HESI RN
HESI Medical Surgical Specialty Exam
1. A client is tested for HIV with the use of an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. The nurse should tell the client that:
- A. HIV infection has been confirmed
- B. The client probably has an opportunistic infection
- C. The test will need to be confirmed with the use of a Western blot
- D. A positive test is a normal result and does not mean that the client is infected with HIV
Correct answer: C
Rationale: When an ELISA test for HIV is positive, it is essential to confirm the result with a Western blot. The Western blot is the confirmatory test for HIV. Choice A is incorrect because a positive ELISA test does not confirm HIV infection. Choice B is incorrect as it assumes a different diagnosis. Choice D is incorrect because a positive ELISA test does indicate potential HIV infection and requires confirmation.
2. The nurse is caring for a patient who will receive 10% calcium gluconate to treat a serum potassium level of 5.9 mEq/L. The nurse performs a drug history prior to beginning the infusion. Which drug taken by the patient would cause concern?
- A. Digitalis
- B. Hydrochlorothiazide
- C. Hydrocortisone
- D. Vitamin D
Correct answer: A
Rationale: Calcium gluconate is administered to treat hyperkalemia by reducing myocardial irritability. When given to a patient taking digitalis, it can lead to digitalis toxicity. Digitalis and calcium gluconate both affect cardiac function, and their concomitant use can potentiate adverse effects. Hydrochlorothiazide, Hydrocortisone, and Vitamin D may impact potassium levels, but they do not interact with calcium gluconate in a way that would cause concern for toxicity.
3. A client is hospitalized in the oliguric phase of acute kidney injury (AKI) and is receiving tube feedings. The nurse is teaching the client’s spouse about the kidney-specific formulation for the enteral solution compared to standard formulas. What components should be discussed in the teaching plan? (Select all that apply.)
- A. Lower sodium
- B. Lower potassium
- C. Higher phosphorus
- D. A & B
Correct answer: D
Rationale: In the oliguric phase of acute kidney injury (AKI), clients may require tube feedings with kidney-specific formulas. These formulations are lower in sodium and potassium, which are crucial considerations due to impaired kidney function. Higher phosphorus content is not a feature of kidney-specific formulations for AKI. Therefore, options A and B (lower sodium and lower potassium) should be discussed in the teaching plan. Option C, higher phosphorus, is incorrect as kidney-specific formulas are not intended to be higher in phosphorus content for AKI patients.
4. 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.
5. 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.
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