HESI RN
Evolve HESI Medical Surgical Practice Exam
1. A nurse checks the residual volume from a client’s nasogastric tube feeding before administering an intermittent tube feeding and finds 35 mL of gastric contents. What should the nurse do before administering the prescribed 100 mL of formula to the client?
- A. Pour the residual volume into the nasogastric tube through a syringe with the plunger removed
- B. Discard the residual volume properly and record it as output on the client’s fluid balance record
- C. Dilute the residual volume with water and inject it into the nasogastric tube, applying pressure on the plunger
- D. Mix the residual volume with the formula and pour it into the nasogastric tube, using a syringe without a plunger
Correct answer: A
Rationale: After checking the residual feeding contents, the nurse should pour the residual volume back into the stomach by removing the syringe bulb or plunger and then pouring the gastric contents, using the syringe, into the nasogastric tube. This helps ensure that the residual volume is reintroduced into the client's gastrointestinal tract. Option B is incorrect because discarding the residual volume without reinstilling it into the stomach can lead to inaccurate medication administration and potential electrolyte imbalances. Option C is incorrect as diluting the residual volume with water and injecting it under pressure can cause aspiration or discomfort for the client. Option D is incorrect because mixing the residual volume with the formula can alter the prescribed dosage and consistency, potentially affecting the client's nutritional intake and causing complications.
2. The client is being taught to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs?
- A. Three apricots
- B. Medium banana
- C. Naval orange
- D. Baked potato
Correct answer: D
Rationale: The correct answer is D. A baked potato is high in potassium and helps prevent digitalis toxicity by maintaining adequate potassium levels. While choices A, B, and C all contain some potassium, a baked potato is a more concentrated source of potassium compared to three apricots, a medium banana, or a naval orange. Therefore, the client should choose a baked potato to better meet the dietary needs for preventing digitalis toxicity.
3. What is the most important action for the nurse to take when caring for a client with a spinal cord injury experiencing autonomic dysreflexia?
- A. Elevate the head of the bed to 45 degrees.
- B. Monitor the client's respiratory rate.
- C. Administer an antihypertensive medication.
- D. Assess the client's blood glucose level.
Correct answer: A
Rationale: In a client with autonomic dysreflexia, the most critical action is to elevate the head of the bed to 45 degrees (A). This positioning helps reduce blood pressure, which is essential in managing autonomic dysreflexia. Monitoring the client's respiratory rate (B) is important for overall assessment but not the priority in this situation. Administering an antihypertensive medication (C) without addressing the positioning issue first can lead to further complications. Assessing the client's blood glucose level (D) is not directly related to autonomic dysreflexia and is not the initial priority in this scenario.
4. An 18-year-old gravida 1, at 41-weeks gestation, is undergoing an oxytocin (Pitocin) induction and has an epidural catheter in place for pain control. With each of the last three contractions, the nurse notes a late deceleration. The client is repositioned and oxygen provided, but the late decelerations continue to occur with each contraction. What action should the nurse take first?
- A. Prepare for immediate cesarean birth
- B. Turn off the oxytocin (Pitocin) infusion
- C. Notify the anesthesiologist that the epidural infusion needs to be disconnected
- D. Apply an internal fetal monitoring device and continue to monitor carefully
Correct answer: B
Rationale: In the scenario described, the presence of late decelerations during contractions indicates fetal compromise. To address this, the nurse's initial action should be to turn off the oxytocin (Pitocin) infusion. Oxytocin can contribute to uteroplacental insufficiency, leading to late decelerations. This intervention aims to improve fetal oxygenation and prevent further stress on the fetus. Immediate cesarean birth is not the first-line action unless other interventions fail. Notifying the anesthesiologist about disconnecting the epidural infusion is not the priority in this situation. Applying an internal fetal monitoring device is invasive and not the immediate step needed when late decelerations are present.
5. A good relationship between a leader and a follower enables the follower to 'manage up.' Which of the following describes the best way for a follower to 'manage up'?
- A. Provide feedback to the unit manager when asked for it.
- B. Assist your manager in capitalizing on his or her strengths and weaknesses.
- C. When working with a manager with poor leadership skills, transferring to a different unit is the best option.
- D. Show respect and appreciation for the manager, even when conversing with coworkers.
Correct answer: B
Rationale: The best way for a follower to 'manage up' is by assisting the manager in capitalizing on his or her strengths and weaknesses. By doing so, the follower helps build a good working relationship with the manager, fostering mutual growth and development. Choice A is not the best option as it only focuses on providing feedback when asked, which may not necessarily contribute to 'managing up.' Choice C is incorrect because transferring to a different unit should not be the first solution when dealing with a manager with poor leadership skills; instead, efforts should be made to improve the current working relationship. Choice D, while important, focuses more on showing respect and appreciation rather than actively helping the manager improve, which is key to 'managing up.'