HESI RN
HESI RN Medical Surgical Practice Exam
1. A nursing student is suctioning a client through a tracheostomy tube while a nurse observes. Which action by the student would prompt the nurse to intervene and demonstrate the correct procedure? Select all that apply.
- A. Setting the suction pressure to 60 mm Hg
- B. Applying suction throughout the procedure
- C. Assessing breath sounds before suctioning
- D. Placing the client in a supine position before the procedure
Correct answer: A
Rationale: The correct suction pressure for an adult client with a tracheostomy tube is typically between 80 to 120 mm Hg. Suction should be applied intermittently during catheter withdrawal to avoid damaging the airway. Assessing breath sounds before suctioning is important to ensure the procedure is necessary. Placing the client in a supine position before suctioning can compromise their airway; instead, the head of the bed should be elevated to facilitate proper drainage and reduce the risk of aspiration. Therefore, setting the suction pressure to 60 mm Hg is incorrect and would prompt the nurse to intervene and correct the procedure.
2. The nurse is teaching a client with asthma to use a peak expiratory flow rate (PEFR) meter to manage asthma at home. The nurse knows the client understands the proper use of the meter when the client:
- A. Inhales as rapidly as possible when using the meter
- B. Records the highest of three readings
- C. Uses the meter after taking a bronchodilator
- D. Blows out forcefully into the meter after taking a deep breath
Correct answer: B
Rationale: The correct answer is B: 'Records the highest of three readings.' When using a peak expiratory flow rate (PEFR) meter, the client should record the highest of three readings to ensure an accurate measurement of their peak expiratory flow rate. Inhaling rapidly, using the meter after taking a bronchodilator, or blowing out forcefully into the meter after a deep breath are not correct techniques for using a PEFR meter and may lead to inaccurate results.
3. A client with a diagnosis of renal failure is receiving hemodialysis. Which assessment finding should the nurse report to the healthcare provider immediately?
- A. The client's blood pressure is 130/80 mm Hg.
- B. The client gains 1 kg in 24 hours.
- C. The client's potassium level is 5.5 mEq/L.
- D. The client's weight decreases by 0.5 kg in 24 hours.
Correct answer: C
Rationale: A potassium level of 5.5 mEq/L (C) is elevated and concerning in a client with renal failure receiving hemodialysis, as it can lead to life-threatening cardiac arrhythmias. Monitoring blood pressure (A), weight gain (B), and weight loss (D) are essential in clients on hemodialysis, but an elevated potassium level poses an immediate risk that requires prompt intervention.
4. A client with a history of chronic kidney disease (CKD) is scheduled for a CT scan with contrast. Which laboratory value should the nurse review before the procedure?
- A. Serum creatinine
- B. Blood urea nitrogen (BUN)
- C. Serum potassium
- D. Serum glucose
Correct answer: A
Rationale: The correct answer is A: Serum creatinine. Before a CT scan with contrast, the nurse should review the serum creatinine level. This is crucial in patients with CKD because contrast agents can potentially worsen kidney function and lead to contrast-induced nephropathy. Monitoring serum creatinine helps assess kidney function and determine the risk of complications. Choices B, C, and D are less relevant in this scenario. Blood urea nitrogen (BUN) is another marker of kidney function, but serum creatinine is a more specific indicator. Serum potassium levels are important in assessing electrolyte balance but are not directly related to the risk of contrast-induced nephropathy. Serum glucose levels are not typically a primary concern before a CT scan with contrast in a patient with CKD.
5. An unlicensed assistive personnel (UAP) reports to the nurse that a client with a postoperative wound infection has a temperature of 103°F (39.4°C), blood pressure of 90/70, pulse of 124 beats/minute, and respirations of 28 breaths/minute. When assessing the client, findings include mottled skin appearance and confusion. Which action should the nurse take first?
- A. Transfer the client to the ICU.
- B. Initiate an infusion of intravenous (IV) fluids.
- C. Assess the client's core temperature.
- D. Obtain a wound specimen for culture.
Correct answer: B
Rationale: Initiating an infusion of IV fluids is the priority action to stabilize blood pressure in a client with signs of sepsis. Intravenous fluids help maintain perfusion to vital organs and prevent further deterioration. Option A is not the immediate priority as stabilizing the client's condition can be initiated in the current setting. Option C, assessing the client's core temperature, is important but not the most critical action at this time. Option D, obtaining a wound specimen for culture, is important for identifying the causative organism but is not the first priority in managing a client with signs of sepsis.