HESI RN
HESI Medical Surgical Practice Quiz
1. A client is recovering after a nephrostomy tube was placed 6 hours ago. The nurse notes drainage in the tube has decreased from 40 mL/hr to 12 mL over the last hour. Which action should the nurse take?
- A. Document the finding in the client’s record.
- B. Evaluate the tube as working in the hand-off report.
- C. Clamp the tube in preparation for removing it.
- D. Assess the client’s abdomen and vital signs.
Correct answer: D
Rationale: The correct action for the nurse to take in this situation is to assess the client’s abdomen and vital signs. The nephrostomy tube should have a consistent amount of drainage, and a decrease may indicate obstruction. Before notifying the provider, the nurse must assess the client for pain, distention, and changes in vital signs. This assessment is crucial to gather essential information to report accurately. Documenting the finding without further assessment may delay necessary intervention. Evaluating the tube as working in the hand-off report or clamping the tube prematurely are not appropriate actions and could lead to complications if there is an obstruction.
2. A client receiving IV heparin reports tarry stools and abdominal pain. What interventions should the nurse implement?
- A. Prepare to administer warfarin.
- B. Assess the characteristics of the client's pain.
- C. Obtain recent partial thromboplastin time results.
- D. Monitor stool for the presence of blood.
Correct answer: D
Rationale: The correct intervention for the client receiving IV heparin who reports tarry stools and abdominal pain is to monitor the stool for the presence of blood. This is crucial to assess for gastrointestinal bleeding, a potential complication of heparin therapy. Assessing the characteristics of the client's pain may be helpful but is not the priority when signs of GI bleeding are present. Administering warfarin is not appropriate without a thorough assessment and confirmation of the cause of symptoms. While obtaining recent partial thromboplastin time results is important in monitoring heparin therapy, in this scenario, the immediate concern is to assess for possible GI bleeding.
3. A diet rich in _______ controls menopause symptoms:
- A. Carbohydrates
- B. Soya items
- C. Fruits and veggies
- D. Eggs and meat
Correct answer: B
Rationale: A diet rich in soya items can help control menopause symptoms. Soya contains phytoestrogens, which are plant-based compounds that mimic the hormone estrogen in the body. These compounds may help alleviate menopause symptoms such as hot flashes and night sweats. Choice A, Carbohydrates, do not specifically target menopause symptoms. Choice C, Fruits and veggies, while generally healthy, do not have the same impact on menopause symptoms as soya. Choice D, Eggs and meat, do not contain phytoestrogens like soya, making them less effective in managing menopause symptoms.
4. The nurse is developing a plan of care for a client who reports tingling in the feet and who is newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for this client?
- A. The client will walk 30 minutes three times a week
- B. The client will demonstrate understanding of proper shoe fit
- C. The client will perform foot care daily
- D. The client's blood pressure readings will be less than 160/90 mmHg
Correct answer: D
Rationale: Controlling blood pressure is critical in managing peripheral vascular disease, as elevated pressure can exacerbate vascular damage and complications. While foot care, shoe fit, and exercise are important, lowering blood pressure is a primary goal. Proper blood pressure management helps in preventing further damage to the blood vessels and reduces the risk of complications associated with peripheral vascular disease, making it the most crucial outcome to include in the plan of care for this client.
5. A two-year-old child with heart failure (HF) is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin), the nurse obtains an apical heart rate of 128 bpm. What action should the nurse take?
- A. Determine the pulse deficit
- B. Administer the scheduled dose
- C. Calculate the safe dose range
- D. Review the serum digoxin level
Correct answer: B
Rationale: The correct action for the nurse to take is to administer the scheduled dose of digoxin. A heart rate of 128 bpm in a two-year-old child with heart failure falls within the safe range for digoxin administration. It indicates that the child's heart rate is not excessively low, which could be a concern for administering digoxin. Therefore, proceeding with the scheduled dose is appropriate in this scenario. Determining the pulse deficit (Choice A) is not necessary in this situation as the heart rate is already obtained. Calculating the safe dose range (Choice C) is not required as the heart rate is within the safe range. Reviewing the serum digoxin level (Choice D) is not needed at this point since the heart rate indicates that administering the next dose is appropriate.