HESI RN
Evolve HESI Medical Surgical Practice Exam Quizlet
1. What is the priority intervention for a patient with a suspected myocardial infarction (MI)?
- A. Administering oxygen.
- B. Administering nitroglycerin.
- C. Administering aspirin.
- D. Administering morphine.
Correct answer: A
Rationale: Administering oxygen is the priority intervention for a patient with a suspected myocardial infarction to improve oxygenation. Oxygen helps ensure an adequate oxygen supply to the heart muscle, reducing the workload on the heart. Nitroglycerin and aspirin are important interventions in the treatment of MI; however, oxygen administration takes precedence to ensure adequate oxygenation. Morphine may be considered for pain relief, but it is not the initial priority in the treatment of a suspected MI.
2. The nurse is caring for a patient who develops marked edema and a low urine output as a result of heart failure. Which medication will the nurse expect the provider to order for this patient?
- A. Digoxin (Lanoxin)
- B. Furosemide (Lasix)
- C. Hydrochlorothiazide (HydroDIURIL)
- D. Spironolactone (Aldactone)
Correct answer: B
Rationale: In heart failure with marked edema and low urine output, the nurse can expect the provider to order Furosemide (Lasix). Furosemide is a loop diuretic that acts quickly to remove excess fluid from the body, making it an appropriate choice for this patient's condition. Digoxin is used to improve heart function but does not directly address fluid overload. Hydrochlorothiazide is a thiazide diuretic that is not as potent as Furosemide in managing acute fluid retention. Spironolactone is a potassium-sparing diuretic that is typically used in heart failure for its aldosterone-blocking effects and not for immediate fluid removal.
3. A nurse is reinforcing dietary teaching with a client who has a burn injury and adheres to a strict vegan diet. Which of the following food choices should the nurse recommend?
- A. Tuna salad
- B. Fresh fruit
- C. Vegetables
- D. Beans
Correct answer: D
Rationale: Beans are an excellent choice for a client with a burn injury who follows a strict vegan diet. They are a rich source of protein, essential for healing, making them the most suitable option among the choices provided. Tuna salad (choice A) is not suitable for a vegan diet as it contains animal products. While fresh fruit (choice B) and vegetables (choice C) are healthy options, they may not provide sufficient protein needed for healing from a burn injury.
4. A client with a history of deep vein thrombosis (DVT) is admitted with unilateral leg swelling. Which intervention should the nurse implement?
- A. Elevate the affected leg on a pillow.
- B. Apply a warm compress to the affected leg.
- C. Perform passive range-of-motion exercises on the affected leg.
- D. Encourage the client to ambulate frequently.
Correct answer: A
Rationale: The correct intervention for a client with a history of deep vein thrombosis (DVT) and unilateral leg swelling is to elevate the affected leg on a pillow. Elevating the affected leg helps reduce swelling and pain by promoting venous return and preventing stasis of blood flow. Applying a warm compress (Choice B) may increase inflammation and worsen the condition. Performing passive range-of-motion exercises (Choice C) and encouraging ambulation (Choice D) can dislodge a clot and lead to potential embolism, making these choices contraindicated in a client with DVT.
5. Although non-steroidal anti-inflammatory drugs such as ibuprofen (Motrin) are beneficial in managing arthritis pain, the nurse should caution clients about which of the following common side effects?
- A. Urinary incontinence
- B. Constipation
- C. Nystagmus
- D. Occult bleeding
Correct answer: D
Rationale: The correct answer is D: Occult bleeding. Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are known to cause gastrointestinal side effects, including occult bleeding. Occult bleeding refers to bleeding in the gastrointestinal tract that may not be visible in the stool, leading to potential complications like anemia. Urinary incontinence (choice A) is not a common side effect of NSAIDs. Constipation (choice B) is also not a typical side effect associated with NSAIDs. Nystagmus (choice C) is an involuntary eye movement and is not a common side effect of NSAIDs. Therefore, the nurse should caution clients about the risk of occult bleeding when using NSAIDs for arthritis pain management.