MED SURG HESI 2024 NEWEST VERSION 5 COMPLETE 55 QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS)

The nurse is caring for a client who returns to the unit following a colonoscopy. Which finding should
the nurse report to the healthcare provider immediately?
A) Large amounts of expelled flatus with mucus.
B) Tympanic abdomen and hyperactive bowel sounds.
C) Increased abdominal pain with rebound tenderness.
D) Complaint of feeling weak with watery diarrheal stools. - AnswersC) Increased abdominal pain
with rebound tenderness.
Positive rebound tenderness (C) may be an indication of peritonitis or perforation and needs followup immediately. Clients typically experience a large amount of flatus (A) and may have mucus from
bowel irritation from the procedure. A tympanic abdomen on percussion and hyperactive bowel
sounds are typical post procedure findings (B). Weakness and watery stools are a result from the
preparation and are common symptoms experienced after a colonoscopy (D).
When caring for a client with a percutaneous endoscopic gastrostomy (PEG) tube, what protocols
should the nurse implement for intermittent feedings? (Select all that apply.)
o Assessing residual amounts once a day.
o Keeping the head of the bed elevated 30 degrees.
o Changing the enteral-feeding bag every 24 hours.
o Checking the placement of the tube by means of gastric aspiration.
o Flushing the tube with 50 ml of normal saline solution after each feeding. - Answerseeping the
head of the bed elevated 30 degrees. Correct
o Changing the enteral-feeding bag every 24 hours. Correct
o Checking the placement of the tube by means of gastric aspiration. Correct
o Flushing the tube with 50 ml of normal saline solution after each feeding.
(B, C, D, and E) are correct. Keeping the head of the bed elevated 30 degrees (B), changing the
enteral-feeding bag every 24 hours (C), checking the placement of the tube by means of gastric
aspiration (D), and flushing the tube with 50 ml of normal saline solution after each feeding (E) are
interventions used to provide care of the client with a PEG tube. Residual amounts should be
assessed prior to each feeding, not once daily (A).
The nurse is assessing a client with a cuffed tracheostomy tube in place who is breathing
spontaneously. To evaluate if the client can tolerate cuff deflation to promote speaking and
swallowing, what action should the nurse implement?
Ask the client to try to speak.
Assess for respiratory distress.
Auscultate for pulmonary crackles after the client drinks a small amount of clear water.
Observe the client for coughing colored sputum after drinking a small amount of colored water. -
AnswersObserve the client for coughing colored sputum after drinking a small amount of colored
water.
A client is admitted to the emergency department after being lost for four days while hiking in a
national forest. Upon review of the laboratory results, the nurse determines the client's serum level
for thyroid-stimulating hormone (TSH) is elevated. Which additional assessment should the nurse
make?
o Body mass index.
o Skin elasticity and turgor.
o Thought processes and speech.
o Exposure to cold environmental temperatures. - AnswersExposure to cold environmental
temperatures. Correct
A client asks the nurse about the purpose of beginning chemotherapy (CT) because the tumor is still
very small. Which information supports the explanation that the nurse should provide?
o Side effects are less likely if therapy is started early.