HESI RN
HESI Medical Surgical Exam
1. Which of the following is a common complication of hypertension?
- A. Diabetes.
- B. Heart failure.
- C. Kidney failure.
- D. Stroke.
Correct answer: D
Rationale: The correct answer is D: Stroke. Hypertension can lead to stroke due to the increased pressure on blood vessels in the brain, which can result in reduced blood flow and oxygen to the brain tissue. While choices B (Heart failure) and C (Kidney failure) can be complications of hypertension, they are not as directly associated as stroke. Choice A, Diabetes, is not a direct complication of hypertension but rather a separate condition that can be influenced by various factors. However, stroke is more commonly linked to the increased pressure on blood vessels in the brain in individuals with hypertension.
2. The home health nurse provides teaching about insulin self-injection to a client who was recently diagnosed with diabetes mellitus. When the client begins to perform a return demonstration of an insulin injection into the abdomen, which instruction should the nurse provide?
- A. Select a different injection site
- B. Continue with the insulin injection
- C. Keep the skin flat rather than bunched
- D. Lie down flat for better skin exposure
Correct answer: B
Rationale: Choosing to continue with the insulin injection is the correct instruction in this scenario because it allows the client to demonstrate proper technique and reinforces their learning. Selecting a different injection site (choice A) is not necessary if the client is injecting into the abdomen as it is a suitable site. Keeping the skin flat rather than bunched (choice C) is a good practice but is not the priority in this situation where the client is demonstrating the injection technique. Lying down flat for better skin exposure (choice D) is not required and may not be practical for the client during routine self-injections.
3. A client recovering from a cystoscopy is being assessed by a nurse. Which assessment findings should alert the nurse to urgently contact the health care provider? (Select all that apply.)
- A. Decrease in urine output
- B. Blood clots present in the urine
- C. Prescription for metformin
- D. A & B
Correct answer: D
Rationale: After a cystoscopy, the nurse should monitor urine output and promptly contact the provider if there is a decrease or absence of urine output. Additionally, the nurse should assess for blood in the urine. While some pink-tinged urine may be expected, the presence of gross bleeding or blood clots warrants immediate provider notification. Tolerating oral fluids is a positive sign and does not require urgent intervention. Metformin would be a concern if the client received contrast dye, which is not used in a cystoscopy. A burning sensation when urinating is a common post-procedure experience and does not necessitate contacting the provider. Therefore, choices A and B are the correct answers as they indicate potentially serious complications that require immediate attention, while choices C and D do not align with urgent concerns following a cystoscopy.
4. After undergoing a renal biopsy, a client reports pain radiating to the front of the abdomen from the biopsy site. What finding should the nurse assess the client for?
- A. Bleeding
- B. Renal colic
- C. Infection at the site
- D. Increased temperature
Correct answer: A
Rationale: The correct answer is A: Bleeding. Pain radiating to the front of the abdomen from the renal biopsy site suggests bleeding, which should be promptly assessed and managed. Bleeding can lead to serious complications if not addressed timely. Renal colic (choice B) is associated with kidney stones and typically presents with severe flank pain. Infection at the site (choice C) would more likely present with localized signs such as redness, swelling, warmth, and tenderness. Increased temperature (choice D) alone is not specific to the issue described and may be indicative of various conditions.
5. A 20-year-old female client calls the nurse to report a lump she found in her breast. Which response is the best for the nurse to provide?
- A. Check it again in one month, and if it is still there schedule an appointment.
- B. Most lumps are benign, but it is always best to come in for an examination.
- C. Try not to worry too much about it, because usually, most lumps are benign.
- D. If you are in your menstrual period it is not a good time to check for lumps.
Correct answer: B
Rationale: The nurse advising the client to come in provides the best response because it addresses the client's anxiety most effectively and encourages prompt and immediate action for a potential problem.
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