HESI RN
RN Medical/Surgical NGN HESI 2023
1. A client is being prepared for transfer to the operating room. Which of the following actions should the nurse take in the care of this client at this time?
- A. Ensuring that the client has voided
- B. Administering all daily medications
- C. Practicing postoperative breathing exercises
- D. Verifying that the client has not eaten for the last 24 hours
Correct answer: A
Rationale: The nurse should ensure that the client has voided, especially if a Foley catheter is not in place. This step is important to prevent urinary retention during the surgical procedure. Administering all daily medications just before surgery is not standard practice. The physician typically provides specific orders regarding which medications can be taken with a sip of water before surgery. Postoperative breathing exercises are usually taught after surgery to prevent complications like atelectasis. Verifying that the client has not eaten for the last 24 hours is not a standard preoperative practice; instead, the client is usually instructed to fast for a specific period before surgery to reduce the risk of aspiration during anesthesia.
2. A 30-year-old male client reports difficulty sleeping due to anxiety about his upcoming surgery. What intervention would be most appropriate for the nurse to suggest?
- A. Suggest taking a mild sedative before bed.
- B. Encourage physical activity before bedtime.
- C. Advise listening to calming music before bed.
- D. Recommend reading a book before bed.
Correct answer: A
Rationale: The most appropriate intervention for the nurse to suggest to a 30-year-old male client experiencing difficulty sleeping due to anxiety about his upcoming surgery is to recommend taking a mild sedative before bed. A mild sedative can help manage anxiety and improve sleep in such situations. Encouraging physical activity before bedtime, advising to listen to calming music, or recommending reading a book may not directly address the client's anxiety and may not be as effective in promoting sleep in this scenario.
3. A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. What action should the nurse take when finding the radiation implant in the bed?
- A. Call radiation therapy for assistance
- B. Place the implant in a lead container using long-handled forceps
- C. Leave the implant in the bed and notify the provider
- D. Dispose of the implant in the nearest sharps container
Correct answer: B
Rationale: The correct action for the nurse to take when finding the radiation implant in the bed is to use long-handled forceps to place the implant in a lead container. This procedure is crucial in reducing radiation exposure to both the patient and healthcare providers. Calling radiation therapy for assistance (Choice A) may delay the immediate need for safe handling of the implant. Leaving the implant in the bed and notifying the provider (Choice C) is unsafe and can lead to increased radiation exposure. Disposing of the implant in a sharps container (Choice D) is incorrect as the implant should be placed in a lead container, not a sharps container, to contain the radiation.
4. A client with hypothyroidism is prescribed levothyroxine. What assessment finding suggests the medication is effective?
- A. Improved tolerance to cold.
- B. Decreased fatigue and improved energy levels.
- C. Reduced anxiety and improved mood.
- D. Increased sensitivity to heat.
Correct answer: B
Rationale: The correct answer is B: Decreased fatigue and improved energy levels. Levothyroxine is a medication used to treat hypothyroidism by providing the body with the thyroid hormone it lacks. Therefore, a positive response to the medication would manifest as decreased fatigue and improved energy levels due to the correction of the thyroid hormone imbalance. Choices A, C, and D are incorrect because improved tolerance to cold, reduced anxiety, and increased sensitivity to heat are not direct indicators of the effectiveness of levothyroxine in managing hypothyroidism.
5. A client with chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which assessment finding is most concerning?
- A. Oxygen saturation of 90%
- B. Respiratory rate of 24 breaths per minute
- C. Use of accessory muscles
- D. Inspiratory crackles
Correct answer: C
Rationale: The correct answer is C: 'Use of accessory muscles.' In a client with COPD and pneumonia, the use of accessory muscles indicates increased work of breathing. This finding is concerning as it may signal respiratory failure, requiring immediate intervention. Oxygen saturation of 90% (choice A) is low but not as immediately concerning as the increased work of breathing. A respiratory rate of 24 breaths per minute (choice B) is slightly elevated but not as critical as the use of accessory muscles. Inspiratory crackles (choice D) may be present in pneumonia but are not as indicative of impending respiratory failure as the increased work of breathing shown by the use of accessory muscles.