HESI RN
HESI Medical Surgical Practice Quiz
1. A nurse reviews the laboratory findings of a client with a urinary tract infection. The laboratory report notes a “shift to the left” in the client’s white blood cell count. Which action should the nurse take?
- A. Request that the laboratory perform a differential analysis on the white blood cells.
- B. Notify the provider and start an intravenous line for parenteral antibiotics.
- C. Collaborate with the unlicensed assistive personnel (UAP) to strain the client’s urine for renal calculi.
- D. Assess the client for a potential allergic reaction and anaphylactic shock.
Correct answer: B
Rationale: A “shift to the left” in a white blood cell count indicates an increase in band cells, which is typically associated with urosepsis. In this scenario, the nurse should notify the provider and initiate IV antibiotics as a left shift is often seen in severe infections like urosepsis. Requesting a differential analysis on white blood cells would not be the immediate action needed in response to a left shift. Collaborating to strain urine for renal calculi is unrelated to the situation of a left shift in white blood cells due to urosepsis. Assessing for allergic reactions and anaphylactic shock is not the priority as a left shift is not indicative of an allergic response; it is associated with an increase in band cells, not eosinophils.
2. A male client with heart failure becomes short of breath, anxious, and has pink frothy sputum. What is the first action the nurse should take?
- A. Consult the charge nurse about administering morphine.
- B. Administer the morphine sulfate as prescribed.
- C. Withhold the morphine until the dyspnea resolves.
- D. Review the need for the morphine prescription with the provider.
Correct answer: B
Rationale: The correct answer is B: Administer the morphine sulfate as prescribed. In this situation, the client is experiencing symptoms of acute pulmonary edema, a complication of heart failure. Morphine is indicated as it helps reduce anxiety and respiratory distress by decreasing preload and afterload. It dilates blood vessels, reducing the workload of the heart and improving oxygenation. The priority is to administer the morphine promptly to alleviate the client's distress and improve oxygenation. Consulting the charge nurse (A) or reviewing the need for the morphine prescription with the provider (D) would cause a delay in providing essential treatment. Withholding the morphine (C) would not be appropriate as it is indicated for this condition.
3. The LPN/LVN is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (Select all that apply.)
- A. Litmus paper.
- B. Fetal scalp electrode.
- C. A sterile glove.
- D. An amniotic hook.
Correct answer: C,D
Rationale: For performing an amniotomy, the nurse should have a sterile glove to maintain asepsis and an amniotic hook to rupture the amniotic sac. Litmus paper is not required for this procedure, and a fetal scalp electrode is used for fetal monitoring, not for an amniotomy.
4. A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is?
- A. Difference in the intake and output
- B. Changes in the mucous membranes
- C. Skin turgor
- D. Weekly weight
Correct answer: D
Rationale: In clients with altered renal function being treated at home, weekly weight is the most accurate indicator of fluid balance. Fluid retention or loss can significantly affect weight, making it a reliable measure. Choices A, B, and C are not as accurate indicators of fluid balance as weekly weight. Intake and output differences can vary in accuracy and may not capture all aspects of fluid balance. Changes in mucous membranes and skin turgor can be influenced by factors other than fluid balance, making them less precise indicators.
5. The nurse is caring for a 2-year-old child who was admitted for dehydration due to gastroenteritis. The child is now receiving IV fluids and appears more alert. What is the best indicator that the child’s condition is improving?
- A. The child is more alert and playful
- B. The child’s urine output has increased
- C. The child’s vital signs are stable
- D. The child is tolerating small amounts of oral fluids
Correct answer: B
Rationale: Increased urine output is a reliable indicator that hydration status is improving. While alertness and playfulness are positive signs, increased urine output directly reflects improved hydration. Stable vital signs are important but may not directly indicate hydration status. Tolerating small amounts of oral fluids is a good sign but may not be as direct an indicator as increased urine output.