HESI RN
HESI Medical Surgical Assignment Exam
1. When preparing a client for intravenous pyelography (IVP), which action by the nurse is most important?
- A. Administering a sedative
- B. Encouraging fluid intake
- C. Administering an oral preparation of radiopaque dye
- D. Questioning the client about allergies to iodine or shellfish
Correct answer: D
Rationale: The most crucial action for the nurse when preparing a client for intravenous pyelography (IVP) is to question the client about allergies to iodine or shellfish. Some IVP dyes contain iodine, and if the client is allergic to iodine or shellfish, they may experience severe allergic reactions such as itching, hives, rash, throat tightness, difficulty breathing, or bronchospasm. Administering a sedative (Choice A) may be needed for relaxation during the procedure, encouraging fluid intake (Choice B) is generally beneficial but not the most crucial for IVP preparation, and administering radiopaque dye (Choice C) should only be done after confirming the client's safety regarding allergies to iodine or shellfish.
2. When preparing to examine a client’s skin using a Wood light, what should the nurse do to facilitate this procedure?
- A. Darken the examining room
- B. Administer a local anesthetic
- C. Obtain a signed informed consent
- D. Shave the skin and scrub it with povidone-iodine (Betadine)
Correct answer: A
Rationale: When using a Wood light to examine the skin, the nurse should darken the examining room. This is necessary because the Wood light emits long-wavelength UV light, which is better visualized in a darkened environment. Administering a local anesthetic (Choice B) is not needed for this procedure. Obtaining a signed informed consent (Choice C) is not directly related to using a Wood light for skin examination. Shaving the skin and scrubbing it with povidone-iodine (Betadine) (Choice D) is not required and may not be appropriate for this type of skin examination.
3. The healthcare provider is caring for a client with severe anemia. Which assessment finding requires immediate intervention?
- A. Pale skin
- B. Increased heart rate
- C. Shortness of breath
- D. Fatigue
Correct answer: C
Rationale: Shortness of breath is a critical sign in severe anemia as it indicates inadequate oxygenation, which can be life-threatening. Immediate intervention is necessary to address this condition. Pale skin (choice A) is a common finding in anemia but not as urgent as shortness of breath. Increased heart rate (choice B) is a compensatory mechanism in anemia to maintain oxygen delivery and is important but not as urgent as addressing inadequate oxygenation. Fatigue (choice D) is a common symptom in anemia but does not indicate an immediate life-threatening situation like shortness of breath does.
4. Which group of the population does the Maternal nutrition component of IRH improve?
- A. Women and adolescent girls
- B. Pregnant women alone
- C. Pregnant women and all children under five
- D. All adolescents
Correct answer: A
Rationale: The correct answer is A: Women and adolescent girls. Maternal nutrition programs typically target women of reproductive age and adolescent girls to improve their health outcomes. Option B is incorrect because maternal nutrition initiatives extend beyond just pregnant women. Option C is incorrect because the focus is not on all children under five but specifically on women and adolescent girls. Option D is incorrect because the program does not target all adolescents, but rather women and adolescent girls.
5. The nurse is caring for a client with a history of atrial fibrillation who is receiving warfarin (Coumadin). Which laboratory value should be closely monitored?
- A. Serum potassium level
- B. Prothrombin time (PT)
- C. International Normalized Ratio (INR)
- D. Serum sodium level
Correct answer: C
Rationale: The correct answer is C, International Normalized Ratio (INR). The INR should be closely monitored in a client receiving warfarin (Coumadin) to assess the effectiveness and safety of anticoagulation therapy. Monitoring the INR helps ensure that the client is within the therapeutic range for anticoagulation to prevent complications such as bleeding or clotting. Choices A, B, and D are incorrect. While monitoring electrolyte levels like serum potassium and sodium is important in overall client care, they are not specific to monitoring the effects of warfarin therapy. Prothrombin time (PT) is a component of INR and helps in monitoring warfarin therapy, but INR gives a standardized result that is independent of the laboratory method used, making it the preferred choice for monitoring warfarin therapy.