HESI RN
HESI Medical Surgical Exam
1. After a transsphenoidal hypophysectomy, the nurse should assess the client for:
- A. Cerebrospinal fluid (CSF) leak.
- B. Fluctuating blood glucose levels.
- C. Cushing's syndrome.
- D. Cardiac arrhythmias.
Correct answer: A
Rationale: Following a transsphenoidal hypophysectomy, assessing the client for a cerebrospinal fluid (CSF) leak is crucial due to the risk of this serious complication. A CSF leak can lead to infection and increased intracranial pressure, which must be promptly identified and managed to prevent further complications. Fluctuating blood glucose levels (Choice B) are not directly associated with a transsphenoidal hypophysectomy. Cushing's syndrome (Choice C) is a condition related to prolonged exposure to high levels of cortisol and is not a common immediate concern post-transsphenoidal hypophysectomy. Cardiac arrhythmias (Choice D) are not typically a direct complication of this surgical procedure, making it a less relevant concern compared to a CSF leak.
2. Which of the following is a common complication of immobility?
- A. Muscle hypertrophy.
- B. Pressure ulcers.
- C. Bone fractures.
- D. Joint stiffness.
Correct answer: B
Rationale: The correct answer is B, Pressure ulcers. Immobility can lead to pressure ulcers due to prolonged pressure on the skin, especially over bony prominences. Muscle hypertrophy (Choice A) is not a common complication of immobility; instead, muscle atrophy is more likely to occur due to disuse. Bone fractures (Choice C) can result from trauma but are not directly associated with immobility unless there is a fall or accident. Joint stiffness (Choice D) can develop due to lack of movement but is not as common or severe as pressure ulcers in cases of prolonged immobility.
3. What is the most important nursing intervention for a patient with increased intracranial pressure (ICP)?
- A. Elevate the head of the bed to 30 degrees.
- B. Administer diuretics to reduce fluid volume.
- C. Administer corticosteroids to reduce inflammation.
- D. Keep the patient in a supine position.
Correct answer: A
Rationale: Elevating the head of the bed to 30 degrees is crucial for a patient with increased intracranial pressure (ICP) because it helps promote venous drainage from the brain, thereby reducing ICP. Keeping the head of the bed elevated helps facilitate cerebral perfusion and can prevent a further increase in ICP. Administering diuretics (Choice B) may be considered in some cases to reduce fluid volume, but it is not the most critical intervention for immediate ICP management. Administering corticosteroids (Choice C) is not typically indicated for managing increased ICP unless there is a specific underlying condition requiring their use. Keeping the patient in a supine position (Choice D) can actually worsen ICP by impeding venous outflow from the brain, making it an incorrect choice for this scenario.
4. After a myocardial infarction, why is the hospitalized client taught to move the legs while resting in bed?
- A. Prepare the client for ambulation.
- B. Promote urinary and intestinal elimination.
- C. Prevent thrombophlebitis and blood clot formation.
- D. Decrease the likelihood of pressure ulcer formation.
Correct answer: C
Rationale: The correct answer is C. Moving the legs helps prevent thrombophlebitis and blood clot formation by promoting venous return in clients on bed rest. This prevents stasis and clot formation in the lower extremities. Choices A, B, and D are incorrect because the primary goal of moving the legs is to prevent thrombophlebitis and blood clot formation, rather than preparing for ambulation, promoting elimination, or decreasing pressure ulcer formation. Ambulation preparation involves different exercises, urinary and intestinal elimination are not directly related to leg movements, and pressure ulcer prevention is more related to repositioning and skin care.
5. The healthcare provider is assessing a client with chronic renal failure who is receiving peritoneal dialysis. Which of the following findings would indicate a complication of the treatment?
- A. Clear dialysate outflow.
- B. Cloudy dialysate outflow.
- C. Decreased urine output.
- D. Increased blood pressure.
Correct answer: B
Rationale: Cloudy dialysate outflow is a sign of peritonitis, a serious complication of peritoneal dialysis that requires immediate medical attention. Peritonitis, an infection of the peritoneum, the lining of the abdominal cavity, can lead to severe complications if not treated promptly. Clear dialysate outflow is an expected finding in peritoneal dialysis, indicating proper functioning of the process. Decreased urine output is common in clients with renal failure due to impaired kidney function. Increased blood pressure may be present in renal failure but is not a direct complication of peritoneal dialysis.
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