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. A nurse is conducting an assessment of a client who underwent thoracentesis of the right side of the chest 3 hours ago. Which findings does the nurse report to the physician? Select all that apply.
- A. Unequal chest expansion
- B. Pulse rate of 82 beats/min
- C. Respiratory rate of 22 breaths/min
- D. Diminished breath sounds in the right lung
Correct answer: A
Rationale: After thoracentesis, the nurse should assess the client for signs of pneumothorax, which include increased respiratory rate, dyspnea, retractions, unequal chest expansion, diminished breath sounds, and cyanosis. Unequal chest expansion is a key sign of pneumothorax due to the accumulation of air in the pleural space, causing the affected lung to collapse partially. Pulse rate and respiratory rate within normal ranges, like in choices B and C, are not the priority findings to report in this situation. Diminished breath sounds in the right lung could be expected after thoracentesis and may not necessarily indicate a complication like pneumothorax, making choice D less urgent to report.
3. The nurse is caring for a patient who is receiving isotonic intravenous (IV) fluids at an infusion rate of 125 mL/hour. The nurse performs an assessment and notes a heart rate of 102 beats per minute, a blood pressure of 160/85 mm Hg, and crackles auscultated in both lungs. Which action will the nurse take?
- A. Decrease the IV fluid rate and notify the provider.
- B. Increase the IV fluid rate and notify the provider.
- C. Request an order for a colloidal IV solution.
- D. Request an order for a hypertonic IV solution.
Correct answer: A
Rationale: The patient is showing signs of fluid volume excess, indicated by crackles in both lungs, increased heart rate, and elevated blood pressure. To address this, the nurse should decrease the IV fluid rate and notify the provider. Increasing the IV fluid rate would worsen fluid overload. Requesting colloidal or hypertonic IV solutions would exacerbate the issue by pulling more fluids into the intravascular space, leading to further volume overload.
4. The client had a thyroidectomy 24 hours ago and reports experiencing numbness and tingling of the face. Which intervention should the nurse implement?
- A. Open and prepare the tracheostomy kit.
- B. Inspect the neck for an increase in swelling.
- C. Monitor for the presence of Chvostek's sign.
- D. Assess lung sounds for laryngeal stridor.
Correct answer: C
Rationale: The correct answer is C: Monitor for the presence of Chvostek's sign. Chvostek's sign is a clinical indicator of hypocalcemia, a common complication after thyroidectomy. Numbness and tingling around the face are associated with hypocalcemia due to potential damage to the parathyroid glands during surgery, leading to decreased calcium levels. Inspecting the neck for swelling (choice B) is important but does not directly address the presenting symptoms. Opening and preparing the tracheostomy kit (choice A) is not necessary based on the client's current symptoms. Assessing lung sounds for laryngeal stridor (choice D) is not directly related to the client's reported numbness and tingling of the face.
5. A nurse plans care for an older adult client. Which interventions should the nurse include in this client’s plan of care to promote kidney health? (Select all that apply.)
- A. Ensure adequate fluid intake.
- B. Leave the bathroom light on at night.
- C. Encourage use of the toilet every 6 hours.
- D. A & B
Correct answer: D
Rationale: The correct interventions to promote kidney health in an older adult client include ensuring adequate fluid intake to maintain hydration and leaving the bathroom light on at night to promote safe ambulation. Adequate hydration supports kidney function and helps prevent urinary tract infections. Encouraging the use of the toilet every 6 hours is not specific to kidney health and may not be individualized to the client's needs. Providing thorough perineal care after each voiding is important for hygiene but not directly related to promoting kidney health. Assessing for urinary retention and urinary tract infections is crucial but falls under assessment rather than interventions for promoting kidney health specifically.
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