HESI RN
HESI Medical Surgical Exam
1. Which of the following assessments is the most important for a patient receiving IV potassium?
- A. Respiratory rate
- B. Heart rate
- C. Blood pressure
- D. Oxygen saturation
Correct answer: C
Rationale: The most important assessment for a patient receiving IV potassium is monitoring blood pressure. IV potassium can cause significant changes in cardiac function, leading to adverse effects such as arrhythmias and cardiac arrest. While respiratory rate, heart rate, and oxygen saturation are important parameters to monitor in clinical practice, blood pressure takes precedence in patients receiving IV potassium due to its direct impact on cardiovascular function. Changes in blood pressure can be an early indicator of potassium-induced cardiac complications, making it crucial to monitor closely during administration.
2. When preparing to examine a client’s skin using a Wood light, what should the nurse do to facilitate this procedure?
- A. Darken the examining room
- B. Administer a local anesthetic
- C. Obtain a signed informed consent
- D. Shave the skin and scrub it with povidone-iodine (Betadine)
Correct answer: A
Rationale: When using a Wood light to examine the skin, the nurse should darken the examining room. This is necessary because the Wood light emits long-wavelength UV light, which is better visualized in a darkened environment. Administering a local anesthetic (Choice B) is not needed for this procedure. Obtaining a signed informed consent (Choice C) is not directly related to using a Wood light for skin examination. Shaving the skin and scrubbing it with povidone-iodine (Betadine) (Choice D) is not required and may not be appropriate for this type of skin examination.
3. When a young client being taught to use an inhaler for asthma symptoms states the intention to use the inhaler but plans to continue smoking cigarettes, what is the best initial action by the nurse?
- A. Inform the healthcare provider of the client's statement.
- B. Explain that denial of illness can interfere with the treatment regimen.
- C. Revise the plan of care based on the client's plans to continue smoking.
- D. Review factors surrounding the client's beliefs about smoking cessation.
Correct answer: B
Rationale: The best initial action by the nurse when a client expresses plans to use an inhaler for asthma symptoms but continue smoking cigarettes is to address denial. By explaining that denial of illness can interfere with the treatment regimen, the nurse educates the client about the impact of smoking on asthma treatment. This approach helps the client understand the importance of smoking cessation in managing asthma symptoms. Informing the healthcare provider (Choice A) may be necessary but is not the initial action in this scenario. Revising the plan of care (Choice C) should be considered after addressing the client's denial and educating them. Reviewing factors surrounding the client's beliefs about smoking cessation (Choice D) is relevant but not the best initial action when denial is identified.
4. A client recovering from surgery has a large abdominal wound. Which of the following foods, high in vitamin C, should the nurse encourage the client to eat to promote wound healing?
- A. Steak
- B. Veal
- C. Cheese
- D. Oranges
Correct answer: D
Rationale: Oranges are a rich source of vitamin C, which is essential for wound healing due to its role in collagen synthesis. Citrus fruits like oranges, as well as other fruits and vegetables such as strawberries, kiwi, bell peppers, and broccoli, are high in vitamin C. Meats like steak and veal are not significant sources of vitamin C; they are primarily sources of protein. Cheese is not a good source of vitamin C but does provide calcium and protein.
5. When a patient starts taking amoxicillin, which foods should the nurse instruct the patient to avoid?
- A. Green leafy vegetables
- B. Beef and other red meat
- C. Coffee, tea, and colas
- D. Acidic fruits and juices
Correct answer: D
Rationale: The correct answer is D: Acidic fruits and juices. Amoxicillin can be irritating to the stomach, so avoiding acidic fruits and juices is recommended to reduce stomach discomfort or potential interactions. Green leafy vegetables (Choice A), beef and other red meat (Choice B), and coffee, tea, and colas (Choice C) are not typically contraindicated with amoxicillin. It is important to focus on acidic foods and beverages to promote comfort and effectiveness of the medication.
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