HESI RN
HESI Medical Surgical Assignment Exam
1. The healthcare provider is caring for a patient who is receiving an intravenous antibiotic. The patient has a serum drug trough of 1.5 mcg/mL. The normal trough for this drug is 1.7 mcg/mL to 2.2 mcg/mL. What will the healthcare provider expect the patient to experience?
- A. Inadequate drug effects
- B. Increased risk of superinfection
- C. Minimal adverse effects
- D. Slowed onset of action
Correct answer: A
Rationale: A serum drug trough level below the normal range (1.7 mcg/mL to 2.2 mcg/mL) indicates that the medication concentration is insufficient to provide therapeutic effects, leading to inadequate drug effects. A low trough level does not directly correlate with an increased risk of superinfection, minimal adverse effects, or a slowed onset of action, as these are more related to the drug's concentration within the therapeutic range.
2. The nurse is caring for a client with liver cirrhosis. Which assessment finding requires immediate intervention?
- A. Jaundice.
- B. Ascites.
- C. Peripheral edema.
- D. Spider angiomas.
Correct answer: D
Rationale: Spider angiomas are abnormal clusters of blood vessels near the skin surface and can be indicative of an underlying liver condition. In the context of liver cirrhosis, spider angiomas can suggest portal hypertension and liver dysfunction, which requires immediate intervention. Jaundice (choice A) is a common manifestation of liver cirrhosis but not typically an immediate intervention priority unless severe. Ascites (choice B) and peripheral edema (choice C) are also common in liver cirrhosis but do not require immediate intervention unless they are causing respiratory compromise or other urgent issues.
3. Which instruction is most important for a client who receives a new plan of care to treat osteoporosis?
- A. Start a weight-bearing exercise plan.
- B. Increase consumption of foods rich in calcium.
- C. Arrange a bone density test every year.
- D. Stay upright after taking the medication.
Correct answer: D
Rationale: The correct answer is D: 'Stay upright after taking the medication.' This instruction is crucial for clients receiving medications like bisphosphonates to prevent esophageal irritation or erosion. While weight-bearing exercises (choice A) are important for bone health, staying upright after medication intake takes precedence. Increasing calcium-rich foods (choice B) is beneficial but not the most important immediate instruction. Scheduling bone density tests (choice C) is necessary for monitoring osteoporosis but is not as critical as staying upright after medication.
4. In a patient with chronic obstructive pulmonary disease (COPD), which of the following interventions is most important?
- A. Encouraging the patient to stop smoking.
- B. Administering bronchodilators.
- C. Monitoring oxygen saturation.
- D. Providing nutritional support.
Correct answer: C
Rationale: Monitoring oxygen saturation is the most important intervention in a patient with COPD because it helps assess the adequacy of oxygenation. In COPD, patients often have compromised lung function, leading to decreased oxygen levels in the blood. Monitoring oxygen saturation allows healthcare providers to promptly identify and address any potential hypoxemia, which is vital in managing COPD exacerbations. While encouraging the patient to stop smoking (Choice A) is critical for long-term management, monitoring oxygen saturation takes precedence in the immediate care of a COPD patient. Administering bronchodilators (Choice B) and providing nutritional support (Choice D) are important aspects of managing COPD but are secondary to monitoring oxygen saturation, which directly impacts the patient's oxygenation status.
5. Warm compresses are ordered for an open wound. Which action is appropriate for the nurse?
- A. Use sterile technique when applying the compresses.
- B. Leave the compresses on the area continuously, pouring warm solution on the area when it cools down.
- C. Alternate warm compresses with cold compresses.
- D. Apply a wet dressing and cover it with a dry dressing.
Correct answer: A
Rationale: Using sterile technique when applying the compresses is crucial to prevent infection and promote wound healing. Ensuring a clean environment during wound care reduces the risk of introducing pathogens that can lead to complications. Proper infection control measures play a significant role in the healing process of open wounds. Choice B is incorrect because leaving the compresses on continuously can lead to skin damage or thermal injury. Choice C is incorrect as alternating warm compresses with cold compresses is not appropriate for an open wound. Choice D is incorrect as applying a wet dressing without following specific orders can be detrimental to wound healing.