HESI RN
HESI Medical Surgical Practice Quiz
1. After pericardiocentesis for cardiac tamponade, for which signs should the nurse assess the client to determine if tamponade is recurring?
- A. Decreasing pulse
- B. Rising blood pressure
- C. Distant muffled heart sounds
- D. Falling central venous pressure (CVP)
Correct answer: C
Rationale: After pericardiocentesis for cardiac tamponade, the nurse should assess for distant muffled heart sounds that were noted before the procedure. If these sounds return, it could indicate recurring pericardial effusion and potential tamponade. Therefore, the correct answer is the return of distant muffled heart sounds (Option C). Decreasing pulse (Option A) and falling central venous pressure (Option D) are not specific signs of recurring tamponade. Rising blood pressure (Option B) is also not a typical sign of tamponade recurrence; in fact, hypotension is more commonly associated with tamponade.
2. What is the correct procedure for performing an ophthalmoscopic examination on a client's right retina?
- A. Instruct the client to focus on a distant object behind the examiner and not move their eyes during the exam.
- B. Set the ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's right eye.
- C. From a distance of 12 to 15 inches and slightly to the side, shine the light into the client's pupil.
- D. For optimal visualization, keep the ophthalmoscope at least 3 inches from the client's eye.
Correct answer: C
Rationale: During an ophthalmoscopic examination, the client should focus on a distant object behind the examiner to dilate the pupil, and the examiner should stand at a distance of 12-15 inches away and slightly to the side. This angle allows for better visualization of the retina. Holding the ophthalmoscope firmly against the examiner's face and shining the light into the client's pupil helps examine the retina effectively. Choice A is incorrect because the client should look at a distant object, not the examiner's nose. Choice B is incorrect as the ophthalmoscope should be directed towards the client's eye, not the examiner's eye. Choice D is incorrect because keeping the ophthalmoscope at least 3 inches away may not provide an optimal view of the retina.
3. A client with bladder cancer who underwent a complete cystectomy with ileal conduit is being assessed by a nurse. Which assessment finding should prompt the nurse to urgently contact the healthcare provider?
- A. The ileostomy is draining blood-tinged urine.
- B. There is serous sanguineous drainage on the surgical dressing.
- C. The ileostomy stoma appears pale and cyanotic.
- D. Oxygen saturations are 92% on room air.
Correct answer: C
Rationale: A pale or cyanotic appearance of the ileostomy stoma indicates compromised circulation, which can lead to necrosis if not promptly addressed. On the other hand, blood-tinged urine and serous sanguineous drainage are common following a complete cystectomy with ileal conduit. These findings do not typically indicate an urgent issue. An oxygen saturation of 92% on room air is slightly below the normal range but does not warrant urgent healthcare provider contact unless accompanied by significant respiratory distress or other concerning symptoms.
4. Polyethylene glycol–electrolyte solution (GoLYTELY) is prescribed for a hospitalized client scheduled for a colonoscopy. The client begins to experience diarrhea after drinking the solution. Which action by the nurse is appropriate?
- A. Calling the physician
- B. Administering a cleansing enema
- C. Documenting the diarrhea in the medical record
- D. Giving intravenous replacement fluids in large amounts
Correct answer: C
Rationale: The correct action by the nurse in this situation is to document the diarrhea in the medical record. Polyethylene glycol–electrolyte solution (GoLYTELY) is a bowel evacuant used to cleanse the bowel before a colonoscopy. It is expected to cause mild diarrhea, which is a normal response to the medication. The diarrhea helps clear the bowel in preparation for the procedure. Calling the physician is not necessary unless there are complications. Administering a cleansing enema or giving intravenous replacement fluids in large amounts are not appropriate actions as they are not indicated for managing the expected diarrhea caused by GoLYTELY.
5. When a patient starts taking amoxicillin, which foods should the nurse instruct the patient to avoid?
- A. Green leafy vegetables
- B. Beef and other red meat
- C. Coffee, tea, and colas
- D. Acidic fruits and juices
Correct answer: D
Rationale: The correct answer is D: Acidic fruits and juices. Amoxicillin can be irritating to the stomach, so avoiding acidic fruits and juices is recommended to reduce stomach discomfort or potential interactions. Green leafy vegetables (Choice A), beef and other red meat (Choice B), and coffee, tea, and colas (Choice C) are not typically contraindicated with amoxicillin. It is important to focus on acidic foods and beverages to promote comfort and effectiveness of the medication.
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