HESI RN
HESI Medical Surgical Specialty Exam
1. A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased to more than 2 L/min. The nurse responds that this would be harmful because it could:
- A. Be drying to nasal passages
- B. Decrease the client’s oxygen-based respiratory drive
- C. Increase the risk of pneumonia due to drier air passages
- D. Decrease the client’s carbon dioxide–based respiratory drive
Correct answer: B
Rationale: Increasing the oxygen flow rate beyond 2 L/min for a client with COPD can decrease the client's oxygen-based respiratory drive. In clients with COPD, the natural respiratory drive is based on the level of oxygen instead of carbon dioxide, as seen in healthy individuals. Increasing the oxygen level independently can suppress the drive to breathe, leading to respiratory failure. Choices A, C, and D are incorrect because drying of nasal passages, increased risk of pneumonia due to drier air passages, and decreasing the carbon dioxide-based respiratory drive are not the primary concerns associated with increasing the oxygen flow rate in a client with COPD.
2. A client who had a vasectomy is in the post-recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse?
- A. Until the healthcare provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception.
- B. This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen, and no sperm are in your ejaculate.
- C. After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days.
- D. The healthcare provider at this clinic recommends rest, ice, an athletic supporter, or over-the-counter pain medication to relieve any discomfort.
Correct answer: A
Rationale: The most crucial point to reinforce to the patient after a vasectomy is the need for continued contraception until it is confirmed that the ejaculate is sperm-free. Choice A emphasizes this by highlighting the importance of using another form of contraception until the healthcare provider confirms the absence of sperm. This is essential to prevent unintended pregnancies. Choices B, C, and D do not address the key point of ensuring contraception until sperm absence is confirmed and are therefore not as important to reinforce in this scenario.
3. A client with hypertension is prescribed lisinopril. What side effect should the nurse teach the client to monitor for?
- A. Monitor for a persistent cough.
- B. Monitor for bradycardia and dizziness.
- C. Report any signs of swelling or difficulty breathing.
- D. Monitor for headache and blurred vision.
Correct answer: A
Rationale: The correct answer is A: 'Monitor for a persistent cough.' Lisinopril, an ACE inhibitor, is associated with a common side effect of a persistent dry cough. This cough can be bothersome to the client and should be reported to their healthcare provider. Choices B, C, and D are incorrect because bradycardia, dizziness, swelling, difficulty breathing, headache, and blurred vision are not typically associated with lisinopril use.
4. The client with type 2 DM is learning to manage blood glucose levels. When should the client monitor blood glucose?
- A. Only when feeling unwell.
- B. Only before meals.
- C. Before meals and at bedtime.
- D. Only after meals.
Correct answer: C
Rationale: The correct answer is to monitor blood glucose before meals and at bedtime. This timing allows the client to assess fasting levels and make informed decisions about mealtime insulin or medication doses. Monitoring only when feeling unwell (choice A) is not sufficient for proper glucose management as it may miss important trends. Monitoring only before meals (choice B) is helpful but does not provide a complete picture of the client's glucose control throughout the day. Monitoring only after meals (choice D) is less beneficial than monitoring before meals as it does not capture fasting levels. Therefore, monitoring before meals and at bedtime (choice C) is the most comprehensive approach to maintain good glucose control and prevent complications.
5. A client who had a cerebral vascular accident (CVA) is paralyzed on the left side of the body and has developed a Stage II pressure ulcer on the left hip. Which nursing diagnosis describes this client's current health status?
- A. Risk for impaired tissue integrity related to impaired physical mobility
- B. Impaired skin integrity related to altered circulation and pressure
- C. Ineffective tissue perfusion related to inability to move self in bed
- D. Impaired physical mobility related to the left side paralysis
Correct answer: B
Rationale: The correct nursing diagnosis for this client is 'Impaired skin integrity related to altered circulation and pressure.' The client's Stage II pressure ulcer on the left hip is a clear indication of impaired skin integrity resulting from altered circulation and pressure due to immobility. Choice A is incorrect because the client already has a pressure ulcer, indicating an actual impairment rather than a risk. Choice C is incorrect as ineffective tissue perfusion is not the primary issue in this case. Choice D is incorrect as it focuses solely on the paralysis and not the actual skin integrity issue.