HESI RN
HESI Medical Surgical Assignment Exam
1. A woman has been scheduled for a routine mammogram. What should the nurse tell the client?
- A. That mammography takes about 1 hour
- B. Not to eat or drink on the morning of the test
- C. That there is no discomfort associated with the procedure
- D. That deodorants, powders, or creams used in the axillary or breast area must be washed off before the test
Correct answer: D
Rationale: The correct answer is D. The nurse should instruct the client to avoid using deodorants, powders, or creams on the day of the mammogram. These products used in the axillary or breast area can interfere with the mammogram results and must be washed off before the test. Choices A, B, and C are incorrect because mammography typically takes less than 30 minutes, there is no need for fasting before the test, and some discomfort may be experienced during the procedure.
2. A client has a chest drainage system in place. The fluid in the water seal chamber rises and falls during inspiration and expiration. The nurse interprets this finding as an indication that:
- A. The tube is patent
- B. There is probably a kink in the tubing
- C. Suction should be added to the system
- D. The client is retaining airway secretions
Correct answer: A
Rationale: The correct answer is A: 'The tube is patent.' When the fluid in the water seal chamber rises and falls during inspiration and expiration, it indicates that the chest tube is patent, allowing for proper drainage. Choice B is incorrect because a kink in the tubing would obstruct the flow of fluid, leading to abnormal fluctuations in the water seal chamber. Choice C is incorrect as adding suction to the system is not indicated based on the described finding. Choice D is incorrect as the rising and falling of fluid in the water seal chamber is not indicative of the client retaining airway secretions.
3. A healthcare professional reviews the blood gas results of a client in respiratory distress. The pH is 7.32, and the PCO2 is 50 mm Hg. Which of the following acid-base imbalances does the professional recognize in these findings?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct answer: C
Rationale: In respiratory acidosis, the pH is low (<7.35) and the PCO2 is increased (>45 mm Hg). These findings indicate that the client is experiencing respiratory acidosis, a condition where there is an excess of carbon dioxide in the blood due to inadequate ventilation, commonly seen in respiratory distress. Metabolic acidosis (Choice A) is characterized by a low pH and decreased bicarbonate levels, which is not the case in this scenario. Metabolic alkalosis (Choice B) is associated with a high pH and increased bicarbonate levels. Respiratory alkalosis (Choice D) is marked by a high pH and decreased PCO2, opposite to the values presented in the blood gas results of this client.
4. A nurse cares for clients with urinary incontinence. Which types of incontinence are correctly paired with their clinical manifestations? (Select all that apply.)
- A. Stress incontinence – Urine loss with physical exertion
- B. Urge incontinence – Large amount of urine with each occurrence
- C. Overflow incontinence – Constant dribbling of urine
- D. All of the above
Correct answer: D
Rationale: The correct answer is D, as all the choices are correctly paired with their clinical manifestations. Stress incontinence is characterized by urine loss with physical exertion, coughing, sneezing, or exercising. Urge incontinence presents with a sudden and strong urge to void, often accompanied by a large amount of urine released during each occurrence. Overflow incontinence occurs when the bladder is distended, leading to a constant dribbling of urine. Functional incontinence, not mentioned in the options, is the leakage of urine due to factors unrelated to a lower urinary tract disorder. Reflex incontinence, also not mentioned, is a condition resulting from abnormal detrusor contractions.
5. The nurse is preparing to begin a medication regimen for a patient who will receive intravenous ampicillin and gentamicin. Which is an important nursing action?
- A. Administer each antibiotic to infuse over 15 to 20 minutes.
- B. Order serum peak and trough levels of ampicillin.
- C. Prepare the schedule so that the drugs are given at the same time.
- D. Set up separate tubing sets for each drug labeled with the drug name and date.
Correct answer: D
Rationale: When administering intravenous aminoglycosides like gentamicin with penicillins such as ampicillin, it is crucial to avoid mixing them in the same container. Separate tubing sets labeled with the drug name and date should be used to prevent interactions between the medications. Administering each antibiotic over 15 to 20 minutes (Choice A) may not be appropriate for all medications and does not address the issue of compatibility. Ordering serum peak and trough levels of ampicillin (Choice B) is important for monitoring drug levels but does not directly address the administration process. Preparing a schedule to give drugs simultaneously (Choice C) may increase the risk of drug interactions and is not recommended when administering incompatible medications.
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