HESI RN
HESI Medical Surgical Practice Exam
1. The nurse is caring for a client who is postoperative for a femoral head fracture repair. Which intervention(s) should the nurse plan to administer for deep vein thrombosis prophylaxis?
- A. Pneumatic compression devices
- B. Incentive spirometry
- C. Assisted ambulation
- D. Calf-pump exercises
Correct answer: A
Rationale: The correct intervention for deep vein thrombosis prophylaxis in a postoperative client with a femoral head fracture repair is the use of pneumatic compression devices. These devices help prevent stasis in the lower extremities by promoting venous return through intermittent compression. Incentive spirometry is used to prevent respiratory complications by promoting lung expansion and clearing secretions, not for DVT prophylaxis. Assisted ambulation and calf-pump exercises are beneficial for promoting circulation and preventing DVT, but pneumatic compression devices are more effective in this specific postoperative scenario.
2. A client with a tracheostomy is experiencing thick, tenacious secretions. Which intervention should the nurse implement first?
- A. Encourage fluid intake to thin secretions.
- B. Administer a mucolytic agent.
- C. Increase humidity in the client's room.
- D. Perform deep suctioning as needed.
Correct answer: C
Rationale: Increasing humidity in the client's room is the initial intervention for managing thick, tenacious secretions in a client with a tracheostomy. Adequate humidity helps to hydrate secretions, making them easier to clear, thus improving airway clearance. Encouraging fluid intake (Choice A) can be beneficial but is not the first-line intervention. Administering a mucolytic agent (Choice B) may be considered if increasing humidity alone is insufficient. Performing deep suctioning (Choice D) should be reserved for when other measures like increasing humidity have been ineffective.
3. The mother of a one-month-old boy born at home brings the infant to his first well-baby visit. She mentions that he was born two weeks after his due date and is a 'good, quiet baby' who almost never cries. To assess for hypothyroidism, what question is most important for the nurse to ask the mother?
- A. Has your son had any immunizations yet?
- B. Is your son sleepy and difficult to feed?
- C. Are you breastfeeding or bottle feeding your son?
- D. Were any relatives born with birth defects?
Correct answer: B
Rationale: The correct answer is B. Sleepiness and difficulty feeding are key signs of congenital hypothyroidism, which requires early diagnosis and treatment. Asking about immunizations (choice A) is important but not directly related to assessing hypothyroidism. The feeding method (choice C) is relevant for overall health but not specific to hypothyroidism. Inquiring about relatives with birth defects (choice D) is not the most crucial question to assess hypothyroidism in this scenario.
4. A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is restless, and her pulse rate is increased. As the nurse continues the assessment, the client begins to vomit a copious amount of bright-red blood. The immediate nursing action is to:
- A. Notify the surgeon
- B. Continue the assessment
- C. Check the client’s blood pressure
- D. Obtain a flashlight, gauze, and a curved hemostat
Correct answer: A
Rationale: In the scenario described, the client's presentation with bright-red blood vomiting after a tonsillectomy and adenoidectomy is highly concerning for an immediate postoperative hemorrhage, which can be life-threatening. The priority action for the nurse is to notify the surgeon immediately. Prompt communication with the surgeon is vital to ensure swift intervention and appropriate management to address the hemorrhage effectively. Continuing the assessment, checking the client's blood pressure, or obtaining equipment are all secondary actions in this critical situation and would delay the necessary urgent intervention required to manage the hemorrhage effectively.
5. Which of the following are layers of endometrium in pregnancy EXCEPT?
- A. Decidua compacta
- B. Decidua spongiosum
- C. Decidua functionalis
- D. Decidua basalis
Correct answer: C
Rationale: During pregnancy, the layers of endometrium include decidua compacta, decidua spongiosum, and decidua basalis. Decidua functionalis is the layer that sheds during menstruation and regenerates each cycle, not a layer of the endometrium during pregnancy. Therefore, choice C is the correct answer. Decidua compacta is the layer closest to the conceptus, decidua spongiosum is the middle layer, and decidua basalis is the layer adjacent to the myometrium.