HESI RN
HESI Medical Surgical Test Bank
1. Which of the following is a characteristic of chronic obstructive pulmonary disease (COPD)?
- A. Increased lung compliance.
- B. Decreased lung elasticity.
- C. Increased respiratory rate.
- D. Increased lung expansion.
Correct answer: B
Rationale: The correct answer is B: Decreased lung elasticity. Chronic obstructive pulmonary disease (COPD) is characterized by a loss of lung elasticity, which leads to difficulty in exhaling air. This decreased elasticity results in air becoming trapped in the lungs, making it challenging for the individual to breathe effectively. Choice A is incorrect as COPD is associated with decreased lung compliance, not increased compliance. Choice C is incorrect as individuals with COPD often have a decreased respiratory rate due to impaired lung function. Choice D is incorrect as COPD causes limited lung expansion due to factors like air trapping and hyperinflation.
2. A client with diabetes mellitus has a blood glucose level of 350 mg/dL. Which of these actions should the nurse take first?
- A. Administer insulin as ordered
- B. Encourage the client to drink fluids
- C. Notify the healthcare provider
- D. Recheck the blood glucose level in 30 minutes
Correct answer: A
Rationale: Administering insulin as ordered is the priority action when a client with diabetes mellitus has a blood glucose level of 350 mg/dL. Insulin helps to lower the high blood glucose level and prevent complications such as diabetic ketoacidosis. Encouraging the client to drink fluids may be beneficial but does not address the immediate need to lower the blood glucose level. Notifying the healthcare provider and rechecking the blood glucose level can be important steps but should come after administering insulin to address the high glucose level promptly.
3. The nurse is conducting diet teaching for a client diagnosed with hypertension. Which foods should the nurse encourage the client to eat?
- A. Pickled olives
- B. Canned soup
- C. Fresh or frozen vegetables without sauce
- D. Fruits without sauce
Correct answer: C
Rationale: The correct answer is C: Fresh or frozen vegetables without sauce. These foods are low in sodium, which is crucial for managing hypertension. Pickled olives (choice A) and canned soup (choice B) are high in sodium, which can exacerbate hypertension. While fruits without sauce (choice D) are generally healthy, emphasizing vegetables is more beneficial for hypertension due to their lower sodium content.
4. The client reports still being unable to sleep a week after learning progressive muscle relaxation techniques. Which action should the nurse take first?
- A. Instruct the client to add regular exercise to the daily routine.
- B. Determine if the client has been keeping a sleep diary.
- C. Encourage the client to continue the routine until sleep is achieved.
- D. Ask the client to describe the routine currently followed.
Correct answer: D
Rationale: The nurse should first assess the client's adherence to the original instructions. By asking the client to describe the routine, the nurse can evaluate if the technique is being correctly implemented before considering further interventions. This choice is correct as it focuses on assessing the client's current practice. Option A is incorrect as adding regular exercise may not address the issue with the relaxation technique. Option B is incorrect as determining if the client has been keeping a sleep diary does not directly address the efficacy of the relaxation technique. Option C is incorrect as blindly encouraging the client to continue may not be the best approach without understanding how the technique is being practiced.
5. The nurse explains to an older adult male the procedure for collecting a 24-hour urine specimen for creatinine clearance. Which action is most important for the nurse to include in their care plan for the shift?
- A. Assess the client for confusion and reteach the procedure
- B. Check the urine for color and texture
- C. Empty the urinal contents into the 24-hour collection container
- D. Discard the contents of the urinal
Correct answer: C
Rationale: To ensure accurate creatinine clearance results, it is crucial to collect all urine within the 24-hour period. The process should begin with discarding the first specimen and then collecting all subsequent urine in the designated 24-hour collection container. This ensures that the sample is complete and accurate for the creatinine clearance calculation.