HESI RN
HESI Medical Surgical Practice Quiz
1. The nurse is teaching a patient who will be discharged home from the hospital to take amoxicillin (Amoxil) twice daily for 10 days. Which statement by the nurse is correct?
- A. Discontinue the antibiotic when your temperature returns to normal and your symptoms have improved.
- B. If diarrhea occurs, stop taking the drug immediately and contact your provider.
- C. Stop taking the drug and notify your provider if you develop a rash while taking this drug.
- D. You may save any unused antibiotic to use if your symptoms recur.
Correct answer: C
Rationale: Patients who develop signs of allergy, such as rash, should notify their provider before continuing medication therapy. Patients should be counseled to continue taking their antibiotics until completion of the prescribed regimen even when they feel well. Diarrhea is an adverse effect but does not warrant cessation of the drug. Before deciding to stop taking a medication due to a side effect, encourage the patient to contact the provider first. Patients should discard any unused antibiotic.
2. A nursing assistant is measuring the blood pressure (BP) of a hypertensive client while a nurse observes. Which action on the part of the assistant would interfere with accurate measurement and prompt the nurse to intervene? Select all that apply.
- A. Measuring the BP after the client has sat quietly for 5 minutes
- B. Having the client sit with the arm bared and supported at heart level
- C. Using a cuff with a rubber bladder that encircles less than 80% of the limb
- D. Measuring the BP after the client reports that he just drank a cup of coffee
Correct answer: C
Rationale: To ensure accurate blood pressure (BP) measurement, the cuff used should have a rubber bladder that encircles at least 80% of the limb being measured. This ensures proper compression and accurate readings. Choices A and B are correct practices as it is recommended to measure BP after the client has sat quietly for 5 minutes and to have the client sit with the arm bared and supported at heart level. Choice D is also a correct reason for intervention as the client should not have consumed caffeine or smoked tobacco within 30 minutes before BP measurement, as it can affect the accuracy of the reading.
3. The nurse is performing a functional assessment for a client requiring nursing home care. Which action should the nurse implement?
- A. Question the client about the frequency of falls.
- B. Request the client to lie still during the assessment.
- C. Ask how often episodes of sundowning are experienced.
- D. Assist the client with values clarification about end-of-life care.
Correct answer: A
Rationale: The correct answer is A: Question the client about the frequency of falls. In the elderly population, falls are a significant risk factor that can impact their functional abilities and safety. By assessing the frequency of falls, the nurse can identify potential risks and implement interventions to prevent future falls. Choices B, C, and D are incorrect because they do not directly address the primary focus of a functional assessment for nursing home care, which is to evaluate the client's functional status and identify areas that may require assistance or intervention.
4. When assessing an IV site used for fluid replacement and medication administration, the client complains of tenderness when the arm is touched above the site. Which additional assessment finding warrants immediate intervention by the nurse?
- A. Cool skin at the IV insertion site
- B. Presence of fluid leaking around the IV catheter
- C. Swelling above the IV site
- D. Red streaks tracking the vein
Correct answer: D
Rationale: The correct answer is D: "Red streaks tracking the vein." Red streaks indicate phlebitis, an inflammation of the vein that can lead to serious complications like infection or thrombophlebitis. Immediate intervention is required to prevent further damage. Choice A, cool skin at the IV insertion site, could indicate decreased circulation but is not as urgent as addressing phlebitis. Choice B, presence of fluid leaking around the IV catheter, may indicate infiltration or dislodgement of the catheter, requiring intervention but not as urgently as phlebitis. Choice C, swelling above the IV site, may suggest localized inflammation but doesn't pose an immediate threat like phlebitis does.
5. The nurse is evaluating the laboratory reports of a client with hypothyroidism. The nurse would expect which of the following laboratory values?
- A. Increased TSH
- B. Increased thyroxine (T4)
- C. Decreased TSH
- D. Decreased T3
Correct answer: A
Rationale: The correct answer is A: Increased TSH. In hypothyroidism, the thyroid gland is underactive, leading to low levels of thyroid hormones. As a compensatory mechanism, the pituitary gland releases more thyroid-stimulating hormone (TSH) to try to stimulate the thyroid gland to produce more hormones. Therefore, increased TSH levels are expected in hypothyroidism. Choice B is incorrect because in hypothyroidism, thyroxine (T4) levels are usually decreased, not increased. Choice C is incorrect as hypothyroidism is characterized by increased TSH levels, not decreased. Choice D is also incorrect because in hypothyroidism, T3 levels may be decreased, but TSH is a more sensitive indicator for diagnosis.