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. A child with leukemia is admitted for chemotherapy, and the nursing diagnosis 'altered nutrition, less than body requirements related to anorexia, nausea, and vomiting' is identified. Which intervention should the nurse include in this child's plan of care?
- A. Encourage a variety of large portions of food at every meal.
- B. Allow the child to eat any food desired and tolerated.
- C. Recommend eating the food as siblings eat at home.
- D. Restrict food brought from fast food restaurants.
Correct answer: B
Rationale: Allowing the child to eat any food desired and tolerated is the most appropriate intervention for a child with altered nutrition due to anorexia, nausea, and vomiting. It is crucial to prioritize maintaining adequate nutritional intake, and by allowing the child to choose foods they desire and can tolerate, the chances of improving their nutritional status increase. This approach helps in ensuring that the child receives necessary nutrients during chemotherapy, even if their appetite is affected by the treatment. Encouraging a variety of large portions of food at every meal (Choice A) may overwhelm the child and worsen their symptoms. Recommending eating the food as siblings eat at home (Choice C) may not align with the child's preferences and tolerances. Restricting food brought from fast food restaurants (Choice D) is not suitable as it may limit the child's options and preferences during a challenging time.
3. A woman brings her 48-year-old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She states that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. The nurse knows that these behaviors are often associated with:
- A. Post-traumatic stress disorder.
- B. Panic disorder.
- C. Dissociative identity disorder.
- D. Obsessive-compulsive disorder.
Correct answer: C
Rationale: The correct answer is C: Dissociative identity disorder. Dissociative identity disorder (DID) is characterized by the presence of two or more distinct personality states or identities, along with memory gaps beyond ordinary forgetfulness. The description of the husband sleepwalking, not recognizing his identity, and exhibiting multiple personalities aligns with the symptoms of DID. Post-traumatic stress disorder (PTSD) (Choice A) involves re-experiencing traumatic events, panic disorder (Choice B) is characterized by recurrent panic attacks, and obsessive-compulsive disorder (OCD) (Choice D) involves obsessions and compulsions. These conditions do not typically present with the specific symptoms described in the scenario.
4. A client with hyperlipidemia is prescribed atorvastatin (Lipitor). Which instruction should the nurse include in the teaching plan?
- A. Take the medication in the morning.
- B. Avoid consuming grapefruit juice.
- C. Increase your intake of dairy products.
- D. Take the medication with food.
Correct answer: B
Rationale: The correct instruction for the nurse to include in the teaching plan is to advise the client to avoid consuming grapefruit juice. Grapefruit juice can increase the risk of atorvastatin (Lipitor) toxicity by inhibiting its metabolism. Atorvastatin is typically taken in the evening as cholesterol synthesis occurs at night. Increasing dairy intake is not specifically recommended for atorvastatin therapy, and the medication can be taken with or without food.
5. A client with hyperthyroidism is prescribed methimazole. The nurse should instruct the client that the purpose of this medication is to:
- A. Decrease thyroid hormone production
- B. Increase thyroid hormone production
- C. Suppress the immune system
- D. Prevent thyroid storm
Correct answer: A
Rationale: The correct answer is A: Decrease thyroid hormone production. Methimazole works by inhibiting the synthesis of thyroid hormones, specifically by blocking the enzyme responsible for this process. By reducing the production of thyroid hormones, methimazole helps to normalize the elevated levels seen in hyperthyroidism. Choices B, C, and D are incorrect. Choice B, 'Increase thyroid hormone production,' is inaccurate as methimazole actually decreases thyroid hormone production. Choice C, 'Suppress the immune system,' is unrelated to the mechanism of action of methimazole. Choice D, 'Prevent thyroid storm,' is not the primary purpose of methimazole; while it may help prevent worsening of hyperthyroidism, its main action is to reduce thyroid hormone levels.