HESI RN
HESI Medical Surgical Test Bank
1. When providing care for an unconscious client who has seizures, which nursing intervention is most essential?
- A. Ensure oral suction is available.
- B. Maintain the client in a semi-Fowler's position.
- C. Provide frequent mouth care.
- D. Keep the room at a comfortable temperature.
Correct answer: A
Rationale: During seizures in an unconscious client, ensuring oral suction is available is crucial to managing secretions and preventing aspiration. This intervention helps maintain a clear airway and reduce the risk of complications. Maintaining the client in a semi-Fowler's position (Choice B) may be important for airway management but is not as critical as having oral suction ready. Providing frequent mouth care (Choice C) and keeping the room at a comfortable temperature (Choice D) are important aspects of overall care but are not as urgently needed as ensuring oral suction for managing secretions during seizures.
2. A client presses the call bell and requests pain medication for a severe headache. To assess the quality of the client's pain, which approach should the nurse use?
- A. Use the Wong-Baker Faces pain rating scale
- B. Assess vital signs to gauge pain severity
- C. Ask the client to describe the pain
- D. Offer a 1-10 pain scale
Correct answer: C
Rationale: Asking the client to describe the pain is the most appropriate approach to assess the quality of pain. It provides valuable qualitative information that aids in understanding the nature, cause, and potential management strategies for the headache. While pain rating scales like the Wong-Baker Faces scale and using vital signs can help quantify pain severity, they do not offer specific descriptive details that can give insights into the type and characteristics of the pain experienced by the client.
3. Herpes simplex type 2 (HSV-2) does not cause cold sores of the lips:
- A. True.
- B. False.
- C. Depends on the person.
- D. Not enough information.
Correct answer: B
Rationale: Herpes simplex type 2 (HSV-2) typically causes genital herpes, not cold sores on the lips. Cold sores on the lips are commonly caused by herpes simplex type 1 (HSV-1). Therefore, the statement that HSV-2 causes cold sores of the lips is incorrect. Choice B, 'False,' is the correct answer. Choice A is incorrect because HSV-2 does not cause cold sores on the lips. Choice C, 'Depends on the person,' is incorrect as the cause of cold sores is predominantly linked to HSV-1. Choice D, 'Not enough information,' is also incorrect as this information is well-established in medical knowledge.
4. What safety measure should the nurse take for a client with a seizure disorder who has an IV line?
- A. Ensure that the IV site is padded and protected.
- B. Limit the client's mobility to prevent dislodging the IV.
- C. Place the IV site on the same side as the seizure activity.
- D. Ensure the client is positioned on the opposite side of the IV line.
Correct answer: D
Rationale: The correct answer is D: Ensure the client is positioned on the opposite side of the IV line. Placing the IV line on the opposite side of any seizure activity is essential to prevent injury. It helps to ensure that the IV line is not dislodged during a seizure. Choices A, B, and C are incorrect. While padding and protecting the IV site is important, the priority is to position the client on the side opposite to the IV line to prevent dislodgement and injury during a seizure.
5. During a community health fair, the nurse conducts a blood pressure screening for a 60-year-old woman who has a blood pressure of 160/100 mm Hg. What should the nurse do first?
- A. Instruct the client to monitor her blood pressure at home
- B. Refer the client to her healthcare provider for further evaluation
- C. Educate the client on lifestyle changes to reduce blood pressure
- D. Recheck the blood pressure in 15 minutes
Correct answer: B
Rationale: When encountering a high blood pressure reading at a community health fair, it is essential for the nurse to refer the client to her healthcare provider for further evaluation. This step ensures that the client receives a comprehensive assessment, diagnosis, and appropriate management plan. In this scenario, it is crucial to prioritize professional evaluation over self-monitoring, lifestyle education, or immediate rechecking of the blood pressure. Referral to a healthcare provider allows for timely intervention and ongoing monitoring of the client's blood pressure to prevent potential complications.