HESI RN
HESI Medical Surgical Practice Exam
1. After three days of persistent epigastric pain, a female client presents to the clinic. She has been taking oral antacids without relief. Her vital signs are heart rate 122 beats/minute, respirations 16 breaths/minute, oxygen saturation 96%, and blood pressure 116/70. The nurse obtains a 12-lead electrocardiogram (ECG). Which assessment finding is most critical?
- A. Irregular pulse rhythm
- B. Bile-colored emesis
- C. ST elevation in three leads
- D. Complaint of radiating jaw pain
Correct answer: C
Rationale: ST elevation in three leads is a critical finding that suggests myocardial infarction, requiring immediate attention. This finding indicates ischemia or injury to the heart muscle. Choices A, B, and D are not as critical in this scenario. Irregular pulse rhythm may be concerning but does not indicate an immediate life-threatening condition like myocardial infarction. Bile-colored emesis and complaint of radiating jaw pain are relevant but not as indicative of a myocardial infarction as ST elevation in three leads.
2. Which of the following symptoms would a healthcare provider expect to find in a patient with hyperkalemia?
- A. Muscle cramps.
- B. Hypertension.
- C. Bradycardia.
- D. Tachycardia.
Correct answer: D
Rationale: Tachycardia is the correct symptom to expect in a patient with hyperkalemia. Hyperkalemia, or high potassium levels in the blood, can affect the electrical activity of the heart. Increased potassium levels can lead to changes in the heart's rhythm, potentially causing tachycardia (rapid heart rate) or other cardiac arrhythmias. Muscle cramps (choice A) are not typically associated with hyperkalemia. Hypertension (choice B) is not a common symptom of hyperkalemia; in fact, high potassium levels can sometimes cause low blood pressure. Bradycardia (choice C), or a slow heart rate, is usually not a primary symptom of hyperkalemia; instead, hyperkalemia tends to be associated with faster heart rates or arrhythmias.
3. A client is receiving a blood transfusion and develops chills and back pain. What is the nurse's first action?
- A. Stop the transfusion and notify the healthcare provider.
- B. Monitor the client's vital signs every 15 minutes.
- C. Administer a PRN dose of diphenhydramine.
- D. Prepare to administer an antihistamine.
Correct answer: A
Rationale: The correct first action for the nurse is to stop the transfusion and notify the healthcare provider. These symptoms suggest a transfusion reaction, and stopping the transfusion is crucial to prevent further complications. Notifying the healthcare provider ensures timely intervention and appropriate management for the client's condition. Monitoring vital signs, administering diphenhydramine, or preparing to administer an antihistamine can be considered after stopping the transfusion and seeking guidance from the healthcare provider. However, the immediate priority is to halt the transfusion and inform the provider.
4. An elderly client with a history of falls is being discharged from the hospital. Which intervention should the home health nurse implement to reduce the client's risk of falling at home?
- A. Install grab bars in the bathroom
- B. Provide a walker for ambulation
- C. Educate the client on fall prevention strategies
- D. Refer the client to a physical therapist
Correct answer: A
Rationale: Installing grab bars in the bathroom is crucial to reducing the elderly client's risk of falling at home. Grab bars provide physical support and stability, especially in areas like the bathroom where slips and falls are common among older adults. While providing a walker for ambulation (Choice B) can assist with mobility, it may not directly address the environmental hazards at home. Educating the client on fall prevention strategies (Choice C) is important but may not be sufficient if the physical environment is not modified to reduce fall risks. Referring the client to a physical therapist (Choice D) may help improve strength and balance but does not directly address the immediate environmental risk of falling at home.
5. A 59-year-old male client is brought to the emergency room where he is assessed to have a Glasgow Coma Scale of 3. Based on this assessment, how should the nurse characterize the client's condition?
- A. The client is experiencing increased intracranial pressure
- B. He has a good prognosis for recovery
- C. This client is conscious, but is not oriented to time and place
- D. He is in a coma, and has a very poor prognosis
Correct answer: D
Rationale: A Glasgow Coma Scale of 3 indicates severe neurological impairment, suggesting a deep coma or even impending death. This client's condition is critical, and he has a very poor prognosis. Choice A is incorrect because a GCS of 3 does not directly indicate increased intracranial pressure. Choice B is incorrect as a GCS of 3 signifies a grave neurological status. Choice C is incorrect as a GCS of 3 represents a state of unconsciousness rather than being conscious but disoriented.