HESI RN
HESI Medical Surgical Practice Quiz
1. A client is returning home after arthroscopy of the shoulder. The nurse should tell the client:
- A. To resume full activity the next day
- B. Not to eat or drink anything until the next morning
- C. To keep the shoulder completely immobilized for the rest of the day
- D. To report to the physician the development of fever or redness and heat at the site
Correct answer: D
Rationale: After arthroscopy, it is important for the client to report any signs of infection, such as the development of fever or redness and heat at the site, to the physician promptly. Options A, B, and C are incorrect. The client should not resume full activity the next day as rest and limited movement are usually recommended post-arthroscopy. It is not necessary to withhold food or fluids until the next morning; the client may resume the usual diet immediately unless otherwise instructed. While immobilization may be recommended for a period, keeping the shoulder completely immobilized for the rest of the day is not typically necessary post-arthroscopy.
2. The client is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portal site should the nurse provide?
- A. Protect the skin of the radiation portal site from sunlight exposure
- B. Apply moisturizing lotions daily to the radiation portal site
- C. Avoid washing the skin inside the radiation portal site
- D. Remove the ink marks of the portal after each radiation treatment
Correct answer: A
Rationale: Protecting the skin from sunlight exposure is crucial to prevent radiation burns and additional skin damage at the treatment site. Sun exposure can exacerbate skin reactions caused by radiation therapy. Applying moisturizing lotions daily may introduce foreign substances or irritants to the treated area, leading to potential complications. Washing the skin inside the radiation portal site is important for maintaining cleanliness and preventing infections. Removing the ink marks after each treatment is unnecessary and may cause unnecessary skin irritation and trauma.
3. After an adult had an indwelling catheter removed, the nurse catheterizes them as ordered and obtains 200 cc of urine. What is the best interpretation of this finding?
- A. Is voiding normally.
- B. Has urinary retention.
- C. Has developed renal failure.
- D. Needs an indwelling catheter.
Correct answer: B
Rationale: The finding of obtaining 200 cc of urine after catheterization indicates urinary retention, as the bladder did not empty completely after the first void. This situation may require further assessment and intervention to address the issue of incomplete bladder emptying. Choice A is incorrect because voiding normally would indicate a larger amount of urine output. Choice C is incorrect as renal failure would typically present with other signs and symptoms. Choice D is incorrect as the presence of urinary retention does not necessarily mean the need for an indwelling catheter immediately.
4. The nurse is caring for a client with deep vein thrombosis (DVT) who is receiving anticoagulant therapy. Which intervention should the nurse implement to prevent complications?
- A. Elevate the affected leg
- B. Encourage early ambulation
- C. Perform frequent range-of-motion exercises
- D. Apply ice packs to the affected leg
Correct answer: A
Rationale: Elevating the affected leg is crucial in managing deep vein thrombosis (DVT) as it helps to reduce swelling and improve venous return. This intervention is essential for preventing complications such as pulmonary embolism. Encouraging early ambulation is generally beneficial for preventing DVT but is secondary to leg elevation. Performing range-of-motion exercises can be helpful for maintaining joint mobility but is not the priority intervention in this case. Applying ice packs to the affected leg is not recommended in DVT management as it can cause vasoconstriction and potentially worsen the condition.
5. The healthcare provider receives a newborn within the first minutes after vaginal delivery and intervenes to establish adequate respirations. What priority issue should the healthcare provider address to ensure the newborn's survival?
- A. Heat loss.
- B. Fluid balance.
- C. Bleeding tendencies.
- D. Hypoglycemia.
Correct answer: A
Rationale: Corrected Rationale: Immediately after birth, newborns are at high risk for heat loss, which can lead to cold stress and associated complications. Maintaining thermal regulation is crucial to prevent hypothermia and ensure the newborn's survival. By addressing heat loss as a priority issue, the healthcare provider can help stabilize the newborn's temperature and support overall well-being. Choices B, C, and D are not the priority issues immediately after birth. While fluid balance, bleeding tendencies, and hypoglycemia are important considerations in newborn care, heat loss is the primary concern right after delivery to prevent complications related to thermal regulation.