HESI RN
HESI Medical Surgical Practice Exam Quizlet
1. During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. What action should the nurse take first?
- A. Use a laryngoscope to check for a foreign body lodged in the airway.
- B. Reposition the head to ensure that the airway is properly opened.
- C. Turn the client to the side and administer three back blows.
- D. Perform a finger sweep of the mouth to clear any obstructions.
Correct answer: B
Rationale: The most common reason for inadequate lung aeration during CPR is the incorrect positioning of the head, leading to airway obstruction. Therefore, the initial action should be to reposition the head to open the airway properly and attempt to ventilate again. Using a laryngoscope to check for foreign bodies in the airway (Choice A) is not the first step and could delay crucial interventions. Turning the client to the side and administering back blows (Choice C) is not indicated in this scenario as the focus is on ventilating the lungs. Performing a finger sweep of the mouth (Choice D) is not recommended as it may push obstructions further into the airway during CPR.
2. While palpating the gallbladder of a mildly obese client, what finding does the nurse expect if the gallbladder is inflamed?
- A. Severe tenderness and guarding
- B. Slight discomfort upon palpation
- C. A sensation of fullness
- D. No symptoms unless the gallbladder is extremely inflamed
Correct answer: A
Rationale: Correct. If the gallbladder is inflamed, the nurse would expect to find severe tenderness and guarding, which are typical signs of acute cholecystitis. This indicates an inflammatory process in the gallbladder. Choices B, C, and D are incorrect because slight discomfort, a sensation of fullness, or no symptoms unless extremely inflamed are not typical findings associated with gallbladder inflammation.
3. A male client reports that he took tadalafil 10 mg two hours ago and now feels flushed. What action should the nurse take?
- A. Instruct the client to increase oral fluid intake.
- B. Reassure the client that flushing is a common side effect.
- C. Advise the client to take nitroglycerin as a precaution.
- D. Ask the client to come to the emergency room.
Correct answer: B
Rationale: The correct answer is B: Reassure the client that flushing is a common side effect. Tadalafil, a medication used for erectile dysfunction, can cause flushing as a common side effect. In this situation, the nurse should provide reassurance to the client that the flushing is expected and not necessarily a cause for concern. Increasing oral fluid intake (choice A) may be beneficial for other conditions but is not directly related to tadalafil-induced flushing. Advising the client to take nitroglycerin (choice C) is incorrect, as nitroglycerin is not indicated for flushing. Asking the client to come to the emergency room (choice D) is unnecessary at this point since flushing is a known side effect and does not typically require urgent medical attention.
4. Discuss the anatomical/physiological changes in pregnancy under the following: Haematological system
- A. Blood volume and plasma volume increase, red blood cells increase, erythropoietin levels decrease, and leukocyte count increases.
- B. Blood volume and plasma volume decrease, and red blood cells decrease.
- C. No changes occur in the haematological system during pregnancy.
- D. Platelet count remains constant, and no change in coagulation factors.
Correct answer: A
Rationale: During pregnancy, the haematological system undergoes changes to support the growing fetus. Blood volume and plasma volume increase to accommodate the needs of the developing baby. Red blood cells increase to support the increased oxygen demand. Contrary to the statement, erythropoietin levels actually increase to stimulate red blood cell production. Additionally, leukocyte count increases to help the mother's immune system cope with the changes during pregnancy. Choice B is incorrect as it describes a decrease in blood components, which is not the case in pregnancy. Choice C is incorrect as there are significant changes in the haematological system during pregnancy. Choice D is incorrect as platelet count can fluctuate during pregnancy, and there are changes in coagulation factors to prevent excessive bleeding.
5. Which hormone regulates the production of milk after childbirth?
- A. Prolactin
- B. Oxytocin
- C. Estrogen
- D. Progesterone
Correct answer: A
Rationale: The correct answer is Prolactin. Prolactin is the hormone responsible for regulating the production of milk after childbirth. It stimulates the mammary glands in the breasts to produce milk. Oxytocin, on the other hand, is responsible for the ejection of milk from the breasts. Estrogen and progesterone play roles in the menstrual cycle and pregnancy but are not directly involved in milk production. Therefore, choices B, C, and D are incorrect.