HESI RN
Evolve HESI Medical Surgical Practice Exam Quizlet
1. The healthcare provider is assessing a client undergoing peritoneal dialysis. Which of the following findings should be reported immediately to the physician?
- A. Clear dialysate outflow.
- B. Clear dialysate inflow.
- C. Cloudy dialysate outflow.
- D. Increased blood pressure.
Correct answer: C
Rationale: Cloudy dialysate outflow should be reported immediately to the physician as it is a concerning sign of peritonitis, a severe infection of the peritoneum. Peritonitis is a serious complication of peritoneal dialysis that requires prompt medical intervention to prevent further complications. Clear dialysate outflow and inflow are normal findings in peritoneal dialysis and do not indicate an immediate need for intervention. Increased blood pressure, while important to monitor, is not directly related to peritoneal dialysis and would not be the priority over the potentially life-threatening complication of peritonitis.
2. What is the primary nursing intervention for a patient experiencing an acute asthma attack?
- A. Administering bronchodilators.
- B. Administering antibiotics.
- C. Administering IV fluids.
- D. Administering corticosteroids.
Correct answer: A
Rationale: The correct answer is administering bronchodilators. During an acute asthma attack, the primary goal is to relieve airway constriction and bronchospasm to improve breathing. Bronchodilators, such as short-acting beta-agonists, are the cornerstone of treatment as they help dilate the airways quickly. Administering antibiotics (choice B) is not indicated unless there is an underlying bacterial infection. Administering IV fluids (choice C) may be necessary in some cases, but it is not the primary intervention for an acute asthma attack. Administering corticosteroids (choice D) is often used as an adjunct therapy to reduce airway inflammation, but it is not the primary intervention during the acute phase of an asthma attack.
3. What is the priority intervention for a patient with a suspected myocardial infarction (MI)?
- A. Administering oxygen.
- B. Administering nitroglycerin.
- C. Administering aspirin.
- D. Administering morphine.
Correct answer: A
Rationale: Administering oxygen is the priority intervention for a patient with a suspected myocardial infarction to improve oxygenation. Oxygen helps ensure an adequate oxygen supply to the heart muscle, reducing the workload on the heart. Nitroglycerin and aspirin are important interventions in the treatment of MI; however, oxygen administration takes precedence to ensure adequate oxygenation. Morphine may be considered for pain relief, but it is not the initial priority in the treatment of a suspected MI.
4. The healthcare provider is developing standards of care for a client with gastroesophageal reflux disease and wants to review current evidence for practice. Which one of the following resources will provide the most helpful information?
- A. A review in the Cochrane Library.
- B. A literature search in a database, such as the Cumulative Index to Nursing and Allied Health Literature (CINAHL).
- C. An online nursing textbook.
- D. The policy and procedure manual at the healthcare agency.
Correct answer: A
Rationale: The Cochrane Library provides systematic reviews of primary research in healthcare, making it a reliable resource for evidence-based practice. Choice B, a literature search in a database like CINAHL, may also be useful but does not guarantee the same level of systematic review and reliability as the Cochrane Library. Choice C, an online nursing textbook, may offer information but might not provide the most current or evidence-based practices. Choice D, the policy and procedure manual at the healthcare agency, is unlikely to offer the comprehensive evidence-based information needed for developing standards of care.
5. To assess the quality of an adult client's pain, what approach should the nurse use?
- A. Observe body language and movement.
- B. Ask the client to describe the pain.
- C. Identify effective pain relief measures.
- D. Provide a numeric pain scale.
Correct answer: B
Rationale: The correct answer is to ask the client to describe the pain. This approach allows the nurse to gather subjective information directly from the client, such as the quality, intensity, location, and factors that aggravate or alleviate the pain. Observing body language and movement (Choice A) can provide additional cues but may not fully capture the client's pain experience. Identifying effective pain relief measures (Choice C) and providing a numeric pain scale (Choice D) are important aspects of pain management but do not directly assess the quality of the client's pain.
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