HESI RN
HESI Medical Surgical Exam
1. In the staging process of Hodgkin's disease, what does Stage I indicate?
- A. Involvement of a single lymph node.
- B. Involvement of two or more lymph nodes on the same side of the diaphragm.
- C. Involvement of lymph node regions on both sides of the diaphragm.
- D. Involvement of diffuse disease of one or more extralymphatic organs.
Correct answer: A
Rationale: In the staging process of Hodgkin's disease, Stage I signifies the involvement of a single lymph node. This stage indicates localized disease with the disease being limited to a single lymph node or a group of adjacent nodes. Choices B, C, and D are incorrect because they describe more extensive involvement of lymph nodes, both sides of the diaphragm, or extralymphatic organs, which would correspond to higher stages in the staging system.
2. The healthcare provider is caring for a client with a chest tube. Which observation indicates that the chest tube is functioning effectively?
- A. Continuous bubbling in the water-seal chamber.
- B. Intermittent bubbling in the suction control chamber.
- C. No fluctuation (tidaling) in the water-seal chamber.
- D. Drainage of clear, pale yellow fluid from the chest tube.
Correct answer: B
Rationale: Intermittent bubbling in the suction control chamber is the correct observation indicating effective functioning of the chest tube. This bubbling signifies that the suction system is working correctly and maintaining the desired negative pressure in the pleural space. Continuous bubbling in the water-seal chamber suggests an air leak, which is not a normal finding. No fluctuation (tidaling) in the water-seal chamber may indicate a blockage or lack of communication between the pleural space and the water-seal, which is not ideal. Drainage of clear, pale yellow fluid from the chest tube is a normal finding, but it does not specifically indicate the effectiveness of the chest tube function.
3. When assisting an older client who can stand but not ambulate from the bed to a chair, what is the best action for the nurse to implement?
- A. Use a mechanical lift to transfer the client from the bed to a chair.
- B. Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair.
- C. Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three.
- D. Place a transfer belt around the client, assist the client to stand, and pivot to a chair that is placed at a right angle to the bed.
Correct answer: D
Rationale: The best action for the nurse when assisting an older client who can stand but not ambulate from the bed to a chair is to use a transfer belt. Placing a transfer belt around the client, assisting the client to stand, and pivoting to a chair that is placed at a right angle to the bed allows for a safe and controlled transfer. This method promotes patient independence while ensuring safety during the transfer process. Choices A, B, and C are incorrect because using a mechanical lift may not be necessary for a client who can stand, using a roller board may not provide enough stability, and lifting the client with the help of another staff member may not be the safest option for the client's independence and safety.
4. 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. Climb the stairs early in the day.
- B. Rest for at least an hour before climbing the stairs.
- C. Take a nitroglycerin tablet before climbing the stairs.
- D. Lie down after climbing the stairs.
Correct answer: C
Rationale: The correct answer is to take a nitroglycerin tablet before climbing the stairs. Nitroglycerin helps prevent angina by dilating the coronary arteries, which increases blood flow to the heart. This medication can help reduce the chest pain and discomfort experienced during physical exertion. Climing the stairs early in the day (Choice A) does not address the underlying issue of inadequate blood flow to the heart. Resting for at least an hour before climbing the stairs (Choice B) may not be as effective in preventing angina as taking nitroglycerin. Lying down after climbing the stairs (Choice D) does not offer a preventive measure for angina; it is more focused on post-activity rest rather than prevention.
5. A client with a history of chronic kidney disease (CKD) is admitted with hyperkalemia. Which assessment finding requires immediate intervention?
- A. Peaked T waves on the ECG
- B. Bradycardia
- C. Decreased deep tendon reflexes
- D. Muscle weakness
Correct answer: A
Rationale: Peaked T waves on the ECG are a critical finding in hyperkalemia as they indicate potential life-threatening cardiac arrhythmias. Immediate intervention is necessary to prevent cardiac complications such as ventricular tachycardia or fibrillation. Bradycardia, decreased deep tendon reflexes, and muscle weakness are not typically associated with hyperkalemia and do not pose the same level of immediate risk to the client's life.