hesi test bank medical surgical nursing HESI Test Bank Medical Surgical Nursing - Nursing Elites
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Nursing Elites

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HESI Test Bank Medical Surgical Nursing

1. The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take?

Correct answer: A

Rationale: When the nurse observes that the distal tip of the client's finger is reddened and engorged after milking, it indicates adequate blood flow. At this point, the appropriate action is to collect the blood sample for glucose level testing. Assessing radial pulse volume (Choice B) is unrelated to the situation and not necessary. Applying pressure to the site (Choice C) may disrupt the blood sample collection process. Selecting another finger (Choice D) is not warranted as the engorgement indicates sufficient blood flow for sampling.

2. A client with peptic ulcer disease is prescribed sucralfate. What is the mechanism of action of this medication?

Correct answer: C

Rationale: The correct answer is C: Covers the ulcer site and protects it from acid. Sucralfate works by forming a protective barrier over ulcers, shielding them from stomach acid and promoting healing. Choice A, neutralizing stomach acid, is incorrect as sucralfate does not neutralize acid but acts as a physical barrier. Choice B, decreasing gastric acid secretion, is not the mechanism of action of sucralfate. Choice D, improving gastric motility, is unrelated to sucralfate's action on peptic ulcers.

3. A client who experienced partial-thickness burns with over 50% body surface area (BSA) 2 weeks ago suddenly becomes restless and agitated.

Correct answer: D

Rationale: In a burn patient with sudden restlessness and agitation, it is crucial to consider hypoxia or other critical conditions. As such, notifying the rapid response team is the most appropriate action to ensure prompt assessment and intervention. Increasing room temperature (Choice A) is not the priority in this scenario. While monitoring vital signs (Choice C) is important, the sudden change in behavior warrants immediate action. Assessing oxygen saturation (Choice B) is a step in the right direction, but involving the rapid response team ensures a comprehensive evaluation and timely management of the patient's condition.

4. A client with a history of seizures is prescribed phenytoin. Which side effect should the nurse instruct the client to report?

Correct answer: B

Rationale: The correct answer is B: Gingival hyperplasia. Phenytoin is known to cause gingival hyperplasia, which is an overgrowth of gum tissue. This side effect is important to report to the healthcare provider because it can lead to oral health problems. Choice A, drowsiness, is a common side effect of many antiepileptic drugs but is not specific to phenytoin. Choice C, weight gain, is not a typical side effect of phenytoin. Choice D, blurred vision, is not a common side effect of phenytoin; it is more commonly associated with other medications.

5. A client with hypertension is prescribed a low-sodium diet. Which food should the client avoid?

Correct answer: B

Rationale: The correct answer is B: Processed cheese. Processed cheese is high in sodium and should be avoided in a low-sodium diet for clients with hypertension. Fresh fruits, whole grain bread, and fresh vegetables are generally low in sodium and can be part of a healthy diet for clients with hypertension.

Similar Questions

A client with hypertension is prescribed a low-sodium diet. Which food should the client avoid?
An adult client who received partial-thickness and full-thickness burns over 40% of the body in a house fire is admitted to the inpatient burn unit.
The nurse is assessing a client who reports sudden onset of severe eye pain and blurred vision. What is the priority nursing intervention?
In the change of shift report, the nurse is told that a client has a stage 2 pressure ulcer. Which ulcer appearance is most likely to be observed?
A client with Addison's disease started taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor which serum laboratory value?
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