HESI RN
HESI RN Medical Surgical Practice Exam
1. A CD4+ lymphocyte count is performed on a client infected with HIV. The results of the test indicate a CD4+ count of 450 cells/L. The nurse interprets this test result as indicating:
- A. Improvement in the client
- B. The need for antiretroviral therapy
- C. The need to discontinue antiretroviral therapy
- D. An effective response to the treatment for HIV
Correct answer: B
Rationale: A CD4+ count of 450 cells/L is below the normal range (500-1600 cells/mcL), indicating a decline in immune function in the client. Antiretroviral therapy is recommended when the CD4+ count falls below 500 cells/mcL or below 25%, or when the client displays symptoms of HIV. Therefore, the interpretation of this test result suggests that the client requires antiretroviral therapy to manage the HIV infection. Choices A, C, and D are incorrect because a CD4+ count of 450 cells/L does not signify improvement, discontinuation of therapy, or an effective response to treatment for HIV.
2. In 1989, the national population policy was formally launched targeting:
- A. Reducing population growth
- B. Making family planning services available
- C. Making services accessible and affordable to all eligible users
- D. All of the above
Correct answer: D
Rationale: The correct answer is D because the national population policy launched in 1989 aimed at reducing population growth by making family planning services available, accessible, and affordable to all eligible users. Choice A is incorrect as it does not encompass the full scope of the policy objectives. Choice B is also incomplete as it focuses solely on availability without considering accessibility and affordability. Choice C is partially correct but lacks the comprehensive approach of the national population policy.
3. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 liters per minute via nasal cannula. The client reports difficulty breathing. What action should the nurse take first?
- A. Increase the oxygen flow rate
- B. Instruct the client to breathe deeply and cough
- C. Check the client's oxygen saturation level
- D. Place the client in a high-Fowler's position
Correct answer: C
Rationale: The correct action for the nurse to take first when a client with COPD reports difficulty breathing while receiving oxygen is to check the client's oxygen saturation level. This helps in determining the adequacy of oxygenation and identifying the cause of the breathing difficulty. Increasing the oxygen flow rate (Choice A) may not be appropriate without knowing the current oxygen saturation level. Instructing the client to breathe deeply and cough (Choice B) may not address the immediate need for oxygen assessment. Placing the client in a high-Fowler's position (Choice D) can help with breathing but should come after ensuring proper oxygenation.
4. Which nursing intervention has the highest priority for a multigravida who delivered twins and is at risk for postpartum hemorrhage?
- A. Maintain cold packs on the perineum for 24 hours.
- B. Assess the client's pain level frequently.
- C. Observe for appropriate interaction with the infants.
- D. Assess fundal tone and lochia flow.
Correct answer: D
Rationale: Assessing fundal tone and lochia flow is crucial in the early detection and prevention of postpartum hemorrhage. Fundal tone helps identify uterine atony, a common cause of postpartum hemorrhage, while monitoring lochia flow can indicate excessive bleeding. Cold packs on the perineum, although helpful for pain and swelling, are not the priority in this situation. Pain assessment and observing interactions with infants are important but secondary to assessing for signs of postpartum hemorrhage.
5. The healthcare provider plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the healthcare provider administer? (Round to the nearest tenth.)
- A. 0.2 mL
- B. 0.8 mL
- C. 1.25 mL
- D. 2.0 mL
Correct answer: B
Rationale: To calculate the volume to administer, use the formula (1 mL × 4 mg) / 5 mg = 0.8 mL. The healthcare provider should administer 0.8 mL of diazepam for a dosage of 4 mg IV push. Choice A is incorrect because it results from an incorrect calculation. Choices C and D are incorrect as they do not align with the correct calculation based on the provided dosage.