HESI RN
HESI Medical Surgical Assignment Exam
1. The nurse is caring for four clients with chronic kidney disease. Which client should the nurse assess first upon initial rounding?
- A. Woman with a blood pressure of 158/90 mm Hg
- B. Client with Kussmaul respirations
- C. Man with skin itching from head to toe
- D. Client with halitosis and stomatitis
Correct answer: B
Rationale: The correct answer is B. Kussmaul respirations indicate a worsening of chronic kidney disease (CKD). The client is increasing the rate and depth of breathing to excrete carbon dioxide through the lungs, a compensatory mechanism for metabolic acidosis common in CKD. Hypertension, as in choice A, is a common finding in CKD due to volume overload and activation of the renin-angiotensin-aldosterone system. Skin itching, as in choice C, is related to calcium-phosphate imbalances seen in CKD. Halitosis and stomatitis, as in choice D, are common in CKD due to uremia, leading to the formation of ammonia. However, Kussmaul respirations indicate a more urgent need for assessment as they suggest impending respiratory distress and metabolic derangement, requiring immediate attention.
2. The nurse is preparing to administer the first dose of hydrochlorothiazide (HydroDIURIL) 50 mg to a patient who has a blood pressure of 160/95 mm Hg. The nurse notes that the patient had a urine output of 200 mL in the past 12 hours. The nurse will perform which action?
- A. Administer the medication as ordered.
- B. Encourage the patient to drink more fluids.
- C. Hold the medication and request an order for serum BUN and creatinine.
- D. Request an order for serum electrolytes and administer the medication.
Correct answer: C
Rationale: The correct action is to hold the medication and request an order for serum BUN and creatinine. Thiazide diuretics, such as hydrochlorothiazide, are contraindicated in renal failure. In this case, the patient has oliguria, which is a reduced urine output, indicating potential renal insufficiency. Before administering the diuretic, it is crucial to evaluate the patient's renal function through serum BUN and creatinine levels. Encouraging the patient to drink more fluids (Choice B) may not address the underlying issue of renal function. Administering the medication as ordered (Choice A) without assessing renal function can be harmful. Requesting serum electrolytes and administering the medication (Choice D) overlooks the need for a specific evaluation of renal function in this scenario.
3. A woman has been scheduled for a routine mammogram. What should the nurse tell the client?
- A. That mammography takes about 1 hour
- B. Not to eat or drink on the morning of the test
- C. That there is no discomfort associated with the procedure
- D. That deodorants, powders, or creams used in the axillary or breast area must be washed off before the test
Correct answer: D
Rationale: The correct answer is D. The nurse should instruct the client to avoid using deodorants, powders, or creams on the day of the mammogram. These products used in the axillary or breast area can interfere with the mammogram results and must be washed off before the test. Choices A, B, and C are incorrect because mammography typically takes less than 30 minutes, there is no need for fasting before the test, and some discomfort may be experienced during the procedure.
4. A client in a physician’s office has just made an appointment for an exercise stress test. The client should be instructed to:
- A. Wear sweatpants and a heavy sweatshirt
- B. Eat a small meal just before the procedure
- C. Wear comfortable rubber-soled shoes such as sneakers
- D. Avoid consuming caffeine for 30 minutes before the procedure
Correct answer: C
Rationale: The client should wear comfortable rubber-soled shoes, such as sneakers, for the exercise stress test. This choice ensures safety and stability during the procedure. Wearing sweatpants and a heavy sweatshirt (Choice A) would not be appropriate as the client needs to wear light, loose, comfortable clothing. Eating a small meal just before the procedure (Choice B) could lead to discomfort during the test. Avoiding caffeine for 30 minutes before the procedure (Choice D) is not a specific instruction related to the attire or preparation for the test.
5. The nurse is preparing to begin a medication regimen for a patient who will receive intravenous ampicillin and gentamicin. Which is an important nursing action?
- A. Administer each antibiotic to infuse over 15 to 20 minutes.
- B. Order serum peak and trough levels of ampicillin.
- C. Prepare the schedule so that the drugs are given at the same time.
- D. Set up separate tubing sets for each drug labeled with the drug name and date.
Correct answer: D
Rationale: When administering intravenous aminoglycosides like gentamicin with penicillins such as ampicillin, it is crucial to avoid mixing them in the same container. Separate tubing sets labeled with the drug name and date should be used to prevent interactions between the medications. Administering each antibiotic over 15 to 20 minutes (Choice A) may not be appropriate for all medications and does not address the issue of compatibility. Ordering serum peak and trough levels of ampicillin (Choice B) is important for monitoring drug levels but does not directly address the administration process. Preparing a schedule to give drugs simultaneously (Choice C) may increase the risk of drug interactions and is not recommended when administering incompatible medications.
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