HESI RN
HESI Medical Surgical Specialty Exam
1. The patient is receiving a high dose of tetracycline (Sumycin). Which laboratory values should the nurse monitor while caring for this patient?
- A. Blood urea nitrogen (BUN) and creatinine levels
- B. Complete blood counts
- C. Electrolytes
- D. Liver enzyme levels
Correct answer: A
Rationale: High doses of tetracyclines can lead to nephrotoxicity, especially when given along with other nephrotoxic drugs. Renal function tests, such as monitoring blood urea nitrogen (BUN) and creatinine levels, should be performed to assess for nephrotoxicity. Monitoring complete blood counts (choice B) is not directly related to tetracycline therapy. Checking electrolytes (choice C) is important but not the priority when monitoring for tetracycline-induced nephrotoxicity. Monitoring liver enzyme levels (choice D) is not typically indicated in the context of tetracycline therapy.
2. A confused client with pneumonia is admitted with an indwelling catheter in place. During interdisciplinary rounds the following day, which question should the nurse ask the primary health care provider?
- A. Do you want daily weights on this client?
- B. Will the client be able to return home?
- C. Can we discontinue the indwelling catheter?
- D. Should we get another chest x-ray today?
Correct answer: C
Rationale: An indwelling catheter dramatically increases the risks of urinary tract infection and urosepsis. Nursing staff should ensure that catheters are left in place only as long as they are medically needed. The nurse should inquire about removing the catheter. All other questions might be appropriate, but because of client safety, this question takes priority.
3. 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.
4. A client who is postmenopausal and has had two episodes of bacterial urethritis in the last 6 months asks, “I never have urinary tract infections. Why is this happening now?” How should the nurse respond?
- A. Your immune system becomes less effective as you age.
- B. Low estrogen levels can make the tissue more susceptible to infection.
- C. You should be more careful with your personal hygiene in this area.
- D. It is likely that you have an untreated sexually transmitted disease.
Correct answer: B
Rationale: Low estrogen levels in postmenopausal women decrease moisture and secretions in the perineal area, causing tissue changes that predispose them to infection, including urethritis. This is a common reason for urethritis in postmenopausal women. While immune function does decrease with aging and sexually transmitted diseases can cause urethritis, the most likely reason in this case is the low estrogen levels. Personal hygiene practices are usually not a significant factor in the development of urethritis.
5. A client with acute kidney injury has a blood pressure of 76/55 mm Hg. The health care provider ordered 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client is starting to develop shortness of breath. What is the nurse’s priority action?
- A. Calculate the mean arterial pressure (MAP).
- B. Ask for insertion of a pulmonary artery catheter.
- C. Take the client’s pulse.
- D. Slow down the normal saline infusion.
Correct answer: D
Rationale: The nurse should recognize that the client may be developing fluid overload and respiratory distress due to the rapid normal saline infusion. The priority action is to slow down the infusion to prevent worsening respiratory distress and potential fluid overload. While calculating the mean arterial pressure (MAP) is important to assess perfusion, addressing the immediate respiratory distress takes precedence. Inserting a pulmonary artery catheter would provide detailed hemodynamic information but is not the initial step in managing acute respiratory distress. Monitoring vital signs, including the client's pulse, is crucial after adjusting the intravenous infusion to ensure a safe response to the intervention.
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