HESI RN
HESI Medical Surgical Specialty Exam
1. A client with bladder cancer who underwent a complete cystectomy with ileal conduit is being assessed by a nurse. Which assessment finding should prompt the nurse to urgently contact the healthcare provider?
- A. The ileostomy is draining blood-tinged urine.
- B. There is serous sanguineous drainage on the surgical dressing.
- C. The ileostomy stoma appears pale and cyanotic.
- D. Oxygen saturations are 92% on room air.
Correct answer: C
Rationale: A pale or cyanotic appearance of the ileostomy stoma indicates compromised circulation, which can lead to necrosis if not promptly addressed. On the other hand, blood-tinged urine and serous sanguineous drainage are common following a complete cystectomy with ileal conduit. These findings do not typically indicate an urgent issue. An oxygen saturation of 92% on room air is slightly below the normal range but does not warrant urgent healthcare provider contact unless accompanied by significant respiratory distress or other concerning symptoms.
2. A nursing assistant is measuring the blood pressure (BP) of a hypertensive client while a nurse observes. Which action on the part of the assistant would interfere with accurate measurement and prompt the nurse to intervene? Select all that apply.
- A. Measuring the BP after the client has sat quietly for 5 minutes
- B. Having the client sit with the arm bared and supported at heart level
- C. Using a cuff with a rubber bladder that encircles less than 80% of the limb
- D. Measuring the BP after the client reports that he just drank a cup of coffee
Correct answer: C
Rationale: To ensure accurate blood pressure (BP) measurement, the cuff used should have a rubber bladder that encircles at least 80% of the limb being measured. This ensures proper compression and accurate readings. Choices A and B are correct practices as it is recommended to measure BP after the client has sat quietly for 5 minutes and to have the client sit with the arm bared and supported at heart level. Choice D is also a correct reason for intervention as the client should not have consumed caffeine or smoked tobacco within 30 minutes before BP measurement, as it can affect the accuracy of the reading.
3. A client has been scheduled for magnetic resonance imaging (MRI). For which of the following conditions, a contraindication to MRI, does the nurse check the client’s medical history?
- A. Pancreatitis
- B. Pacemaker insertion
- C. Type 1 diabetes mellitus
- D. Chronic airway limitation
Correct answer: B
Rationale: The correct answer is B: Pacemaker insertion. Patients with metal devices or implants are contraindicated for MRI. These include pacemakers, orthopedic hardware, artificial heart valves, aneurysm clips, and intrauterine devices. These metal objects can be affected by the strong magnetic field of the MRI, leading to serious risks for the patient. Pancreatitis (choice A), Type 1 diabetes mellitus (choice C), and chronic airway limitation (choice D) are not contraindications to MRI based on the presence of metal objects. Therefore, the nurse should be particularly concerned about pacemaker insertion when reviewing the client's medical history prior to an MRI.
4. A male client comes into the emergency department with a serum creatinine of 2.2 mg/dL and a blood urea nitrogen (BUN) of 24 mg/dL. What question should the nurse ask first when taking this client’s history?
- A. Have you been taking any aspirin, ibuprofen, or naproxen recently?
- B. Do you have anyone in your family with renal failure?
- C. Have you had a diet that is low in protein recently?
- D. Has a relative had a kidney transplant lately?
Correct answer: A
Rationale: The correct question to ask the client first is about their recent intake of nephrotoxic medications like aspirin, ibuprofen, or naproxen. Elevated serum creatinine and BUN levels indicate possible renal issues, making it crucial to assess potential causes such as medication-induced nephrotoxicity. Inquiring about family history of renal failure or recent kidney transplants would not provide immediate insights into the client's current renal condition. While a diet low in protein could influence BUN levels, it is important to address medication history first due to the acute presentation in the emergency department.
5. The nurse is preparing to administer clarithromycin to a patient. When performing a medication history, the nurse learns that the patient takes warfarin to treat atrial fibrillation. The nurse will perform which action?
- A. Ask the provider if azithromycin may be used instead of clarithromycin.
- B. Obtain an order for continuous cardiovascular monitoring.
- C. Request an order for periodic serum warfarin levels.
- D. Withhold the clarithromycin and notify the provider.
Correct answer: C
Rationale: When a patient taking warfarin also needs to receive clarithromycin, it is essential to monitor periodic serum warfarin levels. Macrolides, including clarithromycin, can increase serum levels of drugs like warfarin. Monitoring serum drug levels helps ensure that the patient's warfarin dose can be adjusted, if necessary, to maintain therapeutic levels. Asking about using azithromycin instead is not the most appropriate action in this situation, as all macrolides can interact with warfarin. Continuous cardiovascular monitoring is not indicated solely based on the use of clarithromycin. Withholding the clarithromycin without proper assessment could delay necessary treatment and is not the best initial action.
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