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NSG233 - HESI FINAL EXAM 2 NEWEST 2025 TEST
BANK| COMPLETE 200 ACTUAL EXAM QUESTIONS
AND CORRECT DETAILED AN SWERS (VERIFIED
ANSWERS) ALREADY GRADED A+| NSG233 MEDICAL-
SURGICAL NURSING 3 EXAM REVIEW|| BRAND
NEW!!
A client admitted 3 days ago with respiratory failure is extubated, and 40% oxygen per face mask is initiated. The client's temperature is 99° F (37.2° C), capillary refill is less than 4 seconds, and respiratory effort is within normal limits. Which outcome should the nurse evaluate to measure for successful extubation? – ANSWER - Maintains effective breathing pattern.
A client who sustained a head injury is alert and oriented, moves all extremities on command, has equal muscle strength bilaterally, and equally reactive pupils to light. Which action should the nurse implement next? – ANSWER - Reassess the client every 2 hours.
An older adult male client is admitted after three reported syncopal episodes at home. He has several bruises at various stages of healing noted over his arms and legs. The cardiac monitor shows atrial fibrillation with a ventricular rate of 140 beats/minute. In addition to contacting the client's healthcare provider, which intervention should the nurse implement? – ANSWER - Monitor the client's blood pressure and oxygen saturation.
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pg. 2 The nurse reviews the arterial blood gas (ABG) results of a client who is admitted with a drug overdose. The client is breathing room air and has an oxygen saturation (SaO2) of 84%, with a pH of 7.31, PaCO, 48 mm Hg, HCO3- 23 mEq/L (23 mmol/L) and a PaOz of 58 mm Hg.Which nursing intervention has the highest priority?Reference Ranges Arterial Blood Gases:pH 7.35 to 7.45PaCO, 35 to 45 mm Hg HCO: 21 to 28 mEq/L PaO, 80 to 100 mmHg – ANSWER - Provide supplemental oxygen.
Immediate postoperative nursing care for a client who has had a asurgical repair of an abdominal aortic aneurysm should include which interventions – ANSWER - Assessing pedal pulses frequently and monitoring the nasogastric drainage
A client with a burn in the inner leg from an exhaust pipe while riding on the back of a mototrcycle arrives at the clinic after applying ove the counter( OTC) formula of silver to the ruptured blister are. Which finding is most important for the nurse to report to the healthcare provider? – ANSWER - Rash in the skin perimeter of the burn
The nurse assesses a client with cirrhosis who is admitted with worsening ascites. It is most important for the nurse to address which finding? – ANSWER - Hypotension
When administering 1 unit of packed red blood cells to a client, the nurse obtains vital signs of a temperature of 101.4 a heart rate of 98 beats/minute,respirations of 24 breaths/minuteand a blood pressure of 88/60mm Hg.Which action should the nurse take immediately? – ANSWER - Stop the trasnfusion and infuse 0.9% sodium chloride 2 / 4
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pg. 3 A client with liver disease and esophageal varices is admitted for an episode of hematemesis. Which client teaching should the nurse provide prior to discharge? – ANSWER - Avoid lifting heavy objects
A homeless adult client is admitted to the medical unit for the fourth time this year. The client has ascites, is malnourished, and reports having bloody stools for the past three days. The client's vital signs are temperature 100.5° F (38° C) orally, heart rate 142 beats/minute, respirations shallow at 24 breaths/minute, and blood pressure 80/50 mm Hg. The oxygen saturation level is 94% with oxygen at 2 L/minute via nasal cannula. Which intervention should the nurse implement? – ANSWER - Insert a peripheral IV catheter
On a day when the temperature is expected to drop to below freezing during the night, the nurse is asked to determine which homeless adults are most in need of the limited spaces that are available in a shelter. It is most important for which person to be admitted for the night? – ANSWER - An older adult who is malnourished
A client asks the nurse for information about how to reduce risk factors for benign prostatic hyperplasia (BPH). Which information should the nurse provide? – ANSWER - increase physical activity
A female client comes to the emergency center to report that two days ago she was the victim of date rape. Which action is most important for the nurse to implement? – ANSWER - Assess for the presence of serum flunitrazepam
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pg. 4 A client, who is 4 hours post laparotomy, has rapidly increasing abdominal distention with elevated pulse and respiratory rates. The client's skin is cool and pale, and there is no change in the blood pressure. Which intervention should the nurse implement immediately?– ANSWER - Notify the healthcare provider of the client status
When a client's mechanical ventilator starts to alarm, which is the priority nursing action? – ANSWER - Note the client's oxygen saturation Rate
A client is admitted to the intensive care unit with acute kidney injury (AKI) after sustaining a major multi-system trauma. Which laboratory result should the nurse be alert for when caring for this client? – ANSWER - Hyperkalemia
Following an motor vehicle collision, a client who is unconscious is transported by ambulance to the emergency department. On arrival, the nurse observes bleeding from the client's nose. Vital signs are heart rate 100 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/76 mmHg. Which intervention is most important for the nurse to implement? – ANSWER - Evaluate blood from nose for halo effects
A client is brought to the emergency department following a motor vehicle collision with blunt trauma to the chest. Which finding should the nurse report immediately to the healthcare provider? – ANSWER - Muffled heart tones
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