an unlicensed assistive personnel uap reports to the nurse that a client with a postoperative wound infection has a temperature of 103 f 394 c blood p

HESI RN

HESI Medical Surgical Test Bank

1. An unlicensed assistive personnel (UAP) reports to the nurse that a client with a postoperative wound infection has a temperature of 103°F (39.4°C), blood pressure of 90/70, pulse of 124 beats/minute, and respirations of 28 breaths/minute. When assessing the client, findings include mottled skin appearance and confusion. Which action should the nurse take first?

A. Transfer the client to the ICU.
B. Initiate an infusion of intravenous (IV) fluids.
C. Assess the client's core temperature.
D. Obtain a wound specimen for culture.

Correct answer: B

Rationale: Initiating an infusion of IV fluids is the priority action to stabilize blood pressure in a client with signs of sepsis. Intravenous fluids help maintain perfusion to vital organs and prevent further deterioration. Option A is not the immediate priority as stabilizing the client's condition can be initiated in the current setting. Option C, assessing the client's core temperature, is important but not the most critical action at this time. Option D, obtaining a wound specimen for culture, is important for identifying the causative organism but is not the first priority in managing a client with signs of sepsis.

2. A patient is diagnosed with Mycoplasma pneumonia. Which antibiotic will the nurse expect the provider to order to treat this infection?

A. Azithromycin (Zithromax)
B. Clarithromycin (Biaxin)
C. Erythromycin (E-Mycin)
D. Fidaxomicin (Dificid)

Correct answer: C

Rationale: Erythromycin is the drug of choice for treating Mycoplasma pneumonia. Mycoplasma pneumonia is typically sensitive to macrolide antibiotics, with erythromycin being one of the first-line agents. Azithromycin and clarithromycin are also effective in treating Mycoplasma pneumonia, but erythromycin is specifically mentioned as the drug of choice in this context. Fidaxomicin, on the other hand, is not indicated for the treatment of Mycoplasma pneumonia and is primarily used to treat Clostridium difficile infections.

3. What is the most common symptom of gastroesophageal reflux disease (GERD)?

A. Heartburn.
B. Nausea.
C. Abdominal pain.
D. Vomiting.

Correct answer: A

Rationale: The correct answer is A: Heartburn. Heartburn is the most common symptom of GERD as it occurs due to the reflux of stomach acid into the esophagus. This leads to a burning sensation in the chest that can worsen after eating, lying down, or bending over. Choice B, Nausea, is not typically the most common symptom of GERD, although it can occur in some cases. Choice C, Abdominal pain, is not a primary symptom of GERD and is more commonly associated with other gastrointestinal conditions. Choice D, Vomiting, is also not the most common symptom of GERD, although it can occur in severe cases or as a result of complications.

4. A client is undergoing hemodialysis. The client’s blood pressure at the beginning of the procedure was 136/88 mm Hg, and now it is 110/54 mm Hg. What actions should the nurse perform to maintain blood pressure? (Select all that apply.)

A. Adjust the rate of extracorporeal blood flow.
B. Place the client in the Trendelenburg position.
C. Administer a 250-mL bolus of normal saline.
D. All of the above

Correct answer: D

Rationale: During hemodialysis, a drop in blood pressure can occur due to fluid removal. To maintain blood pressure, the nurse should consider adjusting the rate of extracorporeal blood flow to optimize fluid removal without causing hypotension. Placing the client in the Trendelenburg position can help improve venous return and cardiac output. Administering a bolus of normal saline can help increase intravascular volume and support blood pressure. Therefore, all the actions listed in choices A, B, and C are appropriate measures to maintain blood pressure during hemodialysis. Choice D, 'All of the above,' is the correct answer as it encompasses all the relevant actions to address the dropping blood pressure effectively. Choices A, B, and C, when implemented together, can help manage hypotension during hemodialysis.

5. A client with chronic renal failure is receiving epoetin alfa (Epogen) to treat anemia. The nurse should assess the client for which of the following side effects?

A. Hypertension.
B. Hypotension.
C. Infection.
D. Edema.

Correct answer: A

Rationale: The correct answer is A: Hypertension. Epoetin alfa (Epogen) is a medication used to treat anemia in clients with chronic renal failure. One common side effect of this medication is hypertension. Epoetin alfa stimulates red blood cell production, which can lead to an increase in blood pressure. Therefore, the nurse should closely monitor the client for signs and symptoms of hypertension while on this medication. Choices B, C, and D are incorrect. Hypotension is not typically associated with epoetin alfa administration. Infection is not a direct side effect of epoetin alfa. Edema is also not a common side effect of this medication.