four days following an abdominal aortic aneurysm repair the client is exhibiting edema of both lower extremities and pedal pulses are not palpable whi
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Nursing Elites

HESI RN

HESI Medical Surgical Test Bank

1. Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?

Correct answer: C

Rationale: In this scenario, the priority action for the nurse is to assess pulses with a vascular Doppler. The absence of palpable pedal pulses following an abdominal aortic aneurysm repair raises concerns about compromised blood flow, which could lead to serious complications like ischemia or thrombosis. Evaluating and confirming the presence or absence of pulses is crucial to guide further interventions. Elevating extremities on pillows (Choice A) may be beneficial for managing edema, but it is not the immediate priority when pulses are not palpable. Evaluating edema for pitting (Choice B) can provide additional information about fluid status but does not address the primary concern of absent pulses. Wrapping the feet with warmed blankets (Choice D) is not appropriate in this situation and may not address the underlying vascular issue.

2. The nurse is preparing to administer trimethoprim-sulfamethoxazole (TMP-SMX) to a patient who is being treated for a urinary tract infection. The nurse learns that the patient has type 2 diabetes mellitus and takes a sulfonylurea oral antidiabetic drug. The nurse will monitor this patient closely for which effect?

Correct answer: C

Rationale: When a patient takes oral antidiabetic agents (sulfonylurea) along with sulfonamides like trimethoprim-sulfamethoxazole, it can lead to an increased hypoglycemic effect. Therefore, the nurse should monitor the patient closely for hypoglycemia. Headaches, hypertension, and superinfection are not typically associated with the interaction between sulfonamides and sulfonylureas. Examples of antidiabetic sulfonylurea medications include glipizide, glimepiride, glyburide, tolazamide, and tolbutamide.

3. The nurse is caring for a client who is receiving an IV infusion of normal saline and notices that the infusion is not flowing. The insertion site is not inflamed or swollen. What should the nurse do first?

Correct answer: A

Rationale: The correct first action for the nurse to take when an IV infusion is not flowing despite a normal insertion site is to check the tubing for kinks or obstructions. This step is crucial to ensure that there are no preventable issues impeding the flow of the IV solution. Increasing the flow rate without addressing potential obstructions could lead to complications such as infiltration. Reinserting the IV catheter in another vein should only be considered after ruling out tubing issues. Calling the physician for further instructions is not necessary at this stage as troubleshooting the tubing should be the initial intervention.

4. A client with Herpes Zoster (shingles) on the thorax tells the nurse about having difficulty sleeping. What is the probable cause of this problem?

Correct answer: B

Rationale: The correct answer is B: Pain. Pain is a common and significant symptom of Herpes Zoster (shingles) that can result in difficulty sleeping. The pain associated with shingles can be intense and persistent, making it challenging for the client to find a comfortable position to sleep. Nocturia (choice C), which is excessive urination during the night, is not directly related to difficulty sleeping in this context. While both frequent cough (choice A) and dyspnea (choice D) can cause sleep disturbances, in a client with Herpes Zoster on the thorax, pain is the most probable cause of sleep difficulty.

5. Which of the following medications is commonly prescribed for hypertension?

Correct answer: A

Rationale: The correct answer is Atenolol. Atenolol is a beta-blocker commonly prescribed to manage hypertension due to its ability to reduce the heart rate and lower blood pressure. Options B, C, and D are incorrect because aspirin, ibuprofen, and metformin are not typically used as first-line treatments for hypertension. Aspirin is more commonly used for its antiplatelet effects, ibuprofen is a nonsteroidal anti-inflammatory drug, and metformin is primarily used for managing diabetes.

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