HESI RN
HESI Medical Surgical Test Bank
1. What is the most common symptom of hypoglycemia that the nurse should teach the diabetic client to recognize?
- A. Nervousness
- B. Anorexia
- C. Kussmaul's respirations
- D. Bradycardia
Correct answer: A
Rationale: Nervousness is the most common symptom of hypoglycemia. It is often accompanied by other signs such as weakness, perspiration, confusion, and palpitations. Anorexia (lack of appetite) is not a typical symptom of hypoglycemia; it is more commonly associated with hyperglycemia. Kussmaul's respirations are a deep and labored breathing pattern seen in diabetic ketoacidosis, not hypoglycemia. Bradycardia (slow heart rate) is not a typical symptom of hypoglycemia; tachycardia (fast heart rate) is more commonly associated with hypoglycemia due to the release of catecholamines in response to low blood sugar.
2. A client with a history of chronic kidney disease presents with increased swelling and shortness of breath. What is the nurse's priority action?
- A. Administer oxygen at 2 liters per nasal cannula.
- B. Administer a diuretic as prescribed.
- C. Monitor the client's vital signs.
- D. Reposition the client to improve lung expansion.
Correct answer: B
Rationale: The correct answer is to administer a diuretic as prescribed. In a client with chronic kidney disease experiencing increased swelling and shortness of breath, the priority action is to address fluid retention. Administering a diuretic helps reduce fluid overload, alleviate symptoms, and prevent complications associated with fluid buildup. Option A is not the priority in this situation as addressing fluid retention takes precedence over providing oxygen. While monitoring vital signs is important, it is secondary to addressing the underlying cause of symptoms. Repositioning the client may help with comfort but does not directly address the fluid overload seen in chronic kidney disease.
3. The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is
- A. Heart rate
- B. Pedal pulses
- C. Lung sounds
- D. Pupil responses
Correct answer: D
Rationale: Assessing pupil responses is crucial in a client with hypertensive crisis to monitor for signs of increased intracranial pressure, which can indicate potential neurological complications. While heart rate, pedal pulses, and lung sounds are important assessments, they do not take precedence over neurological assessments in this critical situation.
4. How can menopause affect health?
- A. Causing conjunctivitis
- B. Leading to colitis or bowel upsets
- C. Increasing the risk of cancer
- D. Triggering urinary infections
Correct answer: D
Rationale: Menopause can lead to changes in the urinary tract, such as decreased estrogen levels, which can increase the likelihood of urinary tract infections. While menopause can impact various aspects of health, including bone density and heart health, it is not directly linked to conjunctivitis, colitis, or an increased risk of cancer. Therefore, the correct answer is D.
5. Discuss the anatomical/physiological changes in pregnancy under the following: Uterus
- A. The uterus softens in the anterior midline, becomes flexible at the uterocervical junction, blood vasculature increases in size and number, and hypertrophy of myometrial cells occurs.
- B. The uterus decreases in size during pregnancy and remains rigid.
- C. The uterus size remains unchanged, and no changes occur in the blood vasculature.
- D. Uterus becomes more rigid and hypertrophies.
Correct answer: A
Rationale: During pregnancy, the uterus undergoes various anatomical and physiological changes. The correct answer, Choice A, accurately describes these changes. The uterus softens in the anterior midline, becomes flexible at the uterocervical junction, experiences an increase in blood vasculature size and number, and myometrial cells hypertrophy. This softening and increased vascularity are essential for accommodating the growing fetus and facilitating delivery. Choices B, C, and D are incorrect because they do not reflect the typical changes that occur in the uterus during pregnancy. The uterus does not decrease in size, remain unchanged in size, become more rigid, or hypertrophy without the described softening and vascular changes.