HESI RN
HESI Medical Surgical Practice Quiz
1. A client has a urine specific gravity of 1.040. What action should the nurse take?
- A. Obtain a urine culture and sensitivity.
- B. Place the client on restricted fluids.
- C. Assess the client’s creatinine level.
- D. Increase the client’s fluid intake.
Correct answer: D
Rationale: A urine specific gravity of 1.040 is higher than the normal range (1.005 to 1.030) and can indicate dehydration, decreased kidney blood flow, or the presence of antidiuretic hormone. In this situation, the priority action should be to increase the client's fluid intake to address the high specific gravity. Obtaining a urine culture, placing the client on restricted fluids, or assessing the creatinine level would not directly address the underlying issue of high urine specific gravity caused by dehydration or other factors.
2. A client recently started on warfarin therapy. What laboratory value is most important to monitor for this client?
- A. Platelet count
- B. Prothrombin time (PT)
- C. Creatinine level
- D. Blood urea nitrogen (BUN)
Correct answer: B
Rationale: Prothrombin time (PT) is the most important laboratory value to monitor for clients on warfarin therapy. PT helps determine how long it takes blood to clot and ensures the warfarin dose is within the therapeutic range to prevent either excessive bleeding or clotting. Monitoring platelet count is important for assessing the risk of bleeding, but PT is more specific to warfarin therapy. Creatinine level and BUN are indicators of kidney function and are not directly related to warfarin therapy.
3. A client with a history of asthma is admitted to the emergency department with difficulty breathing. Which of these assessments is the highest priority for the nurse to perform?
- A. Auscultation of breath sounds
- B. Measurement of peak expiratory flow
- C. Observation of the client's use of accessory muscles
- D. Assessment of the client's skin color
Correct answer: A
Rationale: Auscultation of breath sounds is the highest priority assessment in a client with a history of asthma experiencing difficulty breathing. It helps the nurse evaluate the severity of the asthma exacerbation by listening for wheezing, crackles, or decreased breath sounds. This assessment guides treatment decisions, such as administering bronchodilators or oxygen therapy. Measurement of peak expiratory flow, although important in assessing asthma severity, may not be feasible in an emergency situation where immediate intervention is needed. Observation of accessory muscle use and assessment of skin color are also important assessments in asthma exacerbation, but auscultation of breath sounds takes precedence in determining the need for urgent interventions.
4. By which name is family planning currently known?
- A. Reproductive and child care
- B. Family and child care
- C. Reproductive and child health
- D. Reproductive and child health care
Correct answer: C
Rationale: Family planning is currently known as Reproductive and Child Health (RCH). It encompasses a broader scope beyond just care, focusing on the overall health aspects related to reproduction and child well-being. Choices A, B, and D are incorrect as they do not accurately reflect the comprehensive nature of family planning under the term Reproductive and Child Health.
5. Each breast is situated on each side of the sternum and extends between the:
- A. 1st and 6th rib
- B. 2nd and 6th rib
- C. 3rd and 6th rib
- D. 4th and 6th rib
Correct answer: B
Rationale: The correct answer is B: 2nd and 6th rib. Each breast is situated between the 2nd and 6th ribs. This anatomical location is important for understanding breast examination techniques and identifying potential abnormalities. Choices A, C, and D are incorrect because the breasts do not extend as far as the 1st, 3rd, or 4th rib, respectively. Understanding the precise anatomical location of structures is crucial in healthcare to ensure accurate assessments and interventions.