HESI RN
HESI Medical Surgical Specialty Exam
1. A healthcare professional is monitoring the respiratory status of a client who has just undergone surgery and is wearing a pulse oximeter. Which of the following coexisting problems is cause for the healthcare professional to suspect that the oxygen saturation readings are not entirely accurate?
- A. Infection
- B. Hypertension
- C. Low blood pressure
- D. Loss of cough reflex
Correct answer: C
Rationale: Low blood pressure (hypotension), shock, and the use of peripheral vasoconstricting medications can lead to inaccurate pulse oximetry readings due to impaired peripheral perfusion. Hypertension and infection are not typically associated with inaccurate pulse oximetry readings, while the loss of cough reflex does not directly affect oxygen saturation readings.
2. When a patient starts taking amoxicillin, which foods should the nurse instruct the patient to avoid?
- A. Green leafy vegetables
- B. Beef and other red meat
- C. Coffee, tea, and colas
- D. Acidic fruits and juices
Correct answer: D
Rationale: The correct answer is D: Acidic fruits and juices. Amoxicillin can be irritating to the stomach, so avoiding acidic fruits and juices is recommended to reduce stomach discomfort or potential interactions. Green leafy vegetables (Choice A), beef and other red meat (Choice B), and coffee, tea, and colas (Choice C) are not typically contraindicated with amoxicillin. It is important to focus on acidic foods and beverages to promote comfort and effectiveness of the medication.
3. A client with osteoarthritis is prescribed acetaminophen. What is the most important teaching the nurse should provide?
- A. Take the medication with food to improve absorption.
- B. Avoid taking other pain medications to prevent liver damage.
- C. Take acetaminophen on an empty stomach to prevent stomach upset.
- D. Monitor liver function tests regularly to detect any liver damage.
Correct answer: B
Rationale: The correct answer is B. Acetaminophen can cause liver damage if taken in excessive amounts or in combination with other medications containing acetaminophen. Clients should be advised to avoid other pain medications to prevent liver toxicity. Choice A is incorrect because acetaminophen is usually taken with or without food, not specifically on an empty stomach. Choice C is incorrect because taking acetaminophen with food can help prevent stomach upset. Choice D is incorrect because while monitoring liver function tests is important for long-term acetaminophen use, the most crucial teaching is to avoid other pain medications to prevent liver damage.
4. 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.
5. A female client who is admitted to the mental health unit for opiate dependency is receiving clonidine 0.1 mg PO for withdrawal symptoms. The client begins to complain of feeling nervous and tells the nurse that her bones are itching. Which finding should the nurse identify as a contraindication for administering the medication?
- A. Blood pressure 90/76 mm Hg.
- B. Heart rate of 85 bpm.
- C. Respiratory rate of 20 breaths/minute.
- D. Temperature of 99°F (37.2°C).
Correct answer: A
Rationale: Clonidine can lower blood pressure, so a BP of 90/76 mm Hg may indicate that it is unsafe to administer another dose. In this situation, the low blood pressure reading indicates that the client is already experiencing hypotension, which is a common side effect of clonidine. Administering more clonidine could further lower the blood pressure, leading to potential complications. The heart rate, respiratory rate, and temperature are within normal limits and do not serve as contraindications for administering clonidine in this scenario.