HESI RN
HESI Medical Surgical Practice Exam Quizlet
1. A client who was in a motor vehicle collision was admitted to the hospital, and the right knee was placed in skeletal traction. The nurse has documented this nursing diagnosis in the client's medical record: 'Potential for impairment of skin integrity related to immobility from traction.' Which nursing intervention is indicated based on this diagnosis statement?
- A. Release the traction every 4 hours to provide skin care.
- B. Turn the client for back care while suspending traction.
- C. Provide back and skin care while maintaining the traction.
- D. Give back care after the client is released from traction.
Correct answer: C
Rationale: The correct nursing intervention indicated based on the nursing diagnosis 'Potential for impairment of skin integrity related to immobility from traction' is to provide back and skin care while maintaining the traction. This intervention is crucial for maintaining the client's skin integrity and preventing potential complications. Releasing the traction every 4 hours (Choice A) may disrupt the treatment plan and compromise the effectiveness of traction. Turning the client for back care while suspending traction (Choice B) does not address the need for skin care while the client is in traction. Giving back care after the client is released from traction (Choice D) neglects the immediate need to prevent skin impairment while in traction. Therefore, providing back and skin care while maintaining the traction (Choice C) is the most appropriate intervention in this scenario.
2. Using Nägele's rule, what is the estimated date of delivery for a pregnant client who reports that the first day of her last menstrual period was August 2, 2006?
- A. April 25, 2007.
- B. May 9, 2007.
- C. May 29, 2007.
- D. June 2, 2007.
Correct answer: B
Rationale: Nägele's rule is used to estimate the date of delivery. It involves adding 7 days to the first day of the last menstrual period (August 2), which gives August 9. Then, subtracting 3 months from August 9, we arrive at May 9 of the following year as the estimated date of delivery. This makes choice B, 'May 9, 2007,' the correct answer. Choices A, C, and D are incorrect as they do not follow the correct calculation based on Nägele's rule.
3. The client with chronic renal failure is receiving instruction on dietary restrictions. Which of the following food items should the client be instructed to avoid?
- A. Bananas.
- B. Apples.
- C. Rice.
- D. Potatoes.
Correct answer: A
Rationale: The correct answer is A: Bananas. Bananas are high in potassium, and individuals with chronic renal failure are often advised to limit potassium intake to prevent hyperkalemia. Apples, rice, and potatoes are lower in potassium and can be included in moderation in the diet of clients with chronic renal failure.
4. The healthcare provider is caring for a patient who is receiving an intravenous antibiotic. The patient has a serum drug trough of 1.5 mcg/mL. The normal trough for this drug is 1.7 mcg/mL to 2.2 mcg/mL. What will the healthcare provider expect the patient to experience?
- A. Inadequate drug effects
- B. Increased risk of superinfection
- C. Minimal adverse effects
- D. Slowed onset of action
Correct answer: A
Rationale: A serum drug trough level below the normal range (1.7 mcg/mL to 2.2 mcg/mL) indicates that the medication concentration is insufficient to provide therapeutic effects, leading to inadequate drug effects. A low trough level does not directly correlate with an increased risk of superinfection, minimal adverse effects, or a slowed onset of action, as these are more related to the drug's concentration within the therapeutic range.
5. A client is admitted with a diagnosis of fluid volume excess. Which intervention should the nurse include in the client's plan of care?
- A. Encourage increased fluid intake.
- B. Place the client in a high Fowler's position.
- C. Measure the client's intake and output.
- D. Restrict dietary sodium intake.
Correct answer: D
Rationale: Restricting dietary sodium intake (D) is the most critical intervention for a client with fluid volume excess to prevent further fluid retention. Encouraging increased fluid intake (A) would exacerbate the issue by adding more fluid to the body. Placing the client in a high Fowler's position (B) is more relevant for respiratory issues than fluid volume excess. While measuring intake and output (C) is important for assessing fluid balance, restricting sodium intake is the priority as it helps manage fluid levels more effectively by reducing fluid retention.