HESI RN
HESI Medical Surgical Test Bank
1. A client with diabetes begins to cry and says, 'I just cannot stand the thought of having to give myself a shot every day.' Which of the following would be the best response by the nurse?
- A. If you do not give yourself your insulin shots, you will die.
- B. We can teach your daughter to give the shots so you will not have to do it.
- C. I can arrange to have a home care nurse give you the shots every day.
- D. What is it about giving yourself the insulin shots that bothers you?
Correct answer: D
Rationale: The correct response is option D because it is an open-ended question that allows the client to express their feelings and concerns. This approach facilitates a therapeutic communication process by encouraging the client to verbalize their thoughts, emotions, and fears related to giving themselves insulin shots. Option A is incorrect as it uses a fear-inducing statement that may not be helpful in addressing the client's emotional needs. Option B assumes involvement of a family member without exploring the client's feelings further. Option C offers a solution without addressing the client's underlying concerns and emotions, potentially overlooking essential aspects of client-centered care.
2. A client in the early stages of Alzheimer’s disease is very anxious and frequently asks about her deceased parents. Which intervention should the nurse implement to reduce the client’s anxiety?
- A. Remind the client that her parents have passed away
- B. Ask the client about her favorite memories with her parents
- C. Engage the client in an activity to distract her from thinking about her parents
- D. Reorient the client to the present reality and surroundings
Correct answer: C
Rationale: Engaging the client in an activity to distract her from thinking about her deceased parents is the most appropriate intervention to reduce anxiety. This approach helps shift the focus away from distressing thoughts and can provide comfort and a sense of calm to the client.
3. A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother. During the assessment, the mother asks the nurse why her child is at the 5th percentile for growth. What response is best for the nurse to provide?
- A. Does your child seem mentally slower than his peers also?
- B. His smaller size is probably due to the heart disease
- C. Haven't you been feeding him according to recommended daily allowances for children?
- D. You should not worry about the growth tables. They are only averages for children
Correct answer: B
Rationale: Heart disease can affect growth, leading to smaller size in children.
4. A patient is being treated for shock after a motor vehicle accident. The provider orders 6% dextran 75 to be given intravenously. The nurse should expect which outcome as the result of this infusion?
- A. Decreased urine output
- B. Improved blood oxygenation
- C. Increased interstitial fluid
- D. Stabilization of heart rate and blood pressure
Correct answer: D
Rationale: 6% Dextran 75 is a high molecular-weight colloidal solution used to treat shock from burns or trauma. Colloids like 6% dextran 75 are plasma expanders that help increase blood volume, leading to improved heart rate and blood pressure stabilization. The infusion of plasma expanders does not typically decrease urine output. It primarily aims to stabilize circulation rather than affect blood oxygenation or increase interstitial fluid levels.
5. The healthcare provider receives a report that a client with an indwelling urinary catheter has an output of 150 mL for the previous 6-hour shift. Which intervention should the healthcare provider implement first?
- A. Check the drainage tubing for a kink
- B. Review the intake and output record
- C. Notify the healthcare provider
- D. Give the client 8 oz of water to drink
Correct answer: A
Rationale: The first intervention should be to check the drainage tubing for a kink. This step is crucial as any kinks in the tubing could obstruct urine flow, leading to a decreased output. By ensuring the tubing is free from any obstructions, the healthcare provider can address a potential mechanical issue causing the low output before considering other interventions. Reviewing the intake and output record may provide valuable information but should come after ensuring the tubing is clear. Notifying the healthcare provider can be done later if needed, but the immediate concern is to check for any obstructions. Giving the client water to drink may be necessary depending on the assessment findings, but addressing a possible kink in the tubing takes precedence.