HESI RN
HESI Medical Surgical Practice Exam Quizlet
1. Which symptoms should the nurse expect a client to exhibit who is diagnosed with a pheochromocytoma?
- A. Numbness, tingling, and cramps in the extremities.
- B. Headache, diaphoresis, and palpitations.
- C. Cyanosis, fever, and classic signs of shock.
- D. Nausea, vomiting, and muscular weakness.
Correct answer: B
Rationale: Correct. Pheochromocytoma is a catecholamine-secreting non-cancerous tumor of the adrenal medulla. The classic triad of symptoms includes headache, diaphoresis (excessive sweating), and palpitations, which result from the overproduction of catecholamines like epinephrine and norepinephrine. Numbness, tingling, and cramps in the extremities (Option A) are not characteristic of pheochromocytoma. Cyanosis, fever, and classic signs of shock (Option C) are not typical symptoms of this condition. Nausea, vomiting, and muscular weakness (Option D) are not commonly associated with pheochromocytoma.
2. When caring for an older incontinent client at risk for infection, which intervention is best for the nurse to implement based on the nursing diagnosis of risk for infection?
- A. Maintain standard precautions.
- B. Initiate contact isolation measures.
- C. Insert an indwelling urinary catheter.
- D. Instruct the client in the use of adult diapers.
Correct answer: A
Rationale: The correct intervention for an older incontinent client at risk for infection is to maintain standard precautions. Standard precautions, which include proper handwashing, are essential in reducing the risk of infection transmission in vulnerable clients. Initiating contact isolation measures may not be necessary for all clients, and inserting an indwelling urinary catheter should be avoided unless medically necessary to prevent additional risks of infection. Instructing the client in the use of adult diapers is not an appropriate nursing intervention to prevent infection.
3. The husband and adult children of a woman who abuses alcohol ask the nurse what approach to use when her drinking behavior disrupts family plans. Which response is best for the nurse to provide?
- A. Destroy any hidden supplies of alcohol she has at home so she has to stay sober
- B. When she drinks, communicate how disruptive her behaviors are and the burden they inflict on the family
- C. Make her responsible for the consequences of her drinking behaviors
- D. Include her in family activities whether she is drinking or sober
Correct answer: C
Rationale: The best approach for the nurse to suggest is to make the woman responsible for the consequences of her drinking behaviors. By holding her accountable, she is more likely to recognize the impact of her actions and potentially initiate change. Destroying hidden alcohol supplies (Choice A) might lead to conflict and further secretive behavior. Simply communicating the disruptions caused by her drinking (Choice B) may not effectively address the issue. Including her in family activities regardless of her drinking status (Choice D) could enable the behavior and not address the underlying problem.
4. A 9-week-old infant is scheduled for cleft lip repair. Which information is most important for the nurse to convey to the surgeon before transporting the infant to the surgical suite?
- A. Red blood cell count of 2.3 million/mm³
- B. White blood cell count of 10,000/mm³
- C. Weight gain of 2 pounds since birth
- D. Urine specific gravity is 1.011
Correct answer: A
Rationale: The correct answer is A because a low red blood cell count may indicate anemia, which could pose risks during surgery. Anemia can affect oxygen delivery to tissues, impacting wound healing and overall surgical outcomes. The other options, such as white blood cell count, weight gain, and urine specific gravity, are less critical for immediate surgical considerations. White blood cell count is more related to infection risk postoperatively rather than immediate surgical risk. Weight gain reflects good overall growth but does not impact the immediate surgical situation. Urine specific gravity is more indicative of hydration status rather than immediate surgical risk.
5. After observing a mother giving her 11-month-old ferrous sulfate followed by two ounces of orange juice, what should the nurse do next?
- A. Suggest placing the iron drops in the orange juice and feed the infant.
- B. Tell the mother to follow the iron drops with formula instead of orange juice.
- C. Instruct the mother to feed the infant nothing in the next 30 minutes after the iron.
- D. Give positive feedback about the way she administered the sulfate.
Correct answer: D
Rationale: Providing positive feedback to the mother for correctly administering the iron supplements is essential as it reinforces proper medication administration practices. This encouragement can help build the mother's confidence and ensure that she continues to administer the supplements correctly in the future, promoting the infant's health and well-being. Choices A, B, and C are incorrect because there is no need to suggest altering the administration method, changing the liquid used, or restricting feeding immediately after administering the iron supplement. Giving positive feedback is the most appropriate action in this scenario to acknowledge the mother's correct administration technique.