HESI RN
HESI RN Medical Surgical Practice Exam
1. A client has a serum potassium level of 6.5 mmol/L, a serum creatinine level of 2 mg/dL, and a urine output of 350 mL/day. What is the best action by the nurse?
- A. Place the client on a cardiac monitor immediately.
- B. Teach the client to limit high-potassium foods.
- C. Continue to monitor the client’s intake and output.
- D. Ask to have the laboratory redraw the blood specimen.
Correct answer: A
Rationale: The best immediate action by the nurse in this situation is to place the client on a cardiac monitor immediately. A serum potassium level of 6.5 mmol/L indicates hyperkalemia, which can lead to life-threatening dysrhythmias. Monitoring the cardiac status is crucial to detect any potential arrhythmias promptly. Teaching the client to limit high-potassium foods (Choice B) may be important for long-term management, but it is not the priority at this moment. Continuing to monitor intake and output (Choice C) is important for assessing renal function but does not address the immediate risk of dysrhythmias. Asking to have the laboratory redraw the blood specimen (Choice D) is unnecessary since the current results indicate a critical situation that requires immediate action.
2. A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the client’s urine output for the past hour was 25 mL. Based on this finding, the nurse first:
- A. Calls the physician
- B. Increases the rate of the IV infusion
- C. Checks the client’s overall intake and output record
- D. Administers a 250-mL bolus of normal saline solution (0.9%)
Correct answer: C
Rationale: Clients are at risk of hypovolemia postoperatively, and decreased urine output can be an early sign. However, to accurately interpret this finding, the nurse must assess the overall fluid balance by checking the client’s intake and output records. Increasing the IV infusion rate or administering a bolus of normal saline solution without a physician's order would not be appropriate as these interventions require a prescription. The physician should be notified once the nurse has collected all necessary assessment data, including fluid status and vital signs.
3. The nurse is preparing to administer an IV dose of ciprofloxacin to a client with a urinary tract infection. Which client data requires the most immediate intervention by the nurse?
- A. Serum creatinine of 4.5 mg/dL (398 μmol/L SI)
- B. Temperature of 101.3°F
- C. Blood pressure of 140/90 mmHg
- D. Heart rate of 88 bpm
Correct answer: A
Rationale: A serum creatinine level of 4.5 mg/dL indicates severe renal impairment, which requires immediate attention before administering ciprofloxacin. Elevated serum creatinine levels suggest decreased kidney function, and giving ciprofloxacin can further harm the kidneys. Monitoring and addressing renal function are crucial to prevent worsening of renal impairment and potential drug toxicity. The temperature, blood pressure, and heart rate are important parameters to assess, but in this scenario, the priority is to address the severe renal impairment before proceeding with ciprofloxacin administration.
4. The nurse assumes care for a patient who is currently receiving a dose of intravenous vancomycin (Vancocin) infusing at 20 mg/min. The nurse notes red blotches on the patient’s face, neck, and chest and assesses a blood pressure of 80/55 mm Hg. Which action will the nurse take?
- A. Request an order for IV epinephrine to treat anaphylactic shock.
- B. Slow the infusion to 10 mg/min and observe the patient closely.
- C. Stop the infusion and obtain an order for a BUN and serum creatinine.
- D. Suspect Stevens-Johnson syndrome and notify the provider immediately.
Correct answer: B
Rationale: When vancomycin is infused too rapidly, “red man” syndrome may occur; the rate should be 10 mg/min to prevent this. This is a toxic reaction, not an allergic one, so epinephrine is not indicated. Stevens-Johnson syndrome is characterized by a rash and fever. Red man syndrome is not related to renal function.
5. The client with chronic renal failure who is on a low-sodium diet should avoid which of the following foods?
- A. Fresh fruits.
- B. Canned soups.
- C. Lean meats.
- D. Whole grain bread.
Correct answer: B
Rationale: Canned soups are high in sodium, which can lead to fluid retention and hypertension in clients with chronic renal failure who are on a low-sodium diet. Fresh fruits, lean meats, and whole grain bread are generally lower in sodium and can be included in a low-sodium diet. Lean meats provide essential protein, fresh fruits offer vitamins and minerals, and whole grain bread provides fiber, making them suitable choices for individuals with chronic renal failure.