HESI RN
HESI Medical Surgical Practice Quiz
1. A marathon runner comes into the clinic and states, 'I have not urinated very much in the last few days.' The nurse notes a heart rate of 110 beats/min and a blood pressure of 86/58 mm Hg. Which action by the nurse is the priority?
- A. Give the client a bottle of water immediately.
- B. Start an intravenous line for fluids.
- C. Teach the client to drink 2 to 3 liters of water daily.
- D. Perform an electrocardiogram.
Correct answer: A
Rationale: The priority action for the nurse is to give the client a bottle of water immediately. The athlete's symptoms of decreased urination, along with a heart rate of 110 beats/min and low blood pressure of 86/58 mm Hg, indicate mild dehydration. Rehydration should begin promptly to address the dehydration. Teaching the client to drink 2 to 3 liters of water daily is a good long-term strategy but not the immediate priority. Starting an intravenous line for fluids may be necessary if oral hydration is insufficient or if the degree of dehydration is severe. Performing an electrocardiogram is not indicated at this time as the priority is addressing the dehydration.
2. A client with Crohn's disease is scheduled to receive an infusion of infliximab (Remicade). The nurse assisting in caring for the client should take which action to monitor the effectiveness of treatment?
- A. Monitoring the leukocyte count for 2 days after the infusion
- B. Checking the frequency and consistency of bowel movements
- C. Checking serum liver enzyme levels before and after the infusion
- D. Carrying out a Hematest on gastric fluids after the infusion is completed
Correct answer: B
Rationale: To monitor the effectiveness of infliximab (Remicade) treatment in a client with Crohn's disease, the nurse should observe the frequency and consistency of bowel movements. Infliximab is an immunomodulator that works to reduce inflammation in the colon, leading to improvements in bowel symptoms such as frequency and consistency. Monitoring these bowel patterns can provide valuable insight into the response to the medication and the overall management of Crohn's disease. Checking the leukocyte count (Choice A) is not specific to monitoring the effectiveness of infliximab for Crohn's disease. Checking serum liver enzyme levels (Choice C) may be important for liver function but does not directly monitor the effectiveness of infliximab. Carrying out a Hematest on gastric fluids (Choice D) is not relevant to monitoring the effectiveness of infliximab in Crohn's disease.
3. Where should the healthcare provider consider starting a screening program for hypothyroidism?
- A. A business and professional women’s group.
- B. An African-American senior citizens' center.
- C. A daycare center in a Hispanic neighborhood.
- D. An after-school center for Native American teens.
Correct answer: B
Rationale: An African-American senior citizens' center is the most appropriate location to start a screening program for hypothyroidism. Older adults are at an increased risk of hypothyroidism, and African-Americans are more likely to be underserved in healthcare. Therefore, targeting this group can help in early detection and management of hypothyroidism. The other options, such as a business and professional women’s group, a daycare center in a Hispanic neighborhood, and an after-school center for Native American teens, do not align as closely with the demographic at higher risk for hypothyroidism.
4. The nurse assesses a client with advanced cirrhosis of the liver for signs of hepatic encephalopathy. Which finding would the nurse consider an indication of progressive hepatic encephalopathy?
- A. An increase in abdominal girth.
- B. Hypertension and a bounding pulse.
- C. Decreased bowel sounds.
- D. Difficulty in handwriting.
Correct answer: D
Rationale: Difficulty in handwriting is a common early sign of hepatic encephalopathy. Changes in handwriting can indicate progression or reversal of hepatic encephalopathy leading to coma. Choice (A) is a sign of ascites, not hepatic encephalopathy. Hypertension and a bounding pulse (Choice B) are not typically associated with hepatic encephalopathy. Decreased bowel sounds (Choice C) do not directly indicate an increase in serum ammonia level, which is the primary cause of hepatic encephalopathy.
5. While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?
- A. The client’s comfort level is increased when the nurse breaks eye contact to type notes into the record
- B. The interview process is enhanced with electronic documentation and allows the client to speak at a normal pace
- C. The nurse has limited ability to observe nonverbal communication while entering the assessment electronically
- D. Completing the electronic record during an interview is a legal obligation of the examining nurse
Correct answer: C
Rationale: Choosing electronic documentation during an interview may hinder the nurse's ability to observe the client's nonverbal cues. Nonverbal communication, such as body language and facial expressions, plays a crucial role in understanding a client's feelings and needs. Focusing on entering data electronically may lead to missing important nonverbal cues that could provide valuable insights into the client's condition or emotions.