HESI RN
HESI Medical Surgical Exam
1. The healthcare provider is assessing a client with chronic renal failure who is receiving hemodialysis. Which of the following findings would indicate that the client is experiencing a complication of the treatment?
- A. Clear dialysate outflow.
- B. Blood pressure of 150/90 mm Hg.
- C. Increased heart rate.
- D. Fatigue.
Correct answer: B
Rationale: A blood pressure of 150/90 mm Hg during hemodialysis may indicate fluid overload or an ineffective dialysis session, which can lead to complications such as heart failure or pulmonary edema. This finding should be reported promptly for further evaluation and intervention. Clear dialysate outflow is a normal and expected finding during hemodialysis, indicating proper filtration of waste products. Increased heart rate can be a normal compensatory response to hemodialysis due to fluid shifts and should be monitored but does not necessarily indicate a complication. Fatigue is a common symptom in clients with chronic renal failure undergoing hemodialysis and is not specific to complications of the treatment.
2. A client with heart failure who is on a low sodium diet reports a weight gain of 2 kg in 24 hours. Which intervention should the nurse implement first?
- A. Instruct the client to reduce fluid intake
- B. Monitor the client's intake and output
- C. Administer a diuretic as prescribed
- D. Assess the client for signs of fluid overload
Correct answer: D
Rationale: The correct first intervention for a client with heart failure who is on a low sodium diet and reports a significant weight gain is to assess the client for signs of fluid overload. This step is crucial in determining the severity of the situation and guiding further treatment. In this scenario, assessing for signs of fluid overload takes priority over other actions such as instructing the client to reduce fluid intake, monitoring intake and output, or administering a diuretic. While these actions may be necessary depending on the assessment findings, the initial priority is to evaluate the client's immediate condition.
3. 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?
- A. Initiate isolation precautions
- B. Administer an antipyretic
- C. Draw blood cultures
- D. Prepare for lumbar puncture
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.
4. When faced with caring for a close friend in a professional setting, which action should the staff member take first?
- A. Notify the friend that all medical information will be kept confidential.
- B. Explain the relationship to the charge nurse and ask for reassignment.
- C. Approach the client and ask if the assignment is uncomfortable.
- D. Accept the assignment but protect the client's confidentiality.
Correct answer: B
Rationale: When faced with caring for a close friend in a professional setting, the staff member should first explain the relationship to the charge nurse and ask for reassignment. This is important to maintain professional boundaries, prevent conflicts of interest, and ensure that the care provided is unbiased and without compromising the friend's confidentiality. Choice A is incorrect because the priority should be on professional boundaries rather than informing the friend about confidentiality. Choice C is not appropriate as it puts the burden on the client to address any discomfort. Choice D is incorrect as accepting the assignment without addressing the potential conflict of interest could lead to compromised care.
5. The client with a gastric ulcer has a prescription for sucralfate (Carafate), 1 g by mouth four times daily. The nurse schedules the medication for which times?
- A. With meals and at bedtime
- B. Every 6 hours around the clock
- C. One hour after meals and at bedtime
- D. One hour before meals and at bedtime
Correct answer: D
Rationale: Sucralfate is a gastric protectant that forms a protective coating over the ulcer. Administering sucralfate 1 hour before meals and at bedtime is important to create a barrier that protects the ulcer from gastric acid and mechanical irritation. This timing allows sucralfate to effectively coat the ulcer site and provide the desired therapeutic effect, enhancing its efficacy in promoting ulcer healing and symptom relief.