HESI RN
HESI Medical Surgical Practice Exam
1. The nurse is assessing an older adult with a pacemaker who leads a sedentary lifestyle. The client reports being unable to perform activities that require physical exertion. The nurse should further assess the client for which of the following?
- A. Left ventricular atrophy.
- B. Irregular heartbeats.
- C. Peripheral vascular occlusion.
- D. Pacemaker function.
Correct answer: A
Rationale: The correct answer is A: Left ventricular atrophy. Older adults who lead sedentary lifestyles are at risk of developing left ventricular atrophy, which can lead to decreased cardiac output during physical exertion. This condition can contribute to the client's inability to perform activities requiring physical exertion. Choice B, irregular heartbeats, may be a consideration due to the presence of a pacemaker, but the client's reported inability to perform physically exerting activities is more indicative of a structural issue like left ventricular atrophy rather than a rhythm-related problem. Peripheral vascular occlusion (Choice C) is less likely to be the cause of the client's symptoms compared to the cardiac-related issue of left ventricular atrophy. While assessing pacemaker function (Choice D) is important, the client's symptoms are more suggestive of a cardiac structural issue rather than a malfunction of the pacemaker.
2. The healthcare provider is assessing an infant with pyloric stenosis. Which pathophysiological mechanism is the most likely consequence of this infant's clinical picture?
- A. Metabolic alkalosis.
- B. Respiratory acidosis.
- C. Metabolic acidosis.
- D. Respiratory alkalosis.
Correct answer: A
Rationale: Pyloric stenosis leads to obstruction at the outlet of the stomach, causing frequent vomiting and loss of stomach acids. This results in a loss of hydrochloric acid and hydrogen ions, leading to metabolic alkalosis due to an increase in serum bicarbonate levels. Therefore, the correct answer is metabolic alkalosis. Choice B, respiratory acidosis, is incorrect as it is not typically associated with pyloric stenosis. Choice C, metabolic acidosis, is incorrect because the loss of stomach acids in pyloric stenosis leads to metabolic alkalosis, not acidosis. Choice D, respiratory alkalosis, is also incorrect as it is not the usual consequence of pyloric stenosis.
3. The letter 'T' in the Acronym 'GATHER' denotes:
- A. Ask the client about themselves - particular needs, obstetric and medical history
- B. Tell the client about modern FP methods available, and discuss each in detail
- C. Help the client choose a method and repeat information regarding the chosen method if necessary
- D. Explain how to use the method - what, where, when, and how
Correct answer: B
Rationale: The correct answer is B: 'Tell the client about modern FP methods available, and discuss each in detail.' In the GATHER acronym, 'T' stands for providing information about modern family planning methods to the client and having a detailed discussion. Choices A, C, and D are incorrect because they do not accurately represent the 'T' component in the GATHER approach. Choice A focuses more on gathering information from the client, choice C is about helping the client choose a method, and choice D is about explaining how to use the method, none of which align with the 'T' in GATHER.
4. The nurse is caring for a client with pancreatitis who is receiving total parenteral nutrition (TPN). Which assessment finding requires immediate intervention by the nurse?
- A. Blood glucose level of 200 mg/dL
- B. The client reports feeling weak and shaky
- C. The TPN bag is 5% dextrose
- D. The client reports feeling thirsty
Correct answer: B
Rationale: The correct answer is B. Weakness and shakiness can indicate hypoglycemia, a potential complication of TPN. Immediate intervention is necessary to assess blood glucose levels and provide treatment as needed. Choice A is incorrect because a blood glucose level of 200 mg/dL is within an acceptable range and does not require immediate intervention. Choice C is incorrect as a 5% dextrose TPN bag is a standard concentration. Choice D is also incorrect as feeling thirsty is not a critical assessment finding requiring immediate intervention in this context.
5. A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respirations. The nurse determines that the increased respiratory rate is a compensatory mechanism for which acid-base alteration?
- A. Metabolic alkalosis.
- B. Respiratory acidosis.
- C. Respiratory alkalosis.
- D. Metabolic acidosis.
Correct answer: D
Rationale: Kussmaul respirations are deep, rapid breathing patterns observed in metabolic acidosis, such as diabetic ketoacidosis. In this condition, the body tries to compensate for the acidic environment by increasing the respiratory rate to eliminate excess carbon dioxide (CO2) and decrease the acid levels, thereby helping to correct the acid-base imbalance. Therefore, the correct answer is metabolic acidosis.