HESI RN
HESI Medical Surgical Exam
1. The client with deep vein thrombosis (DVT) in the left lower leg is receiving heparin therapy. Which of the following assessments is the most important for the nurse to perform?
- A. Measure the circumference of the left leg.
- B. Assess for signs of bleeding, such as bruising or hematuria.
- C. Monitor the client's vital signs.
- D. Monitor the client's respiratory status.
Correct answer: B
Rationale: The most important assessment for a client with DVT on heparin therapy is to monitor for signs of bleeding, such as bruising or hematuria. Heparin is an anticoagulant medication that can increase the risk of bleeding. Assessing for bleeding is crucial to prevent complications like hemorrhage. Measuring the circumference of the leg may be relevant for assessing for edema but is not as critical as monitoring for bleeding. Monitoring vital signs and respiratory status are important aspects of care but are not the priority when the client is on heparin therapy for DVT.
2. 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.
3. Which of the following is a primary intervention for a patient with sepsis?
- A. Administering antibiotics
- B. Administering IV fluids
- C. Administering antipyretics
- D. Monitoring blood cultures
Correct answer: D
Rationale: Monitoring blood cultures is a primary intervention for a patient with sepsis because it helps identify the causative organism, which is crucial in guiding appropriate antibiotic therapy. Administering antibiotics (Choice A) is important in treating sepsis but is considered a secondary intervention. Administering IV fluids (Choice B) is also crucial for sepsis management to restore perfusion and hemodynamic stability. Administering antipyretics (Choice C) may help reduce fever, but it is not a primary intervention for managing sepsis.
4. An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action?
- A. Monitor hemoglobin and hematocrit
- B. Encourage turning and deep breathing
- C. Administer IV antibiotics as prescribed
- D. Auscultate for presence of bowel sounds
Correct answer: C
Rationale: The priority nursing action for a client diagnosed with acute pyelonephritis is to administer IV antibiotics as prescribed. Acute pyelonephritis is a serious kidney infection that requires prompt antibiotic therapy to prevent systemic complications and worsening of the infection. While monitoring hemoglobin and hematocrit (Choice A) is important, it is not the priority in the acute phase of infection. Encouraging turning and deep breathing (Choice B) and auscultating for bowel sounds (Choice D) are relevant aspects of care but do not take precedence over initiating antibiotic treatment to address the infection promptly.
5. The client with chronic renal failure is on a fluid restriction. Which of the following statements by the client indicates that the teaching has been effective?
- A. I will limit my fluid intake to prevent fluid overload.
- B. I can drink as much fluid as I want as long as I take my medication.
- C. I will skip dialysis sessions if I feel tired.
- D. I will limit my fluid intake to 1 liter per day.
Correct answer: A
Rationale: Choice A is the correct answer because it demonstrates the client's understanding of the need to limit fluid intake to prevent fluid overload, which is crucial in managing chronic renal failure. Adequate fluid restriction is essential to prevent complications such as fluid overload and electrolyte imbalances. Choice B is incorrect as it promotes excessive fluid intake, which can worsen the client's condition by putting additional stress on the kidneys. Choice C is incorrect as skipping dialysis sessions can lead to a buildup of toxins in the body, worsening renal failure and potentially leading to life-threatening complications. Choice D is incorrect because limiting fluid intake to a specific volume may not be appropriate for all clients and can vary depending on individual needs, medical condition, and healthcare provider recommendations.
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