HESI RN
RN Medical/Surgical NGN HESI 2023
1. A nurse performing nasopharyngeal suctioning suddenly notes the presence of bloody secretions. What should the nurse do first?
- A. Continue suctioning to remove the blood
- B. Check the degree of suction being applied
- C. Encourage the client to cough out the bloody secretions
- D. Remove the suction catheter from the client’s nose and begin vigorous suctioning through the mouth
Correct answer: B
Rationale: The correct answer is to check the degree of suction being applied (Choice B). When bloody secretions are encountered during nasopharyngeal suctioning, it is crucial to assess the situation promptly. Checking the degree of suction being applied is the first step as excessive suction pressure may be causing trauma and bleeding. Adjusting the suction pressure may be necessary to prevent further harm. Continuing suctioning to remove the blood (Choice A) or performing vigorous suctioning through the mouth (Choice D) can lead to increased trauma and worsen bleeding. Encouraging the client to cough out the bloody secretions (Choice C) is not appropriate since the client undergoing suctioning is typically unable to expectorate secretions. Therefore, the priority is to check and adjust the suction settings to ensure safe and effective suctioning.
2. Which of the following medications is commonly prescribed for hypertension?
- A. Atenolol
- B. Aspirin
- C. Ibuprofen
- D. Metformin
Correct answer: A
Rationale: The correct answer is Atenolol. Atenolol is a beta-blocker commonly prescribed to manage hypertension due to its ability to reduce the heart rate and lower blood pressure. Options B, C, and D are incorrect because aspirin, ibuprofen, and metformin are not typically used as first-line treatments for hypertension. Aspirin is more commonly used for its antiplatelet effects, ibuprofen is a nonsteroidal anti-inflammatory drug, and metformin is primarily used for managing diabetes.
3. A client presents with a fungal urinary tract infection (UTI). Which assessments should the nurse complete? (Select all that apply.)
- A. Palpate the kidneys and bladder.
- B. Assess the medical history and current medical problems.
- C. Perform a bladder scan to assess post-void residual.
- D. Inquire about recent travel to foreign countries.
Correct answer: B
Rationale: When assessing a client with a fungal UTI, the nurse should prioritize gathering information related to the medical history and current medical problems. Clients who are severely immunocompromised or have conditions like diabetes mellitus are more susceptible to fungal UTIs. Assessing the medical history helps identify risk factors and potential causes of the infection. While physical examinations like palpating the kidneys and bladder and performing a bladder scan may be necessary, they should follow the initial assessment of medical history. Inquiring about recent travel to foreign countries is less relevant in the context of a fungal UTI, as the focus should be on immediate medical factors predisposing the client to the infection.
4. The nurse is caring for a patient who is receiving furosemide (Lasix) and an aminoglycoside antibiotic. The nurse will be most concerned if the patient reports which symptom?
- A. Dizziness
- B. Dysuria
- C. Nausea
- D. Tinnitus
Correct answer: D
Rationale: The correct answer is D: Tinnitus. When furosemide and an aminoglycoside antibiotic are used together, there is an increased risk of ototoxicity. Tinnitus, a ringing in the ears, is a common early sign of ototoxicity. Dizziness (choice A) is a common side effect of furosemide but not specifically related to this drug interaction. Dysuria (choice B) is painful urination and is not directly associated with this drug combination. Nausea (choice C) is a common side effect of furosemide but is not specifically indicative of ototoxicity caused by the drug interaction.
5. A client with partial thickness burns to the lower extremities is scheduled for whirlpool therapy to debride the burned area. Which intervention should the nurse implement before transporting the client to the physical therapy department?
- A. Obtain supplies to re-dress the burn area.
- B. Verify the client's signed consent form.
- C. Give a prescribed narcotic analgesic agent.
- D. Perform active range-of-motion exercises.
Correct answer: C
Rationale: Before transporting the client for whirlpool therapy to debride the burned area, the nurse should give a prescribed narcotic analgesic agent. This intervention is essential to manage pain effectively during the debridement process. Obtaining supplies to re-dress the burn area (Choice A) is important but not as immediate as providing pain relief. Verifying the client's signed consent form (Choice B) is necessary for procedures but does not address the client's immediate pain needs. Performing active range-of-motion exercises (Choice D) is not indicated before whirlpool therapy for debridement of burns and may cause further discomfort to the client.
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