HESI RN
HESI Medical Surgical Practice Exam
1. A client who was involved in a motor vehicle collision is admitted with a fractured left femur that is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that the client's distal pulses are diminished in the left foot. Which intervention should the nurse implement?
- A. Verify pedal pulses using a Doppler pulse device
- B. Evaluate the application of the splint to the left leg
- C. Offer ice chips and clear oral liquids
- D. Monitor the left leg for pain, pallor, paresthesia, paralysis, pressure
Correct answer: B
Rationale: Evaluating the application of the splint is the priority as it ensures it is not too tight, which could impair circulation and exacerbate the diminished pulses. Verifying pedal pulses with a Doppler pulse device may be indicated but does not directly address the immediate concern of proper splint application. Offering ice chips and clear oral liquids would not address the issue of diminished distal pulses. Monitoring the left leg for pain, pallor, paresthesia, paralysis, and pressure is important but would not directly address the cause of the diminished pulses in this scenario.
2. When a pediatric client is taking the beta-adrenergic blocking agent propranolol, what signs of overdose should the nurse instruct the parents to report?
- A. Seizures
- B. Increased respiratory rate
- C. Bradycardia
- D. Irritability
Correct answer: C
Rationale: When a pediatric client is taking propranolol, the nurse should instruct the parents to report signs of overdose, including bradycardia. Propranolol is a beta-blocker that can lead to dangerously slow heart rate as a sign of overdose. While increased respiratory rate, seizures, and irritability may occur in some cases, bradycardia is the most critical symptom indicating an overdose of this medication.
3. The nurse is caring for a client with an acute myocardial infarction. Which symptom requires immediate intervention?
- A. Dizziness
- B. Shortness of breath
- C. Severe chest pain
- D. Nausea and vomiting
Correct answer: C
Rationale: Severe chest pain is the hallmark symptom of an acute myocardial infarction (heart attack) and requires immediate intervention to prevent further damage to the heart muscle. Chest pain in this context is often described as crushing, pressure, tightness, or heaviness. It can radiate to the arms, neck, jaw, back, or upper abdomen. Other symptoms like dizziness, shortness of breath, nausea, and vomiting may also occur in acute myocardial infarction, but chest pain is the most critical sign requiring prompt action as it signifies inadequate blood flow to the heart muscle. Shortness of breath may indicate heart failure, while nausea and vomiting can be associated with the sympathetic response to myocardial infarction. Dizziness could result from decreased cardiac output but is not as specific to myocardial infarction as severe chest pain.
4. A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which clinical finding is most concerning?
- A. Serum glucose of 500 mg/dL
- B. Serum glucose of 600 mg/dL
- C. Serum potassium of 5.5 mEq/L
- D. Serum bicarbonate of 18 mEq/L
Correct answer: D
Rationale: A serum bicarbonate level of 18 mEq/L is most concerning in a client with DKA as it indicates metabolic acidosis, requiring immediate intervention. In DKA, the body produces excess ketones, leading to metabolic acidosis. A low serum bicarbonate level is a key indicator of this acid-base imbalance. Elevated serum glucose levels are expected in DKA but are managed through insulin therapy. Serum potassium levels can fluctuate in DKA due to insulin deficiency, but a value of 5.5 mEq/L is not as immediately concerning as metabolic acidosis. Therefore, the most critical finding in this scenario is the low serum bicarbonate level.
5. What is the measurement of the breast areola?
- A. 3.5cm
- B. 2.5cm
- C. 4.5cm
- D. 1.5cm
Correct answer: B
Rationale: The correct answer is 2.5 cm. The average measurement of the areola is approximately 2.5 cm. Choices A, C, and D are incorrect as they do not align with the typical measurement of the breast areola.