HESI RN
HESI Medical Surgical Practice Exam Quizlet
1. In assessing cancer risk, which woman is at greatest risk of developing breast cancer?
- A. A 35-year-old multipara who never breastfed.
- B. A 50-year-old whose mother had unilateral breast cancer.
- C. A 55-year-old whose mother-in-law had bilateral breast cancer.
- D. A 20-year-old whose menarche occurred at age 9.
Correct answer: B
Rationale: The correct answer is B because family history of breast cancer, specifically in the mother, is a significant risk factor for developing breast cancer. The age of 50 is also a risk factor for breast cancer. Choice A is less likely as breastfeeding can actually reduce the risk of breast cancer. Choice C is less relevant since the risk is higher with a direct family member. Choice D, although early menarche is a risk factor, the age of the individual is much lower compared to the other age-related risk factors.
2. A nurse performing nasopharyngeal suctioning suddenly notes the presence of bloody secretions. What should the nurse do first?
- A. Continue suctioning to remove the blood
- B. Check the degree of suction being applied
- C. Encourage the client to cough out the bloody secretions
- D. Remove the suction catheter from the client’s nose and begin vigorous suctioning through the mouth
Correct answer: B
Rationale: The correct answer is to check the degree of suction being applied (Choice B). When bloody secretions are encountered during nasopharyngeal suctioning, it is crucial to assess the situation promptly. Checking the degree of suction being applied is the first step as excessive suction pressure may be causing trauma and bleeding. Adjusting the suction pressure may be necessary to prevent further harm. Continuing suctioning to remove the blood (Choice A) or performing vigorous suctioning through the mouth (Choice D) can lead to increased trauma and worsen bleeding. Encouraging the client to cough out the bloody secretions (Choice C) is not appropriate since the client undergoing suctioning is typically unable to expectorate secretions. Therefore, the priority is to check and adjust the suction settings to ensure safe and effective suctioning.
3. The nurse observes an unlicensed assistive personnel (UAP) using an alcohol-based gel hand cleaner before performing catheter care. The UAP rubs both hands thoroughly for 2 minutes while standing at the bedside. Which action should the nurse take?
- A. Encourage the UAP to remain in the client's room until the procedure is completed.
- B. Explain that the hand rub can be completed in less than 2 minutes.
- C. Inform the UAP that handwashing helps to promote better asepsis.
- D. Determine why the UAP was not wearing gloves in the client's room.
Correct answer: B
Rationale: The correct answer is B. Explaining that hand rubs can be effective with less time allows the UAP to perform the procedure more efficiently while maintaining asepsis. Choice A is incorrect because the UAP does not need to remain in the client's room until the procedure is completed. Choice C is incorrect as the UAP was using an alcohol-based gel hand cleaner, not handwashing. Choice D is incorrect as the scenario does not mention any issue with glove usage, so it is not relevant to the situation at hand.
4. When assessing an individual with peripheral vascular disease, which clinical manifestation would indicate complete arterial obstruction in the lower left leg?
- A. Aching pain in the left calf.
- B. Burning pain in the left calf.
- C. Numbness and tingling in the left leg.
- D. Coldness of the left foot and ankle.
Correct answer: D
Rationale: Coldness of the left foot and ankle is the correct clinical manifestation indicating complete arterial obstruction in the lower left leg. Complete arterial obstruction results in reduced blood flow, leading to decreased temperature in the affected area. Aching pain (Choice A) and burning pain (Choice B) are more commonly associated with partial obstructions or ischemia, while numbness and tingling (Choice C) can be indicative of nerve involvement or compromised circulation, but not specifically complete arterial obstruction. The coldness in the foot and ankle is a result of severely reduced blood flow, which impairs the delivery of oxygen and nutrients to the tissues in that area, leading to a lower temperature. This symptom is a critical indicator of a more severe blockage compared to the other options provided.
5. What is the most important assessment for the healthcare provider to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?
- A. Maternal blood pressure.
- B. Level of pain sensation
- C. Station of presenting part.
- D. Variability of fetal heart rate.
Correct answer: A
Rationale: Following the administration of epidural anesthesia, the most crucial assessment for the healthcare provider to conduct is monitoring maternal blood pressure. Epidural anesthesia can lead to hypotension as a common side effect, which can have significant implications for both the mother and the fetus. Therefore, close monitoring of maternal blood pressure is essential to detect and manage any hypotensive episodes promptly. Choices B, C, and D are important assessments during labor and delivery, but in this specific scenario of post-epidural anesthesia, monitoring maternal blood pressure takes precedence due to the potential risk of hypotension.