a nurse is getting a client out of bed for the first time since surgery the nurse raises the head of the bed and the client complains of dizziness whi
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Nursing Elites

HESI RN

RN Medical/Surgical NGN HESI 2023

1. A client is getting out of bed for the first time since surgery. The client complains of dizziness after the nurse raises the head of the bed. Which of the following actions should the nurse take first?

Correct answer: D

Rationale: When a client experiences dizziness after being positioned upright for the first time post-surgery, the initial action the nurse should take is to lower the head of the bed slowly until the dizziness subsides. This maneuver helps alleviate the dizziness by allowing the body to adapt gradually to the change in position. Subsequently, the nurse should assess the client's pulse and blood pressure. Checking the blood pressure is essential to evaluate the circulatory status and rule out orthostatic hypotension as a cause of dizziness. Checking the oxygen saturation level and having the client take deep breaths are not the priority in this scenario as the primary concern is addressing the circulatory issue causing dizziness, not a respiratory problem.

2. What is the priority assessment for a patient receiving intravenous morphine?

Correct answer: B

Rationale: The correct answer is monitoring the patient's respiratory rate. When a patient receives intravenous morphine, the priority assessment is to monitor the respiratory rate due to the risk of respiratory depression associated with morphine. This assessment helps in detecting and managing any potential respiratory complications promptly. Assessing blood pressure, checking pain level, and monitoring oxygen saturation are important aspects of patient care but are not the priority when considering the specific risk of respiratory depression with intravenous morphine.

3. Which lab result would be most indicative of renal failure?

Correct answer: A

Rationale: The correct answer is A: Elevated creatinine levels. Creatinine is a waste product that is normally filtered by the kidneys. Elevated creatinine levels indicate impaired kidney function, which is commonly seen in renal failure. Choice B, low potassium levels, is not typically associated with renal failure. In fact, renal failure is more likely to cause high potassium levels due to the kidneys' inability to excrete potassium effectively. Choice C, low calcium levels, are not directly indicative of renal failure. Renal failure can lead to disturbances in calcium levels, but low calcium levels alone are not a specific marker for renal failure. Choice D, high sodium levels, are also not typically associated with renal failure. In renal failure, there may be disturbances in sodium levels, but high sodium levels alone are not a direct indicator of renal failure.

4. Which is a characteristic that distinguishes sulfonamides from other drugs used to treat bacterial infections?

Correct answer: B

Rationale: The characteristic that distinguishes sulfonamides from other drugs used to treat bacterial infections is that sulfonamides are synthetic compounds, not derived from biologic substances. Choice A is incorrect because sulfonamides are bacteriostatic, not bactericidal. Choice C is incorrect because sulfonamides do not have antifungal and antiviral properties. Choice D is incorrect because sulfonamides act by inhibiting bacterial synthesis of folic acid, not increasing it.

5. The healthcare provider provides dietary instructions about iron-rich food to a client with iron deficiency anemia. Which food selection made by the client indicates a need for additional instructions?

Correct answer: C

Rationale: Oranges are not a good source of iron, so selecting oranges indicates a need for additional instructions. Oranges are high in vitamin C, which can enhance iron absorption from other sources, but they are not rich in iron themselves. Liver, kidney beans, and leafy green vegetables are good sources of iron and would be beneficial for a client with iron deficiency anemia. Therefore, the correct answer is C.

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