HESI MED SURG 2024 VERSION 1 ACTUAL 55 QUESTIONS WITH DETAILED VERIFIED ANSWERS AND RATIONALE /A+ GRADE ASSURD

1. The nurse obtains a fingerstick glucose level utilizing bedside lancet/glucose meter equipment from a client with prescribed sliding scale insulin protocol.The meter indicates 56 mg/dl (3.12 mmol/l). At this time which intervention
should the nurse implement first?
A. Collect a blood specimen by venipuncture to send to the laboratory for
serum glucose analysis.
B. Prepare the prescribed dose of rapid acting insulin from the sliding scale
instructions.
C. Give the client six ounces of non-diet carbonated soda and instruct to drink
it entirely.
D. Document the glucose reading in the electronic medical record as the only
action needed.: C
2. To achieve maximum mobility and independence for a client with multiple
sclerosis (MS), which intervention is most important for the nurse to implement?
A. Provide a walker for ambulation
B. Frequently assist the client to the bathroom
C. Apply alternating patches over eyes
D. Teach strengthening exercises: D
3. A client is admitted to the hospital with symptoms consistent with a right
hemisphere stroke. Which neurovascular assessment requires immediate intervention by the nurse?
A. Pupillary changes to ipsilateral dilation
B. Orientation to person and place only
C. Left- sided drooping and dysphagia
D. Unequal bilateral hand grip strengths: C
4. The nurse is teaching a client with glomerulonephritis about self care.Which
dietary recommendations should the nurse encourage the client to follow?
A. Limit oral fluid intake to 500 ml per day
B. Restrict protein intake by limiting meats and other high-protein foods
C. Increase intake of potassium-rich foods such as bananas and cantaloupe.
D. Increase intake of high fiber foods such as bran cereal: B
5. The nurse is caring for a client with Herpes zoster who reports painful, red,
blisters that align from the back along the chest's curvature to the anterior
chest. Which intervention is the highest priority for the nurse?
A. Place the client on contact precautions
B. Administer antiviral medications
C. Place wet compresses to ruptured vesicles
D. Administer narcotic analgesics: B
6. A young adult who suffered a severe brain injury in an automobile collision
has been mechanically ventilated for the past three days and has no spontaneous respiratory effort. After serial electroencephalograms (EEG) reveal no
brain activity, the healthcare provider discusses end-of-life options with the
family who agree to discontinue life support. Which intervention should the
nurse implement?
A. Ask the family if they wish to remain at the bedside during withdrawal
B. Request a living will be placed in the clients medical record
C. Discuss the withdrawal procedure with the family and offer support
D. Turn off mechanical ventilator and note time of death: C