head of the bed elevated
Sitting up in a recliner with the feet elevated
23.ID: 383738711
A client has just returned to the nursing unit after computerized tomography (CT) with contrast
medium. Which of the following actions should the nurse plan to take as part of routine after-care
for this client?
Administering a laxative
Encouraging fluid intake
Maintaining the client on strict bed rest
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Holding all medications for at least 2 hours
24.ID: 383738780
A client reports for a scheduled electroencephalogram (EEG). Which statement by the client
indicates 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.”
25.ID: 383738740
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/dL
5.8 mg/dL
8.9 mg/dL
12.8 mg/dL
26. ID: 383740617

A nurse is providing post-procedure instructions to a client returning home after arthroscopy of
the shoulder. The nurse should tell the client:
To resume full activity the next day
Not to eat or drink anything until the next morning
To keep the shoulder completely immobilized for the rest of the day
To report to the physician the development of fever or redness and heat at the site
27. ID: 383739356

A client is tested for HIV with the use of an enzyme-linked immunosorbent assay (ELISA), and
the test result is positive. The nurse should tell the client that:
HIV infection has been confirmed

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The client probably has an opportunistic infection
The test will need to be confirmed with the use of a Western blot
A positive test is a normal result and does not mean that the client is infected with HIV
28.ID: 383737795
A CD4+ lymphocyte count is performed on a client who is infected with HIV. The results of the
test indicate a CD4+ count of 450 cells/L. The nurse interprets this test result as indicating:
Improvement in the client

The need for antiretroviral therapy The
need to discontinue antiretroviral therapy
An effective response to the treatment for
HIV
29. ID: 383739374

A client has just undergone a renal biopsy. Which intervention should the nurse include
intervention in the post-procedure plan of care?
Restricting fluid intake for the first 24 hours

Periodically testing the urine for occult blood
Avoiding the administration of opioid analgesics
Having the client ambulate in the room and hall for short distances
30.ID: 383739324
A nurse has a prescription to collect a 24-hour urine specimen from a client. Which of the
following measures should the nurse take during this procedure?
Keeping the specimen at room temperature
Saving the first urine specimen collected at the start time
Discarding the last voided specimen at the end of the collection time
Asking the client to void, discarding the specimen, and noting the start time
31.ID: 383738715
A nurse is preparing a client for intravenous pyelography (IVP). Which action by the nurse is
most important?
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Administering a sedative
Encouraging fluid intake
Administering an oral preparation of radiopaque dye
Questioning the client about allergies to iodine or shellfish

32.ID: 383737770
A client who has undergone renal biopsy complains of pain, radiating to the front of the
abdomen, at the biopsy site. For which of the following findings should the nurse assess the
client?
Bleeding Renal
colic Infection at
the site
Increased temperature
33. ID: 383740603

A client has undergone renal angiography by way of the right femoral artery. The nurse
determines that the client is experiencing a complication of the procedure on noting:
Urine output of 40 mL/hr
Blood pressure of 118/76 mm Hg

Respiratory rate of 18 breaths/min
Pallor and coolness of the right leg
34.ID: 383740619
A nurse reviews a client’s urinalysis report. Which finding does the nurse recognize as
abnormal? pH of 6.0
An absence of protein
The presence of ketones
Specific gravity of 1.018
35. ID: 383738713

A nurse provides information to a client who is scheduled for cardiac catheterization to rule out
coronary occlusion. The nurse should tell the client that:
The procedure is performed in the operating room
It is necessary to lie quietly on a hard x-ray table for about 4

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hours The room is bright and well lit, and it is best to keep the
eyes closed
The client may have feelings of warmth or flushing during the procedure
36. ID: 383739376

A client who has sustained a myocardial infarction is scheduled to have an echocardiogram.
Which of the following measures should the nurse take before the procedure?
Imposing nothing-by-mouth (NPO) status for 4

hours Asking the client to sign an informed consent
form
Asking the client about a history of allergy to iodine or shellfish
Telling the client that the procedure is painless and takes 30 to 60 minutes to complete
37. ID: 383737768
A nurse in a physician’s office has just made an appointment for a client to undergo an exercise
stress test. The nurse, in providing pre-procedure teaching, should tell the client to:
Wear sweatpants and a heavy sweatshirt

Eat a small meal just before the
procedure
Wear comfortable rubber-soled shoes such as sneakers
Avoid consuming caffeine for 30 minutes before the procedure
38. ID: 383738707

A nurse has a prescription to apply a Holter monitor to a client for continuous cardiac
monitoring for a 24-hour period. What steps should the nurse take to initiate this prescription?
Select all that apply.
Giving the client a device holder to wear around the waist

Giving the client a diary in which to record all activity and symptoms
Telling the client to rest as much as possible during the next 24 hours
Instructing the client to enclose the monitor in plastic wrap before taking a
bath
Telling the client that occasional slight shocks from the monitor will be felt but that they are
harmless
39. ID: 383738717

A client has undergone pericardiocentesis to treat cardiac tamponade. For which signs should the
nurse assess the client to determine whether the tamponade is recurring?
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Decreasing pulse
Rising blood
pressure
Distant muffled heart sounds
Falling central venous pressure (CVP)

40. ID: 383740412

A nurse is watching as a nursing assistant measures the blood pressure (BP) of a hypertensive
client. Which actions on the part of the assistant that would interfere with accurate measurement
would prompt the nurse to intervene? Select all that apply.
Measuring the BP after the client has sat quietly for 5 minutes
Having the client sit with the arm bared and supported at heart
level
Used a cuff with a rubber bladder that encircles at least 60% of the limb
Measuring the BP after the client reports that he just drank a cup of coffee
Allowing the client to talk as the blood pressure is being measured
41. ID: 383739334

A nurse is watching as a nursing student suctions a client through a tracheostomy tube. Which
actions on the part of the student would prompt the nurse to intervene and demonstrate
procedure? Select all that apply.
Setting the suction pressure to 60 mm Hg Applying

suction throughout the procedure Assessing breath
sounds before suctioning
Placing the client in a supine position before the procedure
Hyperoxygenating the client with 100% oxygen before suctioning

42. ID: 383739346
Oxygen by way of nasal cannula has been prescribed for a client with emphysema. The nurse
checks the physician’s prescriptions to ensure that the prescribed flow is not greater than:
1 L/min
3 L/min
4 L/min
6 L/min
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43.ID: 383739338
A client who experienced the sudden onset of respiratory distress has been intubated with an
endotracheal tube. Immediately after the tube is placed in the trachea, the nurse should:
Tape the tube in place
Send the client for a chest x-ray
Note how far the tube has been inserted
Auscultate both lungs for the presence of breath sounds

44. ID: 383740615

A client has a chest drainage system in place. The fluid in the water seal chamber rises and falls
during inspiration and expiration. The nurse interprets this finding as an indication that:
The tube is patent

There is probably a kink in the tubing
Suction should be added to the
system The client is retaining airway
secretions
45.ID: 383737766
A nurse is performing nasotracheal suctioning on a client. Which of the following observations
should be cause for concern to the nurse? Select all that apply.
The client becomes cyanotic.

Secretions are becoming bloody. The
client gags during the procedure.
Clear to opaque secretions are removed.
The heart rate varies from 80 to 82 beats/min.
46.ID: 383738776
A nurse is monitoring the respiratory status of a client who has just undergone surgery and is
wearing a pulse oximeter. Which of the following coexisting problems is cause for the nurse to
suspect that the oxygen saturation readings are not entirely accurate?
Infection
Hypertensio
n
Low blood pressure
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Loss of cough reflex

47.ID: 383739326
A nurse is reading the radiology report of a client with a chest tube attached to a closed drainage
system who has undergone a chest x-ray. The report states that the client’s affected lung is fully
reexpanded.
The nurse anticipates that the next assessment of the chest tube system will
reveal: No fluctuation in the water seal chamber
Continuous bubbling in the water seal
chamber Increased drainage in the collection
chamber
Continuous gentle suction in the suction control chamber
48.ID: 383740625
A client has just undergone insertion of a chest tube that is attached to a closed chest drainage
system. Which action should the nurse plan to take in the care of this client?
Assessing the client’s chest for crepitus once every 24 hours
Taping the connections between the chest tube and the drainage system Adding
20 mL of sterile water to the suction control chamber every shift
Recording the volume of secretions in the drainage collection chamber every 24 hours
49.ID: 383739370
A client who has just undergone bronchoscopy was returned to the nursing unit 1 hour ago. With
which assessment finding is the nurse most concerned?
Oxygen saturation of 97%

Equal breath sounds in both lungs
Absence of cough and gag reflexes
Respiratory rate of 20 breaths/min
50.ID: 383737783
A nurse is caring for a client who has undergone pulmonary angiography with catheter insertion
through the right femoral vein. The nurse assesses for allergic reaction to the contrast medium by
monitoring for the presence of:
Bradycardia
Respiratory distress
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Hematoma in the right groin

Discomfort in the right groin

51.ID: 383739330
A nurse is conducting an assessment of a client who underwent thoracentesis of the right side of
the chest 3 hours ago. Which findings does the nurse report to the physician? Select all that
apply.
Unequal chest expansion Pulse

rate of 82 beats/min Respiratory
rate of 22 breaths/min
Diminished breath sounds in the right lung
Complaints of discomfort at the needle insertion site
52.ID: 383739362
A nurse is monitoring a client who has undergone pleural biopsy. Which of the following findings
causes the nurse to suspect that the client is experiencing a complication?
Warm, dry skin
Mild pain at the biopsy site
Complaints of shortness of breath Capillary

refill time of less than 3 seconds
53.ID: 383739378
A client has just returned to the nursing unit after bronchoscopy. To which intervention should the
nurse give priority?
Ambulating the client

Administering pain
medication Encouraging
copious fluid intake
Checking for the return of the gag reflex
54.ID: 383740637
A client is receiving intermittent bolus feedings by way of a nasogastric tube. In which position
should the nurse place the client once the feeding is complete?
Supine
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Head of bed flat

Left lateral
position
Head of bed elevated 30 to 45 degrees
55.ID: 383737793
A nurse has a prescription to discontinue a client’s nasogastric tube. The nurse auscultates the
client’s bowel sounds, positions the client properly, and flushes the tube with 15 mL of air to
clear secretions. The nurse then instructs the client to take a deep breath and:
Exhale during tube removal

Bear down during tube
removal
Hold the breath during tube removal
Breathe normally during tube removal
56.ID: 383737762
A nurse checks the residual volume from a client’s nasogastric tube feeding before administering
an intermittent tube feeding and finds 35 mL of gastric contents. What should the nurse do before
administering the prescribed 100 mL of formula to the client?
Pour the residual volume into the nasogastric tube through a syringe with the plunger
removed
Discard the residual volume properly and record it as output on the client’s fluid balance
record Dilute the residual volume with water and inject it into the nasogastric tube, applying
pressure on
the plunger
Mix the residual volume with the formula and pour it into the nasogastric tube, using a
syringe without a plunger
57.ID: 383737754
A nurse has a prescription to insert a nasogastric tube into the stomach of an assigned client.
Which action should the nurse take to insert the tube safely and easily?
Placing the tube in warm water
Hyperextending the head while inserting the tube

Removing the tube if any resistance to insertion is
met
Asking the client to swallow as the tube is being advanced
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58.ID: 383738765
A client who has undergone an esophagogastroduodenoscopy (EGD) returns from the endoscopy
department. After checking the client’s gag reflex, which action should the nurse take?
Taking the client’s vital signs Giving
the client a drink of water Monitoring
the client for a sore throat Being alert
to complaints of heartburn
59.ID: 383738723
A client has just been scheduled for endoscopic retrograde cholangiopancreatography (ERCP).
What should the nurse tell the client about the procedure? Select all that apply.
That informed consent is required That

the test takes about 4 hours to complete
That no premedication for sedation will be necessary
That food and fluids will be withheld before the procedure
That multiple position changes may be necessary to pass the tube

60.ID: 383737776
A client is scheduled for a barium swallow (esophagography) in 2 days. The nurse, providing
preprocedure instructions, should tell the client to:
Eat a regular supper and breakfast
Remove all metal and jewelry before the test

Expect diarrhea for a few days after the procedure
Take all oral medications as scheduled with milk on the day of the test
61.ID: 383739316
A nurse is preparing a client for colonoscopy. Into which position does the nurse assist the client
for the procedure?
Left Sims’ position

Lithotomy position
Knee-chest position
Right Sims’ position
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62. ID: 383739340

Polyethylene glycol–electrolyte solution (GoLYTELY) is prescribed for a hospitalized client
scheduled for colonoscopy. The client begins to experience diarrhea after drinking the solution.
Which action by the nurse is appropriate?
Calling the physician
Administering a cleansing
enema
Documenting the diarrhea in the medical record
Giving intravenous replacement fluids in large amounts
63. ID: 383739372

A physician is about to perform paracentesis on a client with abdominal ascites. Into which
position would the nurse assist the client?
Supine
Upright Left
side–lying
Right side–
lying
64. ID: 383739306

A nurse is reviewing the results of serum laboratory studies of a client with suspected hepatitis.
Which increased parameter is interpreted by the nurse as the most specific indicator of this
disease?
Hemoglobin
Serum bilirubin Blood

urea nitrogen (BUN)
Erythrocyte sedimentation rate (ESR)
65. ID: 383737799

A nurse is preparing to examine a client’s skin using a Wood light. What should the nurse do to
facilitate this procedure?
Darken the examining room

Administer a local anesthetic
Obtain a signed informed
consent
Shave the skin and scrub it with povidone-iodine (Betadine)
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66. ID: 383738709

A nurse is assessing the status of a client with diabetes mellitus. The nurse concludes that the
client is exhibiting adequate diabetic control if the serum level of glycosylated hemoglobin
A1C (HbA1C) is less than:
7%
9%
10%
15%

67.ID: 383739344
A client with diabetes mellitus is scheduled to have blood drawn for a fasting blood glucose
determination drawn in the morning. What does the nurse tell the client that it is acceptable to
consume on the morning of the test?
Water
Tea without any sugar

Coffee without any milk
Clear liquids such as apple juice
68.ID: 383737787
A client is scheduled to undergo computerized tomography (CT) with contrast for evaluation of
an abdominal mass. The nurse should tell the client that:
The test may be painful

The test takes 2 to 3
hours
Food and fluids are not allowed for 4 hours after the test
Dye is injected and may cause a warm flushing sensation
69.ID: 383738782
A pelvic ultrasound is prescribed to evaluate a client’s ovarian mass. What should the nurse
giving preprocedure instructions tell the client that it important to do before the procedure?
Eat only a light breakfast

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Wear comfortable clothing and shoes

Drink 6 to 8 glasses of water without voiding Stop
eating or drinking at midnight before the test
70.ID: 383738721
A client has been given a diagnosis of multiple myeloma. Which of the following results does the
nurse reviewing the client’s laboratory findings recognize as being specifically related to this
diagnosis?
Increased calcium level Increased

white blood cell (WBC) count
Decreased blood urea nitrogen
(BUN)
Decreased number of plasma cells in the bone marrow
71. ID: 383740635

A woman has been scheduled for a routine mammogram. The nurse should tell the
client: That mammography takes about 1 hour
Not to eat or drink on the morning of the test
That there is no discomfort associated with the procedure
That deodorants, powders, or creams used in the axillary or breast area must be washed off
before the test
72.ID: 383740629
A client has made an appointment to for her annual Papanicolaou test (a.k.a. Pap smear). The
nurse who schedules the appointment should tell the client that:
The test cannot be performed while the client is menstruating Vaginal

douching is required an hour before the test
Spicy foods should not be eaten on the day of the test
The test has absolutely no discomfort associated with it
73.ID: 383738778
A client who has just undergone a skin biopsy is listening to discharge instructions from the
nurse. The nurse determines that the client has misunderstood the directions if the client
indicates that as part of aftercare he plans to:
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Use the antibiotic ointment as prescribed

Return in 7 days to have the sutures
removed
Apply cool compresses to the site twice a day for 20 minutes
Call the physician if excessive drainage from the wound occurs
74.ID: 383739368
A serum phenytoin determination is prescribed for a client with a seizure disorder who is taking
phenytoin (Dilantin). Which result indicates that the prescribed dose of phenytoin is therapeutic?
3 mcg/mL
8 mcg/mL
16 mcg/mL
28 mcg/mL
75.ID: 383739318
A client is receiving a continuous IV infusion of heparin for the treatment of deep vein
thrombosis. The client’s activated partial thromboplastin time (aPTT) level is 80 seconds. The
client’s baseline before the initiation of therapy was 30 seconds. Which action does the nurse
anticipate is needed?
Shutting off the heparin infusion

Increasing the rate of the heparin
infusion
Decreasing the rate of the heparin infusion
Leaving the rate of the heparin infusion as is
76.ID: 383738701
A client with cardiovascular disease is scheduled to receive a daily dose of furosemide (Lasix).
Which potassium level would cause the nurse, reviewing the client’s electrolyte values, to contact
the physician before administering the dose?
3.0 mEq/L
3.8 mEq/L
4.2 mEq/L
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5.1 mEq/L
77.ID: 383738727
A young adult asks the nurse about the normal cholesterol level. The nurse tells the client that the
total cholesterol level should be maintained at less than:
140 mg/dL
200 mg/dL
250 mg/dL
300 mg/dL
78.ID: 383740455
A nurse is reviewing the results of renal function testing in a client with renal calculi. Which
finding indicates to the nurse that the client’s blood urea nitrogen (BUN) level is within the
normal range?
2 mg/dL
18 mg/dL
25 mg/dL
35 mg/dL
79.ID: 383739320
An adult female client has undergone a routine health screening in the clinic. Which of the
following values indicates to the nurse who receives the report of the client’s laboratory
work that the client’s hematocrit is normal?
10%
22%
30%
43%
80.ID: 383738705
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A client admitted to the hospital with a diagnosis of acute pancreatitis has blood drawn for
several serum laboratory tests. Which of the following serum amylase values, noted by the nurse
reviewing the results, would be expected in this client at this time?
48 units/L
97 units/L
150 units/L
395 units/L
81.ID: 383739384
A nurse is reviewing laboratory results for a client who is at risk for nephrotoxicity because of
medications he is taking. Which of the following serum creatinine results does the nurse
document as normal?
0.2 mg/dL
1.0 mg/dL
2.8 mg/dL
3.9 mg/dL
82.ID: 383740466
A client with type 1 diabetes mellitus has a blood glucose level of 620 mg/dL. After the nurse
calls the physician to report the finding and monitors the client closely for:
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
83.ID: 383737752
A nurse reviews the blood gas results of a client in respiratory distress. The pH is 7.32 and the
PCO2 is 50 mm Hg. Which of the following acid-base imbalances does the nurse recognize in
these findings?
Metabolic acidosis
Metabolic alkalosis
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84.ID: 383740633
Blood for arterial blood gas determinations is drawn on a client with pneumonia, and testing
reveals a pH of 7.45, PCO2 of 30 mm Hg, and HCO3 of 19 mEq/L. The nurse interprets these
results as indicative of:
Compensated metabolic acidosis

Compensated respiratory alkalosis
Uncompensated metabolic alkalosis
Uncompensated respiratory acidosis
85.ID: 383737789
A nurse is caring for a client who is vomiting. For which acid-base imbalance does the nurse
assess the client?
Metabolic acidosis
Metabolic alkalosis
86.ID: 383737797
A nurse is caring for a client with diarrhea. For which acid-base disorder does the nurse assess
the client?
Metabolic acidosis
Metabolic alkalosis
87.ID: 383739332
A client tells the nurse that he has been experiencing frequent heartburn and has been “living on
antacids.” For which acid-base disturbance does the nurse recognize a risk?
Metabolic acidosis
Metabolic alkalosis
88.ID: 383738749
A client has the following arterial blood gas (ABG) results: pH 7.51, PCO2 31 mm Hg, PO2 94
mm Hg, HCO3 24 mEq/L. Which of the following acid-base disturbances does the nurse
recognize in these results?
Metabolic acidosis
Metabolic alkalosis
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89. ID: 383739354

A client with histoplasmosis has the following arterial blood gas (ABG) results: pH 7.30, PCO2
58 mm Hg, PO2 75 mm Hg, HCO3 27 mEq/L. Which of the following acid-base disturbances
does the nurse recognize in these results?
Metabolic acidosis
Metabolic alkalosis
90. ID: 383738784

A client is brought to the emergency department by a neighbor. The client is lethargic and has a
fruity odor on the breath. The client’s arterial blood gas (ABG) results are pH 7.25, PCO2 34 mm
Hg, PO2 86 mm Hg, HCO3 14 mEq/L. Which of the following acid-base disturbances does the
nurse recognize in these results?
Metabolic acidosis
Metabolic alkalosis
91.ID: 383737772
A client who is anxious about an impending surgery is at risk for respiratory alkalosis. For
which signs and symptoms of respiratory alkalosis does the nurse assess this client?
Disorientation and dyspnea

Drowsiness, headache, and
tachypnea
Tachypnea, dizziness, and paresthesias
Dysrhythmias and decreased respiratory rate and depth
92.ID: 383739366
A client with a history of lung disease is at risk for respiratory acidosis. For which of the
following signs and symptoms does the nurse assess this client?

Drowsiness, headache, and tachypnea
Tachypnea, dizziness, and paresthesias
93.ID: 383740482
A client who has received sodium bicarbonate in large amounts is at risk for metabolic alkalosis.
For which of the following signs and symptoms does the nurse assess this client?
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Drowsiness, headache, and
tachypnea Tachypnea, dizziness,
and paresthesias
94.ID: 383737760
A client who is mouth breathing is receiving oxygen by face mask. The nursing assistant asks
the nurse why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The
nurse responds that the primary purpose of the water is to:
Prevent the client from getting a nosebleed

Give the client added fluid by way of the respiratory tree
Humidify the oxygen that is bypassing the client’s nose
Prevent fluid loss from the lungs during mouth breathing
95.ID: 383738731
A client’s baseline vital signs are temperature 98° F oral, pulse 74 beats/min, respiratory rate 18
breaths/min, and blood pressure 124/76 mm Hg. The client suddenly spikes a fever of 103° F.
Which of the following respiratory rates would the nurse anticipate as part of the body’s
response to the change in client status?
12 breaths/min
16 breaths/min
18 breaths/min
22 breaths/min
96.ID: 383738725
A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy
asks the nurse why the flow rate cannot be increased to more than 2 L/min. The nurse responds
that this would be harmful because it could:
Be drying to nasal passages

Decrease the client’s oxygen-based respiratory drive
Increase the risk of pneumonia as a result of drier air
passages Decrease the client’s carbon dioxide–based
respiratory drive
97.ID: 383738729
A nurse is reading the chest x-ray report of a client who has just been intubated. The report states
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that the tip of the endotracheal tube lies 1 cm above the carina. The nurse interprets that the tube
is positioned above:
The first tracheal cartilaginous ring
The point where the larynx connects to the trachea

The bifurcation of the right and left main stem bronchi The
area connecting the oropharynx to the laryngopharynx
98.ID: 383739336
A nurse is caring for a client who has lost a significant amount of blood as a result of
complications during a surgical procedure. Which parameter does the nurse recognize as the
earliest indication of new decreases in fluid volume?
Pulse rate Blood

pressure
Pulmonary artery systolic pressure
Pulmonary artery end-diastolic pressure
99.ID: 383739352
A nurse is admitting a client with a diagnosis of hypothermia to the hospital. Which of the
following signs does the nurse anticipate that this client will exhibit?
Increased heart rate and increased blood pressure
Increased heart rate and decreased blood pressure
Decreased heart rate and increased blood pressure
Decreased heart rate and decreased blood pressure
100.ID: 383739358
A nurse is teaching a nursing student how to measure a carotid pulse. The nurse should tell the
student to measure the pulse on only one side of the client’s neck primarily because:
It is unnecessary to use both hands
Feeling dual pulsations may lead to an in measurement

Palpating both carotid pulses simultaneously could occlude the trachea
Palpating both carotid pulses simultaneously could cause the heart rate and blood pressure to
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Advanced Medsurg (Miami Dade College)

Contacts the physician

Notify the surgeon Continue

3. ID: 383739348 Answers available

Preparing the client for a perfusion scan

Ensuring that the intravenous (IV) line is patent

Clamping the chest tube

Assessing the system for an external air leak

Contacting the physician

Continue suctioning to remove the blood

Check the degree of suction being applied

Contact the physician

Contacts the physician

Checks for kinks in the drainage system

Calls the physician

Increases the rate of the IV infusion

10. ID: 383740623

Checking the client’s blood pressure

11. ID: 383738719

Calling the physician

Checking the hourly urine

12. ID: 383739342

The client’s vital

14. ID: 383739328

Oxygen saturation monitor

Answers available here https://bit.ly/2VkWqmT

16. ID: 383737778

Complaints of feeling sweaty

17. ID: 383740631

Ensuring that the client has voided

18. ID: 383739360

Assess the patency of the airway

20. ID: 383739350

Answers available here https://bit.ly/2VkWqmT

Sitting up in a recliner with the feet elevated

Holding all medications for at least 2 hours

“I didn’t shampoo my hair.” “I

26. ID: 383740617

To resume full activity the next day

Not to eat or drink anything until the next morning

27. ID: 383739356

HIV infection has been confirmed

The client probably has an opportunistic infection

Improvement in the client

29. ID: 383739374

Restricting fluid intake for the first 24 hours

Keeping the specimen at room temperature

Saving the first urine specimen collected at the start time

Questioning the client about allergies to iodine or shellfish

33. ID: 383740603

Urine output of 40 mL/hr

Blood pressure of 118/76 mm Hg

35. ID: 383738713

The procedure is performed in the operating room

It is necessary to lie quietly on a hard x-ray table for about 4

36. ID: 383739376

Imposing nothing-by-mouth (NPO) status for 4

Wear sweatpants and a heavy sweatshirt

Avoid consuming caffeine for 30 minutes before the procedure

38. ID: 383738707

Giving the client a device holder to wear around the waist

39. ID: 383738717