during spring break a young adult presents to the urgent care clinic and reports stiff neck a fever for the past 6 hours and a headache which interven
Logo

Nursing Elites

HESI RN

HESI Medical Surgical Practice Exam

1. During spring break, a young adult presents to the urgent care clinic and reports a stiff neck, a fever for the past 6 hours, and a headache. Which intervention is most important for the nurse to implement first?

Correct answer: A

Rationale: The correct answer is to initiate isolation precautions. This is the priority action because the patient presents with symptoms that could be indicative of meningitis, an infectious disease that requires isolation to prevent its spread. Administering an antipyretic (Choice B) may help manage the fever but does not address the need for isolation. Drawing blood cultures (Choice C) and preparing for a lumbar puncture (Choice D) are important steps in diagnosing meningitis but should come after initiating isolation precautions to prevent potential transmission of the infection to others.

2. After delegating to an unlicensed assistive personnel (UAP) the task of completing a bladder scan examination for a client, the nurse evaluates the UAP’s performance. Which action by the UAP indicates the nurse must provide additional instructions when delegating this task?

Correct answer: A

Rationale: The correct answer is A because the UAP should select the female icon for women who have not had a hysterectomy to allow the scanner to subtract the volume of the uterus from readings. If a woman has had a hysterectomy, the UAP should choose the male icon. Choice B is incorrect as it is essential for the UAP to explain the procedure to the client to ensure understanding. Choice C is incorrect because applying ultrasound gel to the scanning head and cleaning it after use are appropriate actions. Choice D is incorrect as it is necessary for the UAP to take at least two readings using the aiming icon to position the scanning head accurately for an effective bladder scan examination.

3. A client with chronic kidney disease (CKD) is experiencing nausea, vomiting, visual changes, and anorexia. Which action by the nurse is best?

Correct answer: A

Rationale: In a client with chronic kidney disease experiencing symptoms like nausea, vomiting, visual changes, and anorexia, it is crucial for the nurse to suspect digoxin (Lanoxin) toxicity. These symptoms are indicative of digoxin toxicity. Therefore, the best action for the nurse to take is to check the client's digoxin level. Administering anti-nausea medication, asking about eating crackers, and referring to a gastrointestinal specialist may help with symptom management but do not address the underlying cause of the symptoms, which is digoxin toxicity in this case.

4. A client admitted with left-sided heart failure has a heart rate of 110 beats per minute and is becoming increasingly dyspneic. Which additional assessment finding by the nurse supports the client's admitting diagnosis?

Correct answer: B

Rationale: The correct answer is B. Crackles in the bases of the lungs are indicative of fluid accumulation, which is common in left-sided heart failure. In left-sided heart failure, the heart is unable to effectively pump blood from the lungs to the rest of the body, leading to a backup of fluid in the lungs. This results in crackles heard on auscultation. Choices A, C, and D are not specific to left-sided heart failure. An enlarged, distended abdomen may indicate ascites or liver congestion. Jugular vein distension is more commonly associated with right-sided heart failure, and peripheral edema is a sign of fluid accumulation in the tissues, which can occur in both types of heart failure but is not as specific to left-sided heart failure as crackles in the lungs.

5. The nurse is providing discharge teaching to a client with coronary artery disease (CAD). Which of the following statements by the client indicates a need for further teaching?

Correct answer: A

Rationale: The statement indicates a misunderstanding because medication for CAD should be taken as prescribed, not only when chest pain occurs.

Similar Questions

A client with an oversecretion of renin has a health history reviewed by a nurse. Which disorder should the nurse correlate with this assessment finding?
Why is lactated Ringer’s solution given to a patient experiencing vomiting and diarrhea?
A client with a family history of polycystic kidney disease (PKD is being assessed by a nurse. For which clinical manifestations should the nurse assess? (Select all that apply.)
Following the diagnosis of angina pectoris, a client reports being unable to walk up two flights of stairs without pain. Which of the following measures would most likely help the client prevent this problem?
A client with acute glomerulonephritis (GN) is being evaluated by a nurse. Which manifestation should the nurse recognize as a positive response to the prescribed treatment?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses