HESI RN
HESI Medical Surgical Practice Quiz
1. The charge nurse of the medical-surgical unit is making staff assignments. Which staff member should be assigned to a client with chronic kidney disease who is exhibiting a low-grade fever and a pericardial friction rub?
- A. Registered nurse who just floated from the surgical unit
- B. Registered nurse who just floated from the dialysis unit
- C. Registered nurse who was assigned the same client yesterday
- D. Licensed practical nurse with 5 years of experience on this floor
Correct answer: C
Rationale: The client is exhibiting symptoms of pericarditis, which can occur with chronic kidney disease. Continuity of care is crucial to assess subtle changes in clients' conditions. Therefore, the registered nurse (RN) who previously cared for this client should be assigned again. Float nurses may lack knowledge of the unit and its clients, potentially leading to oversight of critical details. The licensed practical nurse, while experienced, may not possess the advanced assessment skills and education level of an RN to effectively evaluate and manage pericarditis in this client.
2. A client with chronic kidney disease is receiving peritoneal dialysis. Which assessment finding should the nurse report to the healthcare provider immediately?
- A. The client's weight increases by 1 kg in 24 hours.
- B. The client's peritoneal effluent is cloudy.
- C. The client's blood pressure is 140/90 mm Hg.
- D. The client's peritoneal effluent is clear and pale yellow.
Correct answer: B
Rationale: Cloudy peritoneal effluent (B) is a sign of infection and should be reported to the healthcare provider immediately. It indicates the presence of peritonitis, a severe complication that requires prompt intervention. Weight gain (A) may indicate fluid overload but is not as urgent as a potential infection. Elevated blood pressure (C) is a common finding in clients with kidney disease and needs monitoring but does not require immediate reporting. Clear and pale yellow effluent (D) is a normal finding and does not raise immediate concerns.
3. At 16 weeks of pregnancy, the breast changes include:
- A. Montgomery's tubercles are prominent.
- B. Darkening of the nipple.
- C. Prickling, tingling sensation.
- D. Colostrum can be expressed.
Correct answer: C
Rationale: At 16 weeks of pregnancy, the sensation of prickling and tingling in the breasts is common due to hormonal changes. Montgomery's tubercles becoming prominent is more characteristic of early pregnancy, typically around the first trimester. Darkening of the nipple, known as areola darkening, can occur but is more commonly observed later in pregnancy. The expression of colostrum, the first milk produced by the mammary glands, usually happens closer to the end of pregnancy or after childbirth, not typically at 16 weeks.
4. A client with an electrical burn on the forearm asks the nurse why there is no feeling of pain from the burn. During the dressing change, the nurse determines that the burn is dry, waxy, and white. What information should the nurse provide this client?
- A. The depth of tissue destruction is minor
- B. Pain is interrupted due to nerve compression
- C. The full thickness burn has destroyed the nerves
- D. Second-degree burns are not usually painful
Correct answer: C
Rationale: The correct answer is C: 'The full thickness burn has destroyed the nerves.' In full thickness burns, also known as third-degree burns, the nerve endings are destroyed, leading to a lack of pain sensation at the site of the burn. The description of the burn as dry, waxy, and white indicates a full thickness burn. Choices A, B, and D are incorrect because they do not explain the absence of pain in full thickness burns. Choice A is incorrect as a full-thickness burn involves significant tissue destruction. Choice B is incorrect because nerve compression would not explain the lack of pain in this context. Choice D is incorrect because second-degree burns, unlike full-thickness burns, are painful due to nerve endings being intact.
5. The healthcare provider is developing the plan of care for a hospitalized child with von Willebrand disease. What priority nursing intervention should be included in this child's plan of care?
- A. Reduce exposure to infection.
- B. Eliminate contact with cold objects.
- C. Guard against bleeding injuries.
- D. Reduce contact with other children.
Correct answer: C
Rationale: Children with von Willebrand disease have a deficiency in a clotting protein, putting them at risk of bleeding episodes. The priority nursing intervention for a child with von Willebrand disease is to guard against bleeding injuries to prevent excessive bleeding or hemorrhage. Choices A, B, and D are not the priority interventions for von Willebrand disease. While reducing exposure to infection is important for any hospitalized child, it is not the priority for von Willebrand disease. Eliminating contact with cold objects is more relevant for conditions like Raynaud's disease. Reducing contact with other children is not a specific priority related to managing von Willebrand disease.