HESI RN
HESI Medical Surgical Specialty Exam
1. 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.
2. A client is being discharged after lithotripsy for a urinary calculus. Which statements should the nurse include in the discharge teaching? (Select all that apply.)
- A. Finish the prescribed antibiotic even if you are feeling better.
- B. Drink at least 3 liters of fluid each day.
- C. The bruising on your back may take several weeks to resolve.
- D. All of the above
Correct answer: D
Rationale: After lithotripsy for a urinary calculus, it is important for the client to complete the prescribed antibiotic course to prevent urinary tract infections. Drinking at least 3 liters of fluid daily helps dilute stone-forming crystals, prevent dehydration, and promote urine flow. Bruising on the back may occur after the procedure and can take several weeks to resolve. Additionally, the client may experience blood in the urine for several days post-procedure. Reporting any pain, fever, chills, or urination difficulties to the healthcare provider is essential, as these symptoms could indicate infection or stone formation. Choice D is correct as all the statements are appropriate for the client's discharge teaching. Choices A, B, and C are individually correct based on the rationale provided, making D the correct answer.
3. A client in the postanesthesia care unit has an as-needed prescription for ondansetron (Zofran). Which of the following occurrences would prompt the nurse to administer this medication to the client?
- A. Paralytic ileus
- B. Incisional pain
- C. Urine retention
- D. Nausea and vomiting
Correct answer: D
Rationale: The correct answer is D: Nausea and vomiting. Ondansetron is an antiemetic used to manage postoperative nausea and vomiting, as well as nausea and vomiting related to chemotherapy. It is not indicated for treating paralytic ileus, incisional pain, or urine retention. Paralytic ileus is a condition of the gastrointestinal tract characterized by the paralysis of intestinal muscles, which would not be treated with ondansetron. Incisional pain is typically managed with analgesics, not antiemetics. Urine retention is a urinary issue that does not involve nausea and vomiting, making ondansetron an inappropriate choice for this condition.
4. A patient who is being treated for dehydration is receiving 5% dextrose and 0.45% normal saline with 20 mEq/L potassium chloride at a rate of 125 mL/hour. The nurse assuming care for the patient reviews the patient’s serum electrolytes and notes a serum sodium level of 140 mEq/L and a serum potassium level of 3.6 mEq/L. The patient had a urine output of 250 mL during the last 12-hour shift. Which action will the nurse take?
- A. Contact the patient’s provider to discuss increasing the potassium chloride to 40 mEq/L.
- B. Continue the intravenous fluids as ordered and reassess the patient frequently.
- C. Notify the provider and discuss increasing the rate of fluids to 200 mL/hour.
- D. Stop the intravenous fluids and notify the provider of the assessment findings.
Correct answer: D
Rationale: The patient’s potassium level is within normal limits, but the decreased urine output indicates the patient should not receive additional IV potassium. Increasing potassium chloride to 40 mEq/L is not needed as the level is normal. Stopping the IV fluids is appropriate due to the decreased urine output, which suggests potential fluid overload. The nurse should notify the provider of the assessment findings for further management. Increasing the rate of fluids to 200 mL/hour is not recommended without addressing the decreased urine output first.
5. After a urography, a client is instructed by a nurse. Which instruction should the nurse include in this client’s discharge teaching?
- A. Avoid direct contact with your urine for 24 hours until the dye clears.
- B. You may experience dribbling of urine for several weeks post-procedure.
- C. Drink at least 3 liters of fluids today to assist in dye elimination.
- D. Your skin may turn slightly yellow from the dye used in this procedure.
Correct answer: C
Rationale: It is important for the client to increase fluid intake to aid in the rapid elimination of the potentially nephrotoxic dye used in urography. This instruction will help prevent any adverse effects related to the dye. Choices A, B, and D are incorrect because the dye used in urography is not radioactive, so there is no need to avoid direct contact with urine, urine dribbling is not a common post-procedure occurrence, and the dye should not cause the client's skin to change color.
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