HESI RN
HESI Medical Surgical Practice Exam Quizlet
1. A 20-year-old female client calls the nurse to report a lump she found in her breast. Which response is the best for the nurse to provide?
- A. Check it again in one month, and if it is still there schedule an appointment.
- B. Most lumps are benign, but it is always best to come in for an examination.
- C. Try not to worry too much about it, because usually, most lumps are benign.
- D. If you are in your menstrual period it is not a good time to check for lumps.
Correct answer: B
Rationale: The nurse advising the client to come in provides the best response because it addresses the client's anxiety most effectively and encourages prompt and immediate action for a potential problem.
2. A 57-year-old male client is scheduled to have a stress-thallium test the following morning and is NPO after midnight. At 0130, he is agitated because he cannot eat and is demanding food. Which response is best for the nurse to provide to this client?
- A. I'm sorry sir, you have a prescription for nothing by mouth from midnight tonight.
- B. I will let you have one cracker, but that is all you can have for the rest of tonight.
- C. What did the healthcare provider tell you about the test you are having tomorrow?
- D. The test you are having tomorrow requires that you have nothing by mouth tonight.
Correct answer: D
Rationale: Being direct and explaining to the client that the test requires him to be NPO, is the most therapeutic statement because the nurse is responding to the client's question and providing him the reason why.
3. A client with heart disease is on a continuous telemetry monitor and has developed sinus bradycardia. In determining the possible cause of the bradycardia, the nurse assesses the client's medication record. Which medication is most likely the cause of the bradycardia?
- A. Propranolol (Inderal).
- B. Captopril (Capoten).
- C. Furosemide (Lasix).
- D. Dobutamine (Dobutrex).
Correct answer: A
Rationale: Propranolol (Inderal) is a beta-adrenergic blocking agent that acts to decrease heart rate and contractility. Sinus bradycardia is a common side effect of beta blockers due to their negative chronotropic effect on the heart. Captopril (Capoten) is an ACE inhibitor used for hypertension and heart failure, not associated with causing bradycardia. Furosemide (Lasix) is a loop diuretic that can lead to electrolyte imbalances but not commonly linked to bradycardia. Dobutamine (Dobutrex) is a beta-1 adrenergic agonist that increases heart rate and contractility, making it an unlikely cause of bradycardia in this scenario.
4. The nurse is assessing a client with chronic kidney disease (CKD). Which finding is most important for the nurse to respond to first?
- A. Potassium 6.0 mEq/L.
- B. Daily urine output of 400 ml.
- C. Peripheral neuropathy.
- D. Uremic fetor.
Correct answer: A
Rationale: The correct answer is A. Potassium level of 6.0 mEq/L indicates hyperkalemia, which is a critical electrolyte imbalance in clients with chronic kidney disease. Hyperkalemia can lead to life-threatening arrhythmias, making it the priority finding to address. Choice B, a daily urine output of 400 ml, may indicate decreased kidney function but does not pose an immediate life-threatening risk compared to hyperkalemia. Peripheral neuropathy (Choice C) and uremic fetor (Choice D) are common manifestations of CKD but are not as urgent as addressing a potentially fatal electrolyte imbalance like hyperkalemia.
5. 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.
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