HESI RN
Evolve HESI Medical Surgical Practice Exam Quizlet
1. Which of the following is a common cause of chronic obstructive pulmonary disease (COPD)?
- A. Smoking
- B. Asthma
- C. Allergies
- D. Chronic bronchitis
Correct answer: A
Rationale: Smoking is the correct answer as it is a well-established common cause of chronic obstructive pulmonary disease (COPD). Smoking leads to long-term damage to the lungs, contributing to the development of COPD. Choice B, asthma, is not a cause but a separate respiratory condition characterized by airway inflammation and hyperresponsiveness. Allergies, choice C, are not a direct cause of COPD but can exacerbate symptoms in individuals with existing COPD. Chronic bronchitis, choice D, is a type of COPD, not a cause of COPD itself, making it an incorrect choice in this context.
2. A client with gastroesophageal reflux is receiving teaching from a nurse. Which statement by the client indicates a need for further teaching?
- A. I will avoid eating after supper.
- B. I can drink coffee throughout the day.
- C. I drink milk when I get heartburn.
- D. I should not eat foods made with chocolate.
Correct answer: B
Rationale: The correct answer is B. Drinking coffee throughout the day can aggravate gastroesophageal reflux symptoms. Choices A, C, and D are correct statements that can help manage gastroesophageal reflux by avoiding late-night eating, not consuming trigger foods like chocolate, and using milk for relief when experiencing heartburn.
3. A client who has agoraphobia (a fear of crowds) is starting desensitization therapy with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?
- A. Encourage the substitution of positive thoughts for negative ones.
- B. Establish trust by providing a calm, safe environment.
- C. Gradually expose the client to larger crowds.
- D. Encourage deep breathing when anxiety escalates in a crowd.
Correct answer: B
Rationale: Establishing trust by providing a calm and safe environment is crucial for the success of desensitization therapy in clients with agoraphobia. This approach helps the client feel safe and secure, allowing them to gradually confront their fear of crowds. Encouraging positive thoughts (choice A) is beneficial but not as immediately critical as creating a safe space. Progressively exposing the client to larger crowds (choice C) should occur after trust is established and in a controlled manner. Encouraging deep breathing (choice D) is helpful, but creating a safe environment takes precedence to build a foundation for successful desensitization.
4. A client is receiving lactulose for signs of hepatic encephalopathy. To evaluate the therapeutic response, which assessment should the nurse obtain?
- A. Percussion of the abdomen.
- B. Blood glucose level.
- C. Serum electrolytes.
- D. Level of consciousness.
Correct answer: D
Rationale: The correct answer is D: Level of consciousness. Lactulose is used to reduce ammonia levels in hepatic encephalopathy, which can affect brain function. Therefore, monitoring the client's level of consciousness is crucial to evaluate the therapeutic response. Changes in consciousness can indicate the effectiveness of lactulose in reducing ammonia levels. Choices A, B, and C are incorrect because while they are important assessments in various conditions, they are not specifically related to evaluating the therapeutic response of lactulose in hepatic encephalopathy.
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.