HESI RN
HESI Medical Surgical Test Bank
1. When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include?
- A. Eat a high-fiber diet and increase fluid intake.
- B. Have small frequent meals and sit up for at least two hours after meals.
- C. Eat a bland diet and avoid spicy foods.
- D. Eat a soft diet with increased intake of milk and milk products.
Correct answer: A
Rationale: A high-fiber diet with increased fluid intake is the most appropriate diet instruction for a client diagnosed with diverticulosis. High-fiber foods help prevent constipation and promote bowel regularity, reducing the risk of complications such as diverticulitis. Adequate fluid intake is crucial to soften stool and aid in digestion. Choice B, having small frequent meals and sitting up after meals, may be beneficial for some gastrointestinal conditions but is not specific to diverticulosis. Choice C, eating a bland diet and avoiding spicy foods, is not necessary for diverticulosis management. Choice D, consuming a soft diet with increased milk and milk products, may worsen symptoms in diverticulosis due to the potential for increased gas production and bloating.
2. A client with rheumatoid arthritis has just been prescribed methotrexate. What teaching should the nurse include?
- A. Take the medication on an empty stomach.
- B. Report any signs of infection, such as a sore throat.
- C. Take folic acid supplements to prevent anemia.
- D. Use sunscreen to prevent photosensitivity.
Correct answer: D
Rationale: The correct answer is D: 'Use sunscreen to prevent photosensitivity.' Methotrexate increases photosensitivity, so clients should be advised to use sunscreen to protect their skin from sun exposure. Choice A is incorrect because methotrexate is usually taken with food to reduce gastrointestinal side effects. Choice B may be important but is not specific to methotrexate therapy. Choice C is also important, but the primary reason for folic acid supplementation with methotrexate is to reduce the risk of certain side effects like anemia rather than preventing anemia itself.
3. Why is it most important to start intravenous infusions in the upper extremities rather than the lower extremities of adults?
- A. Superficial veins are more easily found in the feet and ankles.
- B. A decreased flow rate could lead to thrombosis formation.
- C. It is more challenging to move a cannulated extremity when using the leg or foot.
- D. Veins in the feet and ankles are located deep, making the procedure more painful.
Correct answer: B
Rationale: The most critical reason for initiating intravenous infusions in the upper extremities of adults is to reduce the risk of thrombosis (B). Venous return is typically better in the upper extremities, decreasing the likelihood of thrombus formation, which could be life-threatening if dislodged. Although superficial veins are easily found in the feet and ankles (A), this is not the primary reason for choosing the upper extremities. Handling a leg or foot with an IV (C) is not significantly more challenging than handling an arm or hand. The depth of veins in the feet and ankles (D) does not primarily determine the site for IV placement.
4. A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse?
- A. The patient’s radial pulse is 105 beats/minute.
- B. There is sediment and blood in the patient’s urine.
- C. The blood pressure increases from 120/80 to 142/94.
- D. There are crackles audible throughout both lung fields.
Correct answer: D
Rationale: Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the presence of sediment and blood in the urine should also be reported, but they are not as immediately dangerous as the presence of fluid in the alveoli, which compromises gas exchange and can lead to respiratory failure.
5. The nurse assumes care for a patient who is currently receiving a dose of intravenous vancomycin (Vancocin) infusing at 20 mg/min. The nurse notes red blotches on the patient’s face, neck, and chest and assesses a blood pressure of 80/55 mm Hg. Which action will the nurse take?
- A. Request an order for IV epinephrine to treat anaphylactic shock.
- B. Slow the infusion to 10 mg/min and observe the patient closely.
- C. Stop the infusion and obtain an order for a BUN and serum creatinine.
- D. Suspect Stevens-Johnson syndrome and notify the provider immediately.
Correct answer: B
Rationale: When vancomycin is infused too rapidly, “red man” syndrome may occur; the rate should be 10 mg/min to prevent this. This is a toxic reaction, not an allergic one, so epinephrine is not indicated. Stevens-Johnson syndrome is characterized by a rash and fever. Red man syndrome is not related to renal function.