HESI RN
Evolve HESI Medical Surgical Practice Exam
1. After an endotracheal tube is placed in a client who experienced sudden onset of respiratory distress, what should the nurse do?
- A. Secure the tube in place with tape
- B. Order a chest x-ray for the client
- C. Document the depth of tube insertion
- D. Auscultate both lungs for breath sounds
Correct answer: D
Rationale: After endotracheal tube insertion, the nurse should auscultate both lungs for the presence of breath sounds. This step helps confirm proper tube placement and adequate ventilation. Auscultation of breath sounds is crucial to ensure that the tube is correctly positioned in the trachea and not in the esophagus. While securing the tube with tape is important, it is not the immediate priority after insertion. Ordering a chest x-ray may be necessary but is not the first action to take immediately post-intubation. Documenting the depth of tube insertion is important but ensuring proper ventilation through auscultation takes precedence.
2. The nurse is caring for a client with liver cirrhosis. Which of these findings would indicate that the client is experiencing complications of the disease?
- A. Yellowing of the skin and eyes
- B. Presence of spider angiomas on the skin
- C. Ascites and peripheral edema
- D. Clay-colored stools and dark urine
Correct answer: D
Rationale: Clay-colored stools and dark urine are classic signs of liver dysfunction, indicating bile flow obstruction commonly seen in liver cirrhosis. This finding is a significant complication requiring immediate medical evaluation. Yellowing of the skin and eyes (jaundice) is a common symptom of liver dysfunction but is not specific to complications. Spider angiomas and ascites with peripheral edema are also associated with liver cirrhosis, but they are not indicative of immediate complications as clay-colored stools and dark urine are.
3. A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three weeks. Which assessment finding indicates to the healthcare provider that the drug is effective?
- A. Slowly increasing urinary output over the last week.
- B. Respiratory rate changes from the 40s to the 60s.
- C. Changes in apical heart rate from the 180s to the 140s.
- D. Change in indirect bilirubin from 12 mg/dl to 8 mg/dl.
Correct answer: C
Rationale: The correct answer is C. Epoetin alfa stimulates erythropoiesis, leading to an increase in red blood cell production and improving oxygen-carrying capacity. As the oxygenation status improves, there is a reduction in heart rate. Therefore, changes in apical heart rate from the 180s to the 140s indicate that the drug is effective. Choices A, B, and D are incorrect because they do not directly reflect the expected outcome of epoetin alfa therapy. Increasing urinary output, changes in respiratory rate, and decreasing bilirubin levels are not primary indicators of the drug's effectiveness in this context.
4. The school nurse who is reviewing immunization records of students who will start kindergarten within the next month notes that most of the students have only received one dose of the measles, mumps, rubella (MMR) vaccine. Which intervention should the nurse implement?
- A. Note in the student records that the second dose of the MMR vaccine should be administered prior to entering first grade
- B. Send notices home with the children on the first day of class advising that MMR vaccine series must be completed
- C. Contact kindergarten parents to remind them that the second dose of MMR is due at the start of the school year
- D. Speak at the next parent-teacher association meeting to teach parents the benefits of immunizing their children
Correct answer: C
Rationale: The correct intervention for the school nurse is to contact kindergarten parents to remind them that the second dose of the MMR vaccine is due at the start of the school year. This approach directly addresses the issue of incomplete vaccination coverage and ensures that children receive the complete vaccination on time. Choice A is incorrect as it only notes the need for the second dose without actively engaging parents. Choice B is not as effective as directly contacting parents and may lead to delays in completing the vaccination series. Choice D, while promoting immunization, does not directly address the current situation of incomplete MMR vaccination among the kindergarten students.
5. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which intervention should the nurse implement first?
- A. Administer a bronchodilator as prescribed.
- B. Assess the client's respiratory rate.
- C. Assess the client's oxygen saturation.
- D. Elevate the head of the bed.
Correct answer: C
Rationale: Assessing the client's oxygen saturation is crucial in a client with COPD receiving supplemental oxygen to ensure adequate oxygenation. This assessment helps determine if the current oxygen therapy is effective or if adjustments are necessary. While administering a bronchodilator is important in managing COPD, assessing oxygen saturation takes precedence to address the client's immediate oxygen needs. Assessing the respiratory rate is also important but evaluating oxygen saturation provides more direct information about the client's oxygen status. Elevating the head of the bed can improve ventilation but is not the priority when assessing oxygen saturation in a client with COPD receiving supplemental oxygen.