HESI RN
HESI Medical Surgical Practice Exam Quizlet
1. A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets about:
- A. Preparing the client for a perfusion scan
- B. Attaching the client to a cardiac monitor
- C. Administering oxygen via nasal cannula
- D. Ensuring that the intravenous (IV) line is patent
Correct answer: C
Rationale: When a client who has just undergone surgery experiences sudden chest pain, dyspnea, and tachypnea, indicating possible pulmonary embolism, the immediate priority for the nurse is to administer oxygen via nasal cannula. This intervention aims to improve oxygenation and alleviate respiratory distress, which is crucial in the setting of a potential pulmonary embolism. Preparing the client for a perfusion scan is not the immediate priority as stabilizing the client's respiratory status comes first. While attaching the client to a cardiac monitor is important for monitoring, administering oxygen takes precedence in this situation. Ensuring IV line patency is relevant for overall client care but is not the priority when a client is experiencing respiratory distress requiring immediate intervention.
2. The nurse finds a 6-month-old infant unresponsive and calls for help. After opening the airway and finding the XXXX, the infant is still not breathing. What action should the nurse take next?
- A. Palpate the femoral pulse and check for regularity.
- B. Deliver cycles of 30 chest compressions and 2 breaths.
- C. Give two breaths that make the chest rise.
- D. Feel the carotid pulse and check for adequate breathing.
Correct answer: C
Rationale: In a scenario where a 6-month-old infant is unresponsive and not breathing after the airway is open, giving two breaths that make the chest rise is the appropriate action. This helps deliver oxygen to the infant's lungs and can help initiate breathing. Chest compressions are not recommended for infants as the first step in resuscitation. Checking pulses like the femoral or carotid pulse is not the priority when an infant is not breathing, as providing oxygen through breaths is essential.
3. What is the content of the acrosome?
- A. Lipids
- B. Hormones
- C. Digestive enzymes
- D. None of the above
Correct answer: C
Rationale: The correct answer is C: Digestive enzymes. The acrosome is a structure found in sperm cells that contains enzymes used to penetrate the egg during fertilization. Choice A (Lipids) and Choice B (Hormones) are incorrect as the primary content of the acrosome is digestive enzymes, not lipids or hormones. Choice D (None of the above) is incorrect as the acrosome does contain a specific substance, which are digestive enzymes.
4. A postoperative client returns to the nursing unit following a ureter lithotomy via a flank incision. Which potential nursing problem has the highest priority when planning nursing care for this client?
- A. Ineffective airway clearance
- B. Altered nutrition less than body requirements
- C. Fluid volume excess
- D. Activity intolerance
Correct answer: A
Rationale: The correct answer is 'Ineffective airway clearance.' Following a ureter lithotomy via a flank incision, the highest priority nursing problem is ensuring the client's airway remains clear. This is crucial for effective breathing and oxygenation. Altered nutrition, fluid volume excess, and activity intolerance are important to address but are of lower priority compared to maintaining a clear airway postoperatively.
5. A client with chronic pain is prescribed transdermal fentanyl (Duragesic) patches. Which instruction should the nurse include in the teaching plan?
- A. Apply the patch to a different site each time.
- B. Avoid using heating pads over the patch.
- C. Change the patch every 72 hours.
- D. Remove the old patch before applying the new one.
Correct answer: B
Rationale: Clients using transdermal fentanyl (Duragesic) patches should avoid using heating pads over the patch as heat can increase the release of the medication, potentially leading to overdose. The patch should be applied to a different site each time, changed every 72 hours, and the old patch should be removed before applying a new one to prevent accidental overdose or excessive drug absorption.