HESI RN
RN Medical/Surgical NGN HESI 2023
1. A patient is taking a thiazide diuretic and reports anorexia and fatigue. The nurse suspects which electrolyte imbalance in this patient?
- A. Hypercalcemia
- B. Hypocalcemia
- C. Hyperkalemia
- D. Hypokalemia
Correct answer: D
Rationale: The correct answer is D: Hypokalemia. Thiazide diuretics lead to potassium loss, potentially causing hypokalemia. Anorexia and fatigue are common manifestations of hypokalemia. Hypercalcemia (choice A) and hypocalcemia (choice B) are not directly associated with thiazide diuretics. Hyperkalemia (choice C) is less likely than hypokalemia to be caused by thiazide diuretics.
2. While taking vital signs, a critically ill male client grabs the nurse's hand and asks the nurse not to leave. What action is best for the nurse to take?
- A. Pull up a chair and sit beside the client's bed.
- B. Reassure the client that you will return shortly.
- C. Ask another nurse to stay with the client.
- D. Continue taking vital signs and then leave the room.
Correct answer: A
Rationale: The best action for the nurse to take in this situation is to pull up a chair and sit beside the client's bed. By doing so, the nurse can provide emotional support and comfort to the critically ill patient who is feeling vulnerable. Sitting with the client also shows empathy and a willingness to listen to the client's needs. Reassuring the client that the nurse will return shortly (Choice B) may not address the immediate need for emotional support. Asking another nurse to stay with the client (Choice C) may not establish the same level of connection and comfort as sitting with the client personally. Continuing to take vital signs and then leaving the room (Choice D) disregards the client's emotional needs in that moment.
3. A client with deep vein thrombosis (DVT) is prescribed heparin. What lab value should the nurse monitor to assess the effectiveness of the therapy?
- A. Prothrombin time (PT).
- B. Partial thromboplastin time (PTT).
- C. International Normalized Ratio (INR).
- D. Hemoglobin and hematocrit.
Correct answer: B
Rationale: The correct answer is B: Partial thromboplastin time (PTT). PTT is the lab value used to monitor the effectiveness of heparin therapy in clients with DVT. It measures the intrinsic pathway of coagulation and is prolonged by heparin therapy. Prothrombin time (PT) and International Normalized Ratio (INR) are primarily used to monitor warfarin therapy, not heparin. Checking hemoglobin and hematocrit levels is important but does not directly assess the effectiveness of heparin therapy in DVT.
4. The nurse is assessing a female client's blood pressure because she reported feeling dizzy. The blood pressure cuff is inflated to 140 mm Hg and as soon as the cuff is deflated a Korotkoff sound is heard. Which intervention should the nurse implement next?
- A. Wait 1 minute and palpate the systolic pressure before auscultating again.
- B. Increase the inflation pressure by 20 mm Hg and measure again.
- C. Switch to a larger cuff and repeat the measurement.
- D. Document the finding as normal.
Correct answer: A
Rationale: If a Korotkoff sound is heard immediately upon deflation, it may indicate an inaccurate reading. Waiting and palpating the systolic pressure can help confirm the accuracy of the measurement. Choice A is the correct intervention because it allows the nurse to ensure the accuracy of the blood pressure reading. Choice B is incorrect as increasing the inflation pressure is not necessary in this situation. Choice C is also incorrect as switching to a larger cuff is not warranted based on the information provided. Choice D is incorrect because documenting the finding as normal without further verification could lead to inaccurate information.
5. During a neurologic assessment of a client with a suspected stroke, which finding is most concerning?
- A. Unilateral facial droop
- B. Slurred speech
- C. Weakness in one arm
- D. Sudden loss of consciousness
Correct answer: D
Rationale: Sudden loss of consciousness in a client with a suspected stroke is the most concerning finding as it indicates a more severe neurological event, such as brain stem involvement or hemorrhage, requiring immediate intervention. While unilateral facial droop, slurred speech, and weakness in one arm are all common signs of a stroke, sudden loss of consciousness signifies a critical condition that needs urgent attention and evaluation to prevent further complications.