HESI RN
HESI Medical Surgical Practice Exam Quizlet
1. A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets about:
- A. Preparing the client for a perfusion scan
- B. Attaching the client to a cardiac monitor
- C. Administering oxygen via nasal cannula
- D. Ensuring that the intravenous (IV) line is patent
Correct answer: C
Rationale: When a client who has just undergone surgery experiences sudden chest pain, dyspnea, and tachypnea, indicating possible pulmonary embolism, the immediate priority for the nurse is to administer oxygen via nasal cannula. This intervention aims to improve oxygenation and alleviate respiratory distress, which is crucial in the setting of a potential pulmonary embolism. Preparing the client for a perfusion scan is not the immediate priority as stabilizing the client's respiratory status comes first. While attaching the client to a cardiac monitor is important for monitoring, administering oxygen takes precedence in this situation. Ensuring IV line patency is relevant for overall client care but is not the priority when a client is experiencing respiratory distress requiring immediate intervention.
2. Upon admission, a 77-year-old female client presents with confusion, loss of appetite, nausea, vomiting, and headache, with a pulse rate of 43 beats per minute. Which question should the nurse prioritize asking the client or her family?
- A. Does the client have her own teeth or dentures?
- B. Does the client take aspirin, and if so, what is the dosage?
- C. Does the client take nitroglycerin?
- D. Does the client take digitalis?
Correct answer: D
Rationale: The correct answer is D. The client's symptoms suggest digitalis toxicity, a potentially life-threatening condition that requires immediate attention. Digitalis toxicity can present with symptoms such as anorexia, nausea, vomiting, headache, and bradycardia (low pulse rate). Given the client's presentation, it is crucial to assess for digitalis use as elderly individuals are more susceptible to this type of intoxication. Choices A, B, and C are important aspects to consider during the assessment, but in this scenario, the priority lies in identifying and addressing the potential digitalis toxicity due to the severity of symptoms and the need for prompt intervention.
3. A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client?
- A. Losing weight.
- B. Decreasing caffeine intake.
- C. Avoiding large meals.
- D. Raising the head of the bed on blocks.
Correct answer: D
Rationale: The correct answer is to raise the head of the bed on blocks (reverse Trendelenburg position). This elevation helps reduce reflux by using gravity to keep stomach contents from flowing back into the esophagus during sleep. Losing weight (Choice A) could be beneficial in managing GERD, but it may not be as effective for immediate relief during sleep. Decreasing caffeine intake (Choice B) and avoiding large meals (Choice C) are also valuable recommendations to manage GERD; however, they may not specifically address the issue of reflux during sleep as directly and effectively as elevating the head of the bed.
4. In assessing cancer risk, which woman is at greatest risk of developing breast cancer?
- A. A 35-year-old multipara who never breastfed.
- B. A 50-year-old whose mother had unilateral breast cancer.
- C. A 55-year-old whose mother-in-law had bilateral breast cancer.
- D. A 20-year-old whose menarche occurred at age 9.
Correct answer: B
Rationale: The correct answer is B because family history of breast cancer, specifically in the mother, is a significant risk factor for developing breast cancer. The age of 50 is also a risk factor for breast cancer. Choice A is less likely as breastfeeding can actually reduce the risk of breast cancer. Choice C is less relevant since the risk is higher with a direct family member. Choice D, although early menarche is a risk factor, the age of the individual is much lower compared to the other age-related risk factors.
5. A middle-aged male client with diabetes continues to eat an abundance of foods that are high in sugar and fat. According to the Health Belief Model, which event is most likely to increase the client's willingness to become compliant with the prescribed diet?
- A. He visits his diabetic brother who just had surgery to amputate an infected foot.
- B. He is provided with the most current information about the dangers of untreated diabetes.
- C. He comments on the community service announcements about preventing complications associated with diabetes.
- D. His wife expresses a sincere willingness to prepare meals that are within his prescribed diet.
Correct answer: A
Rationale: According to the Health Belief Model, the most effective event to increase compliance with the prescribed diet for a middle-aged male client with diabetes is experiencing a significant consequence related to the disease. In this case, visiting his diabetic brother who just had surgery to amputate an infected foot would serve as a strong 'cue to action,' increasing the client's perceived seriousness of the disease. This event is likely to have a more immediate and impactful effect on the client than other options. Option B provides valuable information but may not have the same personal and emotional impact as witnessing a severe consequence firsthand. Option C involves indirect exposure to prevention messages, which might not be as compelling as a direct experience. Option D, while supportive, does not present a direct consequence of non-compliance like option A does.
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