HESI RN
HESI RN Medical Surgical Practice Exam
1. After a lumbar puncture, into which position does the nurse assist the client?
- A. Flat
- B. Semi-Fowler
- C. Side-lying with the head of the bed elevated
- D. Sitting up in a recliner with the feet elevated
Correct answer: A
Rationale: After a lumbar puncture, the client should be positioned flat. This position helps prevent post-procedure spinal headaches and cerebrospinal fluid leakage. Keeping the client flat for up to 12 hours is crucial in minimizing these risks. Choices B, C, and D are incorrect because elevating the head of the bed or sitting up can increase the risk of complications by altering the pressure in the spinal canal, potentially leading to headaches and fluid leakage.
2. The nurse is assessing a client with rheumatoid arthritis who is taking a nonsteroidal anti-inflammatory drug (NSAID). Which laboratory value should the nurse monitor?
- A. Potassium
- B. Hemoglobin
- C. Serum creatinine
- D. White blood cell count
Correct answer: C
Rationale: When a client with rheumatoid arthritis is taking NSAIDs, the nurse should monitor serum creatinine levels. NSAIDs can potentially cause kidney damage, so monitoring creatinine levels helps assess for renal impairment. While monitoring hemoglobin, potassium, and white blood cell count may also be relevant in some cases, serum creatinine is the priority due to the risk of renal complications associated with NSAID use.
3. A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care?
- A. Excessive CNS stimulation will be reduced.
- B. Co-dependent behaviors will be decreased.
- C. Client’s level of consciousness will increase.
- D. Client will not demonstrate cross-addiction.
Correct answer: A
Rationale: The correct answer is A: 'Excessive CNS stimulation will be reduced.' During benzodiazepine withdrawal, the priority is to manage symptoms such as CNS hyperactivity, which can include agitation, anxiety, and seizures. Substitution therapy aims to minimize these withdrawal symptoms by providing a safer alternative to the benzodiazepine. Options B, C, and D are not the highest priority during benzodiazepine withdrawal. Decreasing co-dependent behaviors, increasing the client's level of consciousness, and preventing cross-addiction are important aspects of care but are not as critical as managing the potentially severe CNS stimulation.
4. The healthcare professional observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the healthcare professional's intervention?
- A. The cuff wraps around the girth of the leg.
- B. The UAP auscultates the popliteal pulse with the cuff on the lower leg.
- C. The client is placed in a prone position.
- D. The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.
Correct answer: B
Rationale: When obtaining blood pressure in the lower extremities, the popliteal pulse is the site for auscultation when the blood pressure cuff is applied around the thigh. Auscultating the popliteal pulse with the cuff on the lower leg is incorrect as it may lead to an inaccurate reading. Placing the client in a prone position and wrapping the cuff around the girth of the leg are acceptable practices. A systolic reading that is 20 mm Hg higher in the lower extremity compared to the arm is expected due to the difference in blood pressure between the upper and lower parts of the body.
5. A primipara has delivered a stillborn fetus at 30 weeks gestation. To assist the parents in the grieving process, which intervention is most important for the nurse to implement?
- A. Provide an opportunity for the parents to hold their infant in privacy.
- B. Assist the couple in completing a request for autopsy.
- C. Encourage the couple to seek family counseling within the next few weeks.
- D. Explain the possible causes of fetal demise.
Correct answer: A
Rationale: Allowing the parents to hold their infant in privacy is crucial for facilitating the grieving process after the loss of a stillborn child. This intimate moment can help the parents create memories, bond with their baby, and start the healing process.