a client who experienced partial thickness burns with over 50 body surface area bsa 2 weeks ago has several open wounds and develops watery diarrhea t
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Nursing Elites

HESI RN

HESI Medical Surgical Practice Exam

1. A client who experienced partial-thickness burns involving over 50% body surface area (BSA) 2 weeks ago has several open wounds and develops watery diarrhea. The client's blood pressure is 82/40 mmHg, and temperature is 96°F (36.6°C). Which action is most important for the nurse to take?

Correct answer: D

Rationale: In this scenario, the client is presenting with signs of sepsis, such as hypotension, hypothermia, and a recent history of partial-thickness burns with open wounds. The development of watery diarrhea further raises suspicion for sepsis. With a blood pressure of 82/40 mmHg and a low temperature of 96°F (36.6°C), the nurse should recognize the potential for septic shock. Notifying the rapid response team is crucial in this situation as the client requires immediate intervention and management to prevent deterioration and address the underlying septic process. Increasing the room temperature (Choice A) is not the priority as the low body temperature is likely due to systemic vasodilation and not environmental factors. While assessing oxygen saturation (Choice B) is important, the client's hypotension and hypothermia take precedence. Continuing to monitor vital signs (Choice C) alone is insufficient given the critical condition of the client and the need for prompt action to address the sepsis and potential septic shock.

2. A nurse checks the residual volume from a client’s nasogastric tube feeding before administering an intermittent tube feeding and finds 35 mL of gastric contents. What should the nurse do before administering the prescribed 100 mL of formula to the client?

Correct answer: A

Rationale: After checking the residual feeding contents, the nurse should pour the residual volume back into the stomach by removing the syringe bulb or plunger and then pouring the gastric contents, using the syringe, into the nasogastric tube. This helps ensure that the residual volume is reintroduced into the client's gastrointestinal tract. Option B is incorrect because discarding the residual volume without reinstilling it into the stomach can lead to inaccurate medication administration and potential electrolyte imbalances. Option C is incorrect as diluting the residual volume with water and injecting it under pressure can cause aspiration or discomfort for the client. Option D is incorrect because mixing the residual volume with the formula can alter the prescribed dosage and consistency, potentially affecting the client's nutritional intake and causing complications.

3. A client reports for a scheduled electroencephalogram (EEG). Which statement by the client indicates a need for additional preparation for the test?

Correct answer: A

Rationale: The correct answer is A. For an EEG, it is essential that the client's hair is clean, without any products like hairspray or gel, to ensure good electrode contact with the scalp. Choice B is not a concern as having breakfast is allowed before the test. Choice C, not taking an anticonvulsant, might be required for certain types of EEGs to capture accurate brain activity. Choice D, not drinking coffee, is not a specific requirement for an EEG preparation.

4. A confused client with pneumonia is admitted with an indwelling catheter in place. During interdisciplinary rounds the following day, which question should the nurse ask the primary health care provider?

Correct answer: C

Rationale: An indwelling catheter dramatically increases the risks of urinary tract infection and urosepsis. Nursing staff should ensure that catheters are left in place only as long as they are medically needed. The nurse should inquire about removing the catheter. All other questions might be appropriate, but because of client safety, this question takes priority.

5. Which symptoms should the nurse expect a client to exhibit who is diagnosed with a pheochromocytoma?

Correct answer: B

Rationale: Correct. Pheochromocytoma is a catecholamine-secreting non-cancerous tumor of the adrenal medulla. The classic triad of symptoms includes headache, diaphoresis (excessive sweating), and palpitations, which result from the overproduction of catecholamines like epinephrine and norepinephrine. Numbness, tingling, and cramps in the extremities (Option A) are not characteristic of pheochromocytoma. Cyanosis, fever, and classic signs of shock (Option C) are not typical symptoms of this condition. Nausea, vomiting, and muscular weakness (Option D) are not commonly associated with pheochromocytoma.

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