HESI RN
HESI Medical Surgical Practice Quiz
1. A client with overflow incontinence needs assistance with elimination. What intervention should the nurse include in the plan of care?
- A. Stroke the medial aspect of the thigh.
- B. Use intermittent catheterization.
- C. Provide digital anal stimulation.
- D. Use the Valsalva maneuver.
Correct answer: D
Rationale: In clients with overflow incontinence, the voiding reflex arc is impaired. The Valsalva maneuver, which involves holding the breath and bearing down as if to defecate, can help initiate voiding by applying mechanical pressure. Options A and C (stroking the thigh or anal stimulation) rely on an intact reflex arc to trigger elimination and are not effective for clients with overflow incontinence. Intermittent catheterization (Option B) is a last resort due to the high risk of infection and should only be considered if other interventions fail.
2. The nurse observes an unlicensed assistive personnel (UAP) using an alcohol-based gel hand cleaner before performing catheter care. The UAP rubs both hands thoroughly for 2 minutes while standing at the bedside. Which action should the nurse take?
- A. Encourage the UAP to remain in the client's room until the procedure is completed.
- B. Explain that the hand rub can be completed in less than 2 minutes.
- C. Inform the UAP that handwashing helps to promote better asepsis.
- D. Determine why the UAP was not wearing gloves in the client's room.
Correct answer: B
Rationale: The correct answer is B. Explaining that hand rubs can be effective with less time allows the UAP to perform the procedure more efficiently while maintaining asepsis. Choice A is incorrect because the UAP does not need to remain in the client's room until the procedure is completed. Choice C is incorrect as the UAP was using an alcohol-based gel hand cleaner, not handwashing. Choice D is incorrect as the scenario does not mention any issue with glove usage, so it is not relevant to the situation at hand.
3. Which of the following hormone ratios is MOST likely to be increased in a patient with PCOS?
- A. Progesterone/estrogen
- B. LH/FSH
- C. FSH/LH
- D. Glucagon/insulin
Correct answer: B
Rationale: In patients with Polycystic Ovary Syndrome (PCOS), the LH/FSH ratio is most likely to be increased. This hormonal imbalance is a key characteristic of PCOS, where elevated LH levels relative to FSH contribute to the pathophysiology of the condition. Choice A, progesterone/estrogen ratio, is not typically a defining feature of PCOS. Choice C, FSH/LH ratio, is the reverse of what is commonly observed in PCOS. Choice D, glucagon/insulin ratio, is not directly related to the hormonal imbalances seen in PCOS.
4. Nurse Ruth is assessing a client after a thyroidectomy. The assessment reveals muscle twitching and tingling, along with numbness in the fingers, toes, and mouth area. The nurse should suspect which complication?
- A. Tetany
- B. Hemorrhage
- C. Thyroid storm
- D. Laryngeal nerve damage
Correct answer: A
Rationale: The correct answer is 'Tetany.' Tetany is characterized by muscle twitching, tingling, and numbness, which are indicative of hypocalcemia. After a thyroidectomy, accidental removal or damage to the parathyroid glands can lead to decreased calcium levels, resulting in tetany. Choice B, 'Hemorrhage,' is incorrect as it typically presents with symptoms such as sudden swelling, increased pain, or drop in blood pressure. Choice C, 'Thyroid storm,' is incorrect as it involves a sudden exacerbation of hyperthyroidism, leading to symptoms like fever, tachycardia, and confusion. Choice D, 'Laryngeal nerve damage,' is incorrect as it would manifest with voice changes, difficulty swallowing, or respiratory distress, not the symptoms described in the scenario.
5. A nurse manager in the emergency department considers policy changes in the organization and changes in the community, and tries to predict how these may impact the functioning of the unit. Which of the following decisional activities best describes this manager's actions?
- A. Resource allocation
- B. Monitoring
- C. Job analysis and redesign
- D. Planning for the future
Correct answer: D
Rationale: The correct answer is 'Planning for the future.' In this scenario, the nurse manager is engaging in strategic planning by considering policy changes and community dynamics to forecast potential impacts on the unit's functioning. This decisional activity involves anticipating future changes, challenges, and opportunities, and preparing the unit to adapt accordingly. Choice A, 'Resource allocation,' involves distributing resources effectively to support daily operations, which is not the primary focus of the nurse manager's actions described. Choice B, 'Monitoring,' typically involves overseeing current activities and performance to ensure adherence to standards and goals, rather than proactively planning for future changes as the nurse manager is doing. Choice C, 'Job analysis and redesign,' pertains to evaluating and modifying job roles and responsibilities within the unit, which is not directly related to the strategic forecasting and planning involved in anticipating organizational and community impacts.