a client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint i
Logo

Nursing Elites

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?

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 preparing to examine a client’s skin using a Wood light, what should the nurse do to facilitate this procedure?

Correct answer: A

Rationale: When using a Wood light to examine the skin, the nurse should darken the examining room. This is necessary because the Wood light emits long-wavelength UV light, which is better visualized in a darkened environment. Administering a local anesthetic (Choice B) is not needed for this procedure. Obtaining a signed informed consent (Choice C) is not directly related to using a Wood light for skin examination. Shaving the skin and scrubbing it with povidone-iodine (Betadine) (Choice D) is not required and may not be appropriate for this type of skin examination.

3. The nurse is caring for a patient who is receiving isotonic intravenous (IV) fluids at an infusion rate of 125 mL/hour. The nurse performs an assessment and notes a heart rate of 102 beats per minute, a blood pressure of 160/85 mm Hg, and crackles auscultated in both lungs. Which action will the nurse take?

Correct answer: A

Rationale: The patient is showing signs of fluid volume excess, indicated by crackles in both lungs, increased heart rate, and elevated blood pressure. To address this, the nurse should decrease the IV fluid rate and notify the provider. Increasing the IV fluid rate would worsen fluid overload. Requesting colloidal or hypertonic IV solutions would exacerbate the issue by pulling more fluids into the intravascular space, leading to further volume overload.

4. The nurse is preparing to administer digoxin to a patient who is newly admitted to the intensive care unit. The nurse reviews the patient’s admission electrolytes and notes a serum potassium level of 2.9 mEq/L. Which action by the nurse is correct?

Correct answer: B

Rationale: In the scenario presented, the patient has a low serum potassium level, which can predispose the patient to digoxin toxicity. It is essential for the nurse to hold the digoxin dose and promptly notify the healthcare provider of the abnormal lab values. Option A is incorrect because administering digoxin without addressing the low potassium level can potentiate toxicity. Option C is inappropriate as potassium should not be given as an IV bolus, especially in the case of hypokalemia. Option D is incorrect because oral potassium supplements may not be sufficient for rapidly correcting severe hypokalemia in an acute care setting.

5. The nurse is administering intravenous fluids to a dehydrated patient. On the second day of care, the patient's weight has increased by 2.25 pounds. The nurse would expect that the patient's fluid intake has

Correct answer: B

Rationale: A weight gain of 1 kg, or approximately 2.2 to 2.5 lb, is generally equivalent to 1 liter (L) of fluid retained by the body. In this case, the patient's weight gain of 2.25 pounds suggests an excess fluid retention of approximately 1 liter, indicating that the patient's fluid intake has exceeded urine output by 1 liter. Choices C and D are incorrect as they overestimate the fluid excess based on the patient's weight gain. Choice A is incorrect as it implies an exact balance between fluid intake and urine output, which is not reflected in the given weight increase.

Similar Questions

A client with kidney stones from secondary hyperoxaluria requires medication. Which medication should the nurse anticipate administering?
A client with chronic kidney disease (CKD) is experiencing nausea, vomiting, visual changes, and anorexia. Which action by the nurse is best?
The nurse is caring for a newly admitted patient who will receive digoxin to treat a cardiac dysrhythmia. The patient takes hydrochlorothiazide (HydroDIURIL) and reports regular use of over-the-counter laxatives. Before administering the first dose of digoxin, the nurse will review the patient’s electrolytes with careful attention to the levels of which electrolytes?
During an assessment on a patient brought to the emergency department for treatment for dehydration, the nurse notes a respiratory rate of 26 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 86/50 mm Hg, and a temperature of 39.5° C. The patient becomes dizzy when transferred from the wheelchair to a bed. The nurse observes cool, clammy skin. Which diagnosis does the nurse suspect?
A client has undergone renal angiography via the right femoral artery. The nurse determines that the client is experiencing a complication of the procedure upon noting:

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses