HESI RN
HESI Medical Surgical Assignment Exam
1. A patient is admitted to the hospital for treatment of pneumonia after complaining of high fever and shortness of breath. The patient was not able to produce sputum for a culture. The nurse will expect the patient’s provider to order
- A. a broad-spectrum antibiotic.
- B. a narrow-spectrum antibiotic.
- C. multiple antibiotics.
- D. the pneumococcal vaccine.
Correct answer: A
Rationale: In this scenario where the offending organism causing pneumonia is unknown due to the inability to produce sputum for culture, the appropriate choice is a broad-spectrum antibiotic. Broad-spectrum antibiotics are effective against a wide range of bacteria and are commonly used when the specific pathogen is unidentified. Narrow-spectrum antibiotics target specific types of bacteria and are chosen based on culture and sensitivity results. Using multiple antibiotics without a clear indication from culture and sensitivity testing can lead to antibiotic resistance and is not recommended in this situation. Additionally, the pneumococcal vaccine is preventive and does not treat an ongoing infection like pneumonia.
2. A nurse is planning discharge teaching for a client with congestive heart failure (CHF). Which dietary instruction should the nurse provide?
- A. Limit sodium intake to reduce fluid retention
- B. Consume high-protein foods to strengthen the heart
- C. Increase potassium intake to manage blood pressure
- D. Increase fluid intake to promote hydration
Correct answer: A
Rationale: The correct answer is A: Limit sodium intake to reduce fluid retention. Limiting sodium intake is crucial for managing congestive heart failure (CHF) as it helps reduce fluid retention. Excess fluid retention can worsen CHF by increasing the workload on the heart. Choice B is incorrect because while protein is essential for overall health, it is not directly related to managing CHF. Choice C is incorrect because potassium, although important, is not the primary focus in managing CHF. Choice D is incorrect because increasing fluid intake can exacerbate fluid retention in CHF patients.
3. The nurse is providing discharge instructions to a client after a total hip replacement. Which statement by the client indicates a need for further teaching?
- A. I will avoid crossing my legs when sitting.
- B. I will use a raised toilet seat to prevent bending too far.
- C. I should keep my legs together to prevent dislocation.
- D. I will use a walker when moving around initially.
Correct answer: C
Rationale: The correct answer is C. Clients who have had a hip replacement should not keep their legs together to prevent dislocation. This position increases the risk of hip dislocation. Choices A, B, and D are correct statements. Avoiding crossing legs, using a raised toilet seat to prevent excessive bending, and using a walker when moving around initially are all appropriate measures to ensure proper recovery and prevent complications after a total hip replacement.
4. A male client with schizophrenia is socially reclusive and pacing in the hallway. What is the most important intervention for the nurse to implement?
- A. Take the client's temperature and blood pressure.
- B. Encourage the client to rest.
- C. Plan an activity that includes physical exercise.
- D. Carefully observe the client throughout the shift.
Correct answer: D
Rationale: The correct answer is to carefully observe the client throughout the shift. In this situation, the client's behavior suggests agitation and restlessness, which could potentially escalate. Observation is crucial to monitor any changes in behavior, assess for signs of distress, and ensure the client's safety. Taking the client's temperature and blood pressure (Choice A) may not address the immediate need for managing the client's behavior. Encouraging the client to rest (Choice B) might not be effective if the client is highly agitated. Planning an activity that includes physical exercise (Choice C) could exacerbate the situation rather than address the current behavior. Therefore, the priority is to observe the client closely to provide appropriate support and intervention as needed.
5. During a sterile procedure at a client's bedside, a healthcare provider contaminates a sterile glove and the sterile field. What is the best action for the nurse to implement?
- A. Report the incident to the supervisor for aseptic technique violation.
- B. Allow the completion of the procedure.
- C. Inquire about the contamination of the glove and sterile field.
- D. Identify the breach in surgical asepsis and provide a new set of sterile supplies.
Correct answer: D
Rationale: In the scenario where a healthcare provider contaminates a sterile glove and the sterile field during a procedure, it is crucial to identify any breach in surgical asepsis. Any potential contamination should be considered compromised, and the nurse must act promptly to maintain sterility by providing a fresh set of sterile supplies for the procedure to continue safely.