HESI RN
HESI Medical Surgical Practice Exam
1. How can a nurse best help a client undergoing a bone marrow aspiration and biopsy, along with two upset family members, manage anxiety during the procedure?
- A. Allow the client's family to stay for emotional support.
- B. Accompany the client silently.
- C. Encourage the client to take slow, deep breaths to promote relaxation.
- D. Provide the client an opportunity to verbalize emotions.
Correct answer: C
Rationale: Encouraging the client to take slow, deep breaths is an effective way for the nurse to help the client manage anxiety during the bone marrow aspiration and biopsy procedure. Slow, deep breathing can promote relaxation and help reduce anxiety levels. Choice A, allowing the client's family to stay for emotional support, may provide comfort but does not address a direct intervention to help manage anxiety. Choice B, staying with the client silently, may not actively help the client address their anxiety. Choice D, allowing the client to express feelings, is important but may not directly address anxiety management during the procedure.
2. The healthcare provider is applying a topical corticosteroid to a client with eczema. The healthcare provider should monitor for the potential of increased systemic absorption of the medication if the medication were being applied to which of the following body areas?
- A. Back
- B. Axilla
- C. Soles of the feet
- D. Palms of the hands
Correct answer: B
Rationale: The axilla has thinner skin, making it more permeable to topical medications. Areas with thinner skin, like the axilla, allow for higher systemic absorption of topical corticosteroids.
3. Which of the following actions by the healthcare provider would be considered false imprisonment?
- A. The healthcare provider tells the client they are not allowed to leave until the physician has released them.
- B. The healthcare provider asks the client why they wish to leave.
- C. The healthcare provider asks the client to explain what they understand about their medical diagnosis.
- D. The healthcare provider asks the client to sign an against medical advice discharge form.
Correct answer: A
Rationale: The correct answer is A. False imprisonment occurs when a healthcare provider restrains a client from leaving against their will, even if the provider believes it is in the client's best interest. In this scenario, telling the client they are not allowed to leave until the physician has released them constitutes false imprisonment as it restricts the client's freedom of movement. Choice B is incorrect because asking the client why they wish to leave is a form of assessment and does not involve restraining the client. Choice C is incorrect as it pertains to educating the client about their medical condition. Choice D is incorrect because asking the client to sign an against medical advice discharge form is a legal and ethical procedure to ensure the client understands the risks of leaving against medical advice.
4. A 3-year-old with a congenital heart defect has had a steady decrease in heart rate, now at 76 bpm from 110 bpm four hours ago. Which additional finding should be reported immediately to a healthcare provider?
- A. Oxygen saturation of 94%.
- B. Respiratory rate of 25 breaths/minute.
- C. Urine output of 20 mL/hr.
- D. Blood pressure of 70/40.
Correct answer: D
Rationale: A significant drop in heart rate and blood pressure should be reported immediately as it may indicate worsening of the congenital heart defect. The blood pressure of 70/40 is dangerously low and requires immediate attention to prevent further complications. Oxygen saturation of 94% is within an acceptable range and does not indicate immediate danger. A respiratory rate of 25 breaths/minute is slightly elevated but not a critical finding. Urine output of 20 mL/hr is low but may not be the most concerning finding in this scenario compared to the drop in blood pressure.
5. The healthcare professional counts an adult's apical heartbeat at 110 beats per minute. The healthcare professional describes this as:
- A. Asystole
- B. Bigeminy
- C. Tachycardia
- D. Bradycardia
Correct answer: C
Rationale: Tachycardia is a heart rate greater than 100 beats per minute. In this case, an adult's heart rate of 110 beats per minute falls within the range of tachycardia. Tachycardia can be a common physiological response to various stresses on the body, leading to an increased heart rate. Asystole refers to the absence of cardiac activity, bigeminy is a specific heart rhythm pattern, and bradycardia is a heart rate below 60 beats per minute in adults.