HESI RN
Evolve HESI Medical Surgical Practice Exam
1. Upon arrival of a client transferred to the surgical unit, what should the nurse plan to do first?
- A. Assess the patency of the airway
- B. Check tubes and drains for patency
- C. Check the dressing for bleeding
- D. Assess the vital signs to compare them with preoperative measurements
Correct answer: A
Rationale: The initial action for the nurse upon the arrival of a client to the surgical unit is to assess the patency of the airway. This step takes priority to ensure that the client has a clear airway for adequate breathing. Checking tubes and drains for patency, inspecting the dressing for bleeding, and assessing vital signs to compare with preoperative measurements are important subsequent steps in the assessment process. However, ensuring the airway is patent is the immediate priority to maintain the client's respiratory function and overall well-being.
2. A client with a history of type 1 diabetes Mellitus (DM) and asthma is readmitted to the unit for the third time in two months with a current fasting blood sugar (FBS) of 325mg/dl (18mmol/L SI). The client describes to the nurse not understanding why the blood glucose level continues to be out of control. Which interventions should the nurse implement?
- A. Have the client describe a typical day at work, home, and social activities
- B. Determine if the client is using a new insulin needle for each administration
- C. Evaluate the client's asthma medications that can elevate blood glucose
- D. Have the client demonstrate the technique used to monitor blood glucose levels
Correct answer: A
Rationale: The correct answer is to have the client describe a typical day at work, home, and social activities. By understanding the client's daily routine, the nurse can gain valuable insights into lifestyle factors that may be impacting blood glucose control. This information is essential for identifying potential triggers or patterns contributing to the elevated blood sugar levels. Option B, determining if the client is using a new insulin needle for each administration, focuses more on the technical aspect of insulin delivery and is not directly related to daily activities affecting blood glucose levels. Option C, evaluating the client's asthma medications that can elevate blood glucose, could be relevant but is not as directly linked to the client's lifestyle choices as option A. Option D, having the client demonstrate the technique for monitoring blood glucose levels, is important for assessing their skills but does not provide information on daily activities that may be influencing blood sugar levels.
3. A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first?
- A. Ask the client to cough sputum into a container
- B. Have the client take several deep breaths
- C. Provide an appropriate specimen container
- D. Assist with oral hygiene
Correct answer: D
Rationale: Assisting with oral hygiene is the essential initial step before collecting a sputum specimen for acid-fast bacillus (AFB) to prevent contamination of the sample. Ensuring the client's mouth is clean reduces the risk of introducing unwanted bacteria into the specimen. Asking the client to cough sputum into a container, having the client take deep breaths, and providing a specimen container are important steps in the specimen collection process, but they should follow ensuring proper oral hygiene.
4. After teaching a client with nephrotic syndrome and a normal glomerular filtration rate, the nurse assesses the client’s understanding. Which statement made by the client indicates a correct understanding of the nutritional therapy for this condition?
- A. I must decrease my intake of fat.
- B. I will increase my intake of protein.
- C. A decreased intake of carbohydrates will be required.
- D. An increased intake of vitamin C is necessary.
Correct answer: B
Rationale: In nephrotic syndrome, there is significant renal loss of protein leading to hypoalbuminemia and edema formation. If glomerular filtration is normal or near normal, increased protein loss should be matched by an increased intake of protein. Therefore, the correct statement indicating a correct understanding of the nutritional therapy for this condition is increasing protein intake. Decreasing fat, decreasing carbohydrates, or increasing vitamin C intake is not necessary for addressing the underlying issues associated with nephrotic syndrome.
5. A client has an elevated AST 24 hours following chest pain and shortness of breath. This is suggestive of which of the following?
- A. Gallbladder disease
- B. Liver disease
- C. Myocardial infarction
- D. Skeletal muscle injury
Correct answer: C
Rationale: An elevated AST level following chest pain and shortness of breath is suggestive of myocardial infarction. AST is released from damaged heart muscle cells during a heart attack, indicating cardiac involvement. This enzyme is not specific to liver disease, gallbladder disease, or skeletal muscle injury in this clinical context.