HESI RN
HESI Medical Surgical Test Bank
1. An overweight client taking warfarin (Coumadin) has dry skin due to decreased arterial blood flow. What should the nurse instruct the client to do? Select all that apply.
- A. Apply lanolin or petroleum jelly to intact skin.
- B. Follow a reduced-calorie, reduced-fat diet.
- C. Inspect the involved areas daily for new ulcerations.
- D. Instruct the client to limit activities of daily living (ADLs).
Correct answer: A
Rationale: To address dry skin and prevent chronic ulcers and infections in an overweight client on warfarin with decreased arterial blood flow, the nurse should instruct the client to apply lanolin or petroleum jelly to intact skin. This helps maintain skin integrity and moisture. Following a reduced-calorie, reduced-fat diet (Choice B) may be beneficial for weight management but is not directly related to skin care. Inspecting involved areas daily for new ulcerations (Choice C) is important for skin assessment and early intervention but does not specifically address dry skin. Instructing the client to limit activities of daily living (ADLs) (Choice D) is not necessary for addressing dry skin; in fact, promoting mobility and circulation through appropriate activities is crucial.
2. The nurse is assessing a client with a suspected deep vein thrombosis (DVT). Which finding supports this diagnosis?
- A. Positive Homan's sign.
- B. Unilateral leg swelling.
- C. Bilateral calf pain.
- D. Redness and warmth in the affected leg.
Correct answer: D
Rationale: The correct answer is D: Redness and warmth in the affected leg. These are classic signs of deep vein thrombosis (DVT) and support the diagnosis. Choice A, Positive Homan's sign, is an outdated and unreliable test for DVT, so it is not the best choice. Choice B, Unilateral leg swelling, can be seen in DVT but is less specific compared to redness and warmth. Choice C, Bilateral calf pain, is not a typical finding in DVT, as the pain in DVT is usually unilateral.
3. A new nurse is working hard to follow the established procedures on the unit and is focusing on being as efficient as possible. Which of the following best describes this nurse’s behavior?
- A. The nurse is demonstrating the concept of efficiency, which involves following established procedures to complete tasks in the most effective way possible.
- B. The nurse is demonstrating the concept of task orientation, which focuses on completing tasks efficiently without necessarily considering the impact on patient care.
- C. The nurse is demonstrating the concept of patient-centered care, which focuses on providing care that is respectful of and responsive to individual patient preferences and needs.
- D. The nurse is demonstrating the concept of transformational leadership, which involves inspiring and motivating others to achieve a higher level of performance.
Correct answer: A
Rationale: The correct answer is A: The nurse is demonstrating the concept of efficiency by following established procedures to complete tasks effectively. Efficiency in healthcare involves optimizing processes and resources to achieve the best outcomes. Choice B is incorrect as task orientation refers to focusing on task completion without considering broader aspects like patient care. Choice C is incorrect as patient-centered care emphasizes individual patient needs and preferences rather than operational efficiency. Choice D is incorrect as transformational leadership involves inspiring and motivating others, not specifically related to task efficiency.
4. The client with type 2 diabetes mellitus is being educated about lifestyle modifications. Which of the following recommendations is appropriate?
- A. Avoiding all forms of physical exercise
- B. Limiting carbohydrate intake to less than 30 grams per day
- C. Increasing physical activity to help control blood glucose levels
- D. Consuming a high-protein, low-fat diet
Correct answer: C
Rationale: The correct answer is to increase physical activity to help control blood glucose levels. Physical activity is essential in managing type 2 diabetes mellitus as it helps improve insulin sensitivity, control weight, and regulate blood sugar levels. Avoiding all forms of physical exercise (Choice A) is incorrect as exercise plays a crucial role in diabetes management. While limiting carbohydrate intake (Choice B) can be beneficial, setting a strict limit of less than 30 grams per day is too restrictive and may not be suitable for everyone. Consuming a high-protein, low-fat diet (Choice D) is generally a healthy choice, but it is not the primary lifestyle modification recommended for managing type 2 diabetes mellitus.
5. A client’s baseline vital signs are temperature 98°F oral, pulse 74 beats/min, respiratory rate 18 breaths/min, and blood pressure 124/76 mm Hg. The client suddenly spikes a fever to 103°F. Which of the following respiratory rates would the nurse anticipate as part of the body’s response to the change in client status?
- A. 12 breaths/min
- B. 16 breaths/min
- C. 18 breaths/min
- D. 22 breaths/min
Correct answer: D
Rationale: When a client experiences a fever, there is an increase in body temperature, leading to a higher metabolic rate and oxygen demand. As a result, the respiratory rate typically increases to meet the body's increased oxygen needs. Therefore, in response to the fever spike from 98°F to 103°F, the nurse would anticipate a higher respiratory rate. Choices A, B, and C are incorrect because a decrease in body temperature, not an increase as seen in fever, would lead to a decrease in respiratory rate to conserve energy and oxygen consumption.