HESI RN
Evolve HESI Medical Surgical Practice Exam
1. 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.
2. An adolescent with anorexia nervosa is undergoing nutritional therapy. Which finding best indicates that the client is making progress in treatment?
- A. Client gains 2 pounds in a week.
- B. Client describes a positive body image.
- C. Client engages in recreational activities.
- D. Client begins to talk about future goals.
Correct answer: A
Rationale: The correct answer is A. Weight gain is a crucial indicator of progress in the treatment of anorexia nervosa. In individuals with anorexia, restoring and maintaining a healthy weight is a primary goal to address the underlying nutritional deficiencies and health complications associated with the disorder. While choices B, C, and D are positive developments in the client's overall well-being and recovery journey, they are not as directly linked to the core issue of nutritional rehabilitation in anorexia nervosa. Describing a positive body image, engaging in recreational activities, and talking about future goals are important aspects of psychological and emotional recovery, but weight gain is a more immediate and objective measure of progress in treating anorexia nervosa.
3. The weight of the non-pregnant uterus is approximately ___________grams.
- A. 57
- B. 80
- C. 66
- D. 71
Correct answer: B
Rationale: The correct answer is B: 80. The non-pregnant uterus typically weighs around 80 grams. This weight may vary slightly among individuals, but 80 grams is a commonly accepted average. Choices A, C, and D are incorrect as they do not reflect the typical weight of the non-pregnant uterus. It is important to remember this approximate weight for medical reference and understanding of normal anatomical variations.
4. A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to the child, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. Which action should the nurse take?
- A. Involve the older brother in supporting the child
- B. Ask the older brother how he felt during the incident
- C. Ask the parents for more information about the brother's behavior
- D. Reassure the brother that everything is fine now
Correct answer: B
Rationale: The older brother's withdrawal likely indicates emotional trauma or stress from the near-drowning event. Asking how he felt provides an opportunity for emotional support and allows the child to express feelings that may need addressing. Involving him in supporting the child may be overwhelming and not address his emotional needs directly. Asking the parents for more information may not allow the older brother to express his own feelings. Simply reassuring him that everything is fine now may dismiss his emotional experience without providing a chance for him to process his feelings.
5. Following discharge teaching, a male client with a duodenal ulcer tells the nurse he will drink plenty of dairy products to help coat and protect his ulcer. What is the best follow-up action by the nurse?
- A. Remind the client that it is also important to switch to decaffeinated coffee and tea.
- B. Suggest that the client also plans to eat frequent small meals to reduce discomfort.
- C. Review with the client the need to avoid foods that are rich in milk and cream.
- D. Reinforce this teaching by asking the client to list a dairy food that he might select.
Correct answer: C
Rationale: The correct answer is C because diets rich in milk and cream stimulate gastric acid secretion, which can exacerbate a duodenal ulcer. Therefore, it is essential to avoid foods that are rich in milk and cream. Choice A is incorrect because switching to decaffeinated coffee and tea does not address the issue of avoiding milk and cream products. Choice B is incorrect because while eating frequent small meals can help with discomfort, it does not address the specific issue of avoiding milk and cream. Choice D is incorrect as it does not address the need to avoid milk and cream products.