HESI RN
HESI Medical Surgical Practice Exam Quizlet
1. After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 ml for the last 2 hours. What priority nursing action should be implemented?
- A. Report the findings to the surgeon.
- B. Irrigate the indwelling urinary catheter.
- C. Apply manual pressure to the bladder.
- D. Increase the IV flow rate for 15 minutes.
Correct answer: A
Rationale: In this situation, the nurse's priority action should be to report the findings to the surgeon. An adult should typically produce about 60 ml of urine per hour, so a dark, concentrated, and low urine output of 54 ml over 2 hours raises concerns. This change in urine output may indicate issues such as dehydration, renal problems, or inadequate fluid intake. Reporting this finding to the surgeon is crucial to ensure appropriate evaluation and intervention. Irrigating the catheter, applying manual pressure to the bladder, or increasing the IV flow rate are not appropriate actions based on the information provided and could potentially worsen the situation.
2. What is the most important assessment for the healthcare provider to conduct before the administration of epidural anesthesia to a client at 40 weeks' gestation?
- A. Maternal blood pressure.
- B. Level of pain sensation.
- C. Station of presenting part.
- D. Variability of fetal heart rate.
Correct answer: A
Rationale: Assessing maternal blood pressure is crucial before administering epidural anesthesia because it can cause hypotension, affecting both the mother and the fetus. Hypotension can lead to decreased placental perfusion, potentially compromising the fetal oxygen supply. Monitoring and maintaining maternal blood pressure within a safe range are essential to ensure the well-being of both the mother and the fetus during the administration of epidural anesthesia. The other options, such as assessing the level of pain sensation, station of presenting part, and variability of fetal heart rate, are important in obstetric care but are not as critical as monitoring maternal blood pressure to prevent complications related to epidural anesthesia administration.
3. During the assessment, a client receiving a continuous infusion of heparin for deep vein thrombosis (DVT) is found to have a nosebleed. Which finding requires immediate action?
- A. The client's activated partial thromboplastin time (aPTT) is 70 seconds.
- B. The client has developed a nosebleed.
- C. The client's blood pressure is 150/90 mm Hg.
- D. The client reports feeling lightheaded.
Correct answer: B
Rationale: A nosebleed (B) in a client receiving heparin is a sign of heparin toxicity and requires immediate action. It indicates that the client is at risk of excessive bleeding. While a prolonged aPTT of 70 seconds (A) is worth monitoring, active bleeding takes precedence. Elevated blood pressure (C) and lightheadedness (D) are potential side effects of heparin but are not as urgently concerning as active bleeding.
4. The client is reviewing the signed operative consent with a nurse, who is admitted for the removal of a lipoma on the left leg. The client states that the consent form should say the removal of a lipoma on the right leg. Which intervention should the nurse implement?
- A. Notify the surgical team of the client’s confusion
- B. Have the client sign a new surgical consent
- C. Add the correct leg information to the consent form
- D. Inform the surgeon about the client’s concern
Correct answer: D
Rationale: In this scenario, the nurse should inform the surgeon about the client’s concern immediately. This is important to ensure that the correct procedure is performed on the intended leg. Communication with the surgeon is crucial to address any discrepancies in the consent form and prevent errors during the surgical procedure. Having the surgeon clarify and correct the consent form is essential to maintain patient safety and uphold the principles of informed consent.
5. A client with a history of chronic alcoholism is admitted with confusion, ataxia, and diplopia. Which nursing intervention is a priority for this client?
- A. Monitor for signs of alcohol withdrawal.
- B. Administer thiamine as prescribed.
- C. Provide a quiet environment to reduce confusion.
- D. Initiate fall precautions.
Correct answer: B
Rationale: The correct answer is to administer thiamine as prescribed. This intervention is a priority for clients with chronic alcoholism to prevent Wernicke's encephalopathy, a serious complication of thiamine deficiency. Monitoring for signs of alcohol withdrawal (choice A) is important but not the priority in this scenario. Providing a quiet environment (choice C) may be beneficial but does not address the immediate need to prevent Wernicke's encephalopathy. Initiating fall precautions (choice D) is also important but not the priority compared to administering thiamine to prevent a life-threatening condition.