HESI RN
Evolve HESI Medical Surgical Practice Exam Quizlet
1. What is a priority intervention for a patient experiencing a thyroid storm?
- A. Administering antipyretics.
- B. Cooling the patient.
- C. Administering beta-blockers.
- D. Administering antithyroid medications.
Correct answer: D
Rationale: During a thyroid storm, the priority intervention is to administer antithyroid medications to reduce thyroid hormone levels quickly. These medications, such as propylthiouracil or methimazole, help inhibit the production of thyroid hormones. Administering antipyretics (choice A) may help reduce fever, but it does not address the underlying cause of the thyroid storm. Cooling the patient (choice B) may provide symptomatic relief but does not address the thyroid hormone dysregulation. Administering beta-blockers (choice C) can help manage symptoms like tachycardia and hypertension, but it does not target the root cause of the thyroid storm.
2. Which of the following is the most important nursing action when administering a blood transfusion?
- A. Monitoring the patient's blood pressure.
- B. Monitoring the patient's temperature.
- C. Monitoring the patient's heart rate.
- D. Monitoring the patient's oxygen saturation.
Correct answer: A
Rationale: The most important nursing action when administering a blood transfusion is monitoring the patient's blood pressure. This is crucial because monitoring blood pressure allows for the prompt identification of any signs of adverse transfusion reactions, such as transfusion reactions or fluid overload. Immediate intervention can be initiated if any complications arise. While monitoring temperature, heart rate, and oxygen saturation are also essential aspects of patient care, they are not as critical as blood pressure monitoring during a blood transfusion. Therefore, the correct answer is to monitor the patient's blood pressure.
3. When a patient is receiving high doses of a cephalosporin, which laboratory values will this patient's nurse monitor closely?
- A. Blood urea nitrogen (BUN), serum creatinine, and liver function tests
- B. Complete blood count and electrolytes
- C. Serum calcium and magnesium
- D. Serum glucose and lipids
Correct answer: A
Rationale: When a patient is receiving high doses of a cephalosporin, such as cefazolin, the nurse should closely monitor laboratory values that indicate renal and hepatic function. This includes checking the Blood Urea Nitrogen (BUN) and serum creatinine levels to assess kidney function. Additionally, monitoring liver function tests, such as AST, ALT, ALP, LDH, and bilirubin, is essential as cephalosporins can affect liver enzymes. Therefore, options B, C, and D are incorrect as they do not specifically address the parameters that are most pertinent when administering high doses of cephalosporins.
4. A client with partial thickness burns to the lower extremities is scheduled for whirlpool therapy to debride the burned area. Which intervention should the nurse implement before transporting the client to the physical therapy department?
- A. Obtain supplies to re-dress the burn area.
- B. Verify the client's signed consent form.
- C. Give a prescribed narcotic analgesic agent.
- D. Perform active range-of-motion exercises.
Correct answer: C
Rationale: Before transporting the client for whirlpool therapy to debride the burned area, the nurse should give a prescribed narcotic analgesic agent. This intervention is essential to manage pain effectively during the debridement process. Obtaining supplies to re-dress the burn area (Choice A) is important but not as immediate as providing pain relief. Verifying the client's signed consent form (Choice B) is necessary for procedures but does not address the client's immediate pain needs. Performing active range-of-motion exercises (Choice D) is not indicated before whirlpool therapy for debridement of burns and may cause further discomfort to the client.
5. What is the most common symptom of hypoglycemia that the nurse should teach the diabetic client to recognize?
- A. Nervousness
- B. Anorexia
- C. Kussmaul's respirations
- D. Bradycardia
Correct answer: A
Rationale: Nervousness is the most common symptom of hypoglycemia. It is often accompanied by other signs such as weakness, perspiration, confusion, and palpitations. Anorexia (lack of appetite) is not a typical symptom of hypoglycemia; it is more commonly associated with hyperglycemia. Kussmaul's respirations are a deep and labored breathing pattern seen in diabetic ketoacidosis, not hypoglycemia. Bradycardia (slow heart rate) is not a typical symptom of hypoglycemia; tachycardia (fast heart rate) is more commonly associated with hypoglycemia due to the release of catecholamines in response to low blood sugar.
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