HESI RN
RN Medical/Surgical NGN HESI 2023
1. While assisting a client with a closed chest tube drainage system to move from bed to a chair, the chest tube gets caught on the chair leg and becomes dislodged from the insertion site. What is the immediate priority for the nurse?
- A. Contacting the physician
- B. Reinserting the chest tube
- C. Transferring the client back to bed
- D. Covering the insertion site with a sterile occlusive dressing
Correct answer: D
Rationale: The immediate priority for the nurse when a chest tube becomes dislodged from the insertion site is to cover the site with a sterile occlusive dressing. This action helps prevent air from entering the pleural space, which could lead to a pneumothorax. The nurse should then perform a respiratory assessment to monitor the client's breathing, assist the client back into bed to a position of comfort, and notify the physician. Reinserting the chest tube is a task for the physician, not the nurse, as it requires specific training and expertise.
2. A client is prescribed metronidazole (Flagyl) for a trichomoniasis infection. Which of the following should the nurse include in the teaching plan?
- A. Avoid consuming alcohol while taking this medication.
- B. Take the medication with food.
- C. Increase fluid intake to prevent kidney stones.
- D. Report any gastrointestinal upset to the healthcare provider.
Correct answer: A
Rationale: The correct answer is A. Metronidazole (Flagyl) can cause a disulfiram-like reaction when taken with alcohol, resulting in severe nausea, vomiting, and headache. Therefore, the client should be advised to avoid alcohol while taking this medication to prevent adverse effects. Avoiding alcohol is crucial to prevent these reactions and ensure the effectiveness of the treatment. The other options are not directly related to the specific medication or the condition being treated.
3. A client has burns covering 40% of their total body surface area (TBSA). What is the nurse’s priority action?
- A. Monitor the client's urinary output hourly.
- B. Apply cool, moist dressings to the burned areas.
- C. Administer pain medication to reduce discomfort.
- D. Administer IV fluids to prevent hypovolemia.
Correct answer: A
Rationale: The correct answer is A: Monitor the client's urinary output hourly. Clients with burns covering a large percentage of their total body surface area are at high risk for hypovolemia due to fluid loss. Monitoring urinary output is crucial because it helps assess kidney function and fluid balance, providing essential information about the client's hemodynamic status. Applying cool, moist dressings (choice B) is important but not the priority over assessing fluid balance. Administering pain medication (choice C) is essential for comfort but not the priority over monitoring for potential complications like hypovolemia. Administering IV fluids (choice D) is important to prevent hypovolemia, but monitoring urinary output should be the priority to guide fluid resuscitation.
4. A client in the postanesthesia care unit has an as-needed prescription for ondansetron (Zofran). Which of the following occurrences would prompt the nurse to administer this medication to the client?
- A. Paralytic ileus
- B. Incisional pain
- C. Urine retention
- D. Nausea and vomiting
Correct answer: D
Rationale: The correct answer is D: Nausea and vomiting. Ondansetron is an antiemetic used to manage postoperative nausea and vomiting, as well as nausea and vomiting related to chemotherapy. It is not indicated for treating paralytic ileus, incisional pain, or urine retention. Paralytic ileus is a condition of the gastrointestinal tract characterized by the paralysis of intestinal muscles, which would not be treated with ondansetron. Incisional pain is typically managed with analgesics, not antiemetics. Urine retention is a urinary issue that does not involve nausea and vomiting, making ondansetron an inappropriate choice for this condition.
5. A client with a history of congestive heart failure (CHF) is admitted with fluid volume overload. Which assessment finding should the nurse report to the healthcare provider?
- A. Weight gain of 2 pounds in 24 hours
- B. Presence of a cough
- C. Edema in the lower extremities
- D. Shortness of breath
Correct answer: D
Rationale: The correct answer is 'D - Shortness of breath.' In a client with congestive heart failure experiencing fluid volume overload, shortness of breath is a critical finding that indicates possible pulmonary congestion and worsening heart failure. This symptom requires immediate attention to prevent further complications. Choices A, B, and C are common findings in clients with CHF but are not as urgent as shortness of breath. Weight gain may indicate fluid retention, cough can be due to pulmonary congestion, and edema in lower extremities is a common manifestation of CHF, but none of these findings are as concerning as shortness of breath in this scenario.