HESI RN
HESI Medical Surgical Exam
1. Assessment of the diabetic client for common complications should include examination of the:
- A. Abdomen.
- B. Lymph glands.
- C. Pharynx.
- D. Eyes.
Correct answer: D
Rationale: The correct answer is D: Eyes. Diabetic clients are at high risk of developing complications such as diabetic retinopathy, making regular eye examinations crucial. Assessing the eyes helps in early detection and management of diabetic eye diseases. Choices A, B, and C are incorrect because while they may be relevant in certain assessments, they are not commonly associated with complications specific to diabetes. Examination of the abdomen, lymph glands, and pharynx are not typically part of routine assessments for common complications in diabetic clients.
2. The client with deep vein thrombosis (DVT) in the left lower leg is receiving heparin therapy. Which of the following assessments is the most important for the nurse to perform?
- A. Measure the circumference of the left leg.
- B. Assess for signs of bleeding, such as bruising or hematuria.
- C. Monitor the client's vital signs.
- D. Monitor the client's respiratory status.
Correct answer: B
Rationale: The most important assessment for a client with DVT on heparin therapy is to monitor for signs of bleeding, such as bruising or hematuria. Heparin is an anticoagulant medication that can increase the risk of bleeding. Assessing for bleeding is crucial to prevent complications like hemorrhage. Measuring the circumference of the leg may be relevant for assessing for edema but is not as critical as monitoring for bleeding. Monitoring vital signs and respiratory status are important aspects of care but are not the priority when the client is on heparin therapy for DVT.
3. After a session of hemodialysis, the nurse should monitor the client for which of the following complications of hemodialysis?
- A. Hyperkalemia.
- B. Hypotension.
- C. Infection.
- D. Fever.
Correct answer: B
Rationale: The correct answer is 'B: Hypotension.' Hypotension is a common complication of hemodialysis because fluid removal during the process can lead to a drop in blood pressure. The nurse should closely monitor the client for signs of hypotension such as dizziness, lightheadedness, or a decrease in blood pressure readings. Choice 'A: Hyperkalemia' is incorrect because hemodialysis actually helps lower potassium levels by removing excess potassium from the blood. Choice 'C: Infection' is incorrect as it is not a direct complication of hemodialysis but rather a risk associated with invasive procedures. Choice 'D: Fever' is incorrect as fever is not a typical immediate post-hemodialysis complication unless an underlying infection is present.
4. The client is preparing a morning dose of insulin, which includes 10 units of regular and 22 units of NPH. The nurse is verifying the client's preparation accuracy. What should the syringe read for the correct dose?
- A. 22 units.
- B. 10 units.
- C. 32 units.
- D. 42 units.
Correct answer: C
Rationale: The correct answer is 32 units. To determine the correct dose, the nurse needs to add the 10 units of regular insulin to the 22 units of NPH, resulting in a total of 32 units. Therefore, the syringe should read 32 units. Choices A, B, and D are incorrect because they do not reflect the accurate total dose required for the morning insulin administration.
5. Prior to administering tissue plasminogen activator (t-PA), the nurse should assess the client for which of the following contraindications to administering the drug?
- A. Age over 60 years.
- B. History of cerebral hemorrhage.
- C. History of heart failure.
- D. Cigarette smoking.
Correct answer: B
Rationale: The correct answer is B: History of cerebral hemorrhage. A history of cerebral hemorrhage is a contraindication to t-PA administration because of the increased risk of bleeding. Choices A, C, and D are incorrect. Age over 60 years is not a contraindication for t-PA administration. While older age may pose some risks, it is not an absolute contraindication. History of heart failure is not a direct contraindication to t-PA administration. Cigarette smoking, while a risk factor for cardiovascular disease, is not a specific contraindication for t-PA administration.
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