HESI RN
HESI Medical Surgical Practice Exam Quizlet
1. In a client with congestive heart failure, the nurse would be correct in withholding a dose of digoxin without specific instruction from the healthcare provider if the client's
- A. serum digoxin level is 1.5 ng/mL.
- B. blood pressure is 104/68 mmHg.
- C. serum potassium level is 3 mEq/L.
- D. apical pulse is 68/min.
Correct answer: C
Rationale: The correct answer is C. Hypokalemia can precipitate digitalis toxicity in individuals on digoxin, increasing the risk of dangerous dysrhythmias. A serum potassium level of 3 mEq/L is below the normal range (3.5 to 5.5 mEq/L) and indicates hypokalemia, which can potentiate the effects of digoxin. Choices A, B, and D are not directly related to the potential for digitalis toxicity. Serum digoxin level of 1.5 ng/mL is within the therapeutic range, blood pressure of 104/68 mmHg is not a contraindication for administering digoxin, and an apical pulse of 68/min is within the normal range and not a reason to withhold digoxin.
2. A client who was in a motor vehicle collision was admitted to the hospital, and the right knee was placed in skeletal traction. The nurse has documented this nursing diagnosis in the client's medical record: 'Potential for impairment of skin integrity related to immobility from traction.' Which nursing intervention is indicated based on this diagnosis statement?
- A. Release the traction every 4 hours to provide skin care.
- B. Turn the client for back care while suspending traction.
- C. Provide back and skin care while maintaining the traction.
- D. Give back care after the client is released from traction.
Correct answer: C
Rationale: The correct nursing intervention indicated based on the nursing diagnosis 'Potential for impairment of skin integrity related to immobility from traction' is to provide back and skin care while maintaining the traction. This intervention is crucial for maintaining the client's skin integrity and preventing potential complications. Releasing the traction every 4 hours (Choice A) may disrupt the treatment plan and compromise the effectiveness of traction. Turning the client for back care while suspending traction (Choice B) does not address the need for skin care while the client is in traction. Giving back care after the client is released from traction (Choice D) neglects the immediate need to prevent skin impairment while in traction. Therefore, providing back and skin care while maintaining the traction (Choice C) is the most appropriate intervention in this scenario.
3. A client with early breast cancer receives the results of a breast biopsy and asks the nurse to explain the meaning of staging and the type of receptors found on the cancer cells. Which explanation should the nurse provide?
- A. Lymph node involvement is not significant.
- B. Small tumors are aggressive and indicate poor prognosis.
- C. The tumor's estrogen receptor guides treatment options.
- D. Stage I indicates metastasis.
Correct answer: C
Rationale: Treatment decisions and prediction of prognosis are related to the tumor's receptor status, such as estrogen and progesterone receptor status which commonly are well-differentiated, have a lower chance of recurrence, and are receptive to hormonal therapy. Tumor staging designates tumor size and spread of breast cancer cells into axillary lymph nodes, which is one of the most important prognostic factors in early-stage breast cancer.
4. When planning activities for a socialization group for older residents of a long-term facility, what information would be most useful for the nurse?
- A. The length of time each resident has resided at the facility.
- B. A brief description of each resident's family life.
- C. The age of each resident.
- D. The usual activity patterns of each resident.
Correct answer: D
Rationale: The most useful information for the nurse when planning activities for a socialization group for older residents of a long-term facility would be the usual activity patterns of each resident. An older person's level of activity is a determining factor in adjustment to aging, as described by the Activity Theory of Aging. By understanding the usual activity patterns of each resident, the nurse can tailor activities that cater to their interests and abilities, promoting social engagement and overall well-being. The other options, such as the length of time residing at the facility, a brief description of family life, or the age of each resident, may provide some insights but do not directly relate to planning activities that support adjustment to aging and socialization within the group.
5. An elderly client is admitted with a diagnosis of bacterial pneumonia. The nurse's assessment of the client will most likely reveal which sign/symptom?
- A. Leukocytosis and febrile.
- B. Polycythemia and crackles.
- C. Pharyngitis and sputum production.
- D. Confusion and tachycardia.
Correct answer: D
Rationale: The onset of pneumonia in the elderly may be signaled by general deterioration, confusion, increased heart rate or increased respiratory rate due to the decreased oxygen- carbon dioxide exchange at the alveoli, known as the V-Q mismatch.
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