HESI RN
HESI Medical Surgical Practice Exam Quizlet
1. A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client?
- A. Losing weight.
- B. Decreasing caffeine intake.
- C. Avoiding large meals.
- D. Raising the head of the bed on blocks.
Correct answer: D
Rationale: The correct answer is to raise the head of the bed on blocks (reverse Trendelenburg position). This elevation helps reduce reflux by using gravity to keep stomach contents from flowing back into the esophagus during sleep. Losing weight (Choice A) could be beneficial in managing GERD, but it may not be as effective for immediate relief during sleep. Decreasing caffeine intake (Choice B) and avoiding large meals (Choice C) are also valuable recommendations to manage GERD; however, they may not specifically address the issue of reflux during sleep as directly and effectively as elevating the head of the bed.
2. In a client with congestive heart failure, the nurse would be correct in withholding a dose of digoxin without specific instruction from the healthcare provider if the client's
- A. serum digoxin level is 1.5 ng/mL.
- B. blood pressure is 104/68 mmHg.
- C. serum potassium level is 3 mEq/L.
- D. apical pulse is 68/min.
Correct answer: C
Rationale: The correct answer is C. Hypokalemia can precipitate digitalis toxicity in individuals on digoxin, increasing the risk of dangerous dysrhythmias. A serum potassium level of 3 mEq/L is below the normal range (3.5 to 5.5 mEq/L) and indicates hypokalemia, which can potentiate the effects of digoxin. Choices A, B, and D are not directly related to the potential for digitalis toxicity. Serum digoxin level of 1.5 ng/mL is within the therapeutic range, blood pressure of 104/68 mmHg is not a contraindication for administering digoxin, and an apical pulse of 68/min is within the normal range and not a reason to withhold digoxin.
3. A 20-year-old female client calls the nurse to report a lump she found in her breast. Which response is the best for the nurse to provide?
- A. Check it again in one month, and if it is still there schedule an appointment.
- B. Most lumps are benign, but it is always best to come in for an examination.
- C. Try not to worry too much about it, because usually, most lumps are benign.
- D. If you are in your menstrual period it is not a good time to check for lumps.
Correct answer: B
Rationale: The nurse advising the client to come in provides the best response because it addresses the client's anxiety most effectively and encourages prompt and immediate action for a potential problem.
4. A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets about:
- A. Preparing the client for a perfusion scan
- B. Attaching the client to a cardiac monitor
- C. Administering oxygen via nasal cannula
- D. Ensuring that the intravenous (IV) line is patent
Correct answer: C
Rationale: When a client who has just undergone surgery experiences sudden chest pain, dyspnea, and tachypnea, indicating possible pulmonary embolism, the immediate priority for the nurse is to administer oxygen via nasal cannula. This intervention aims to improve oxygenation and alleviate respiratory distress, which is crucial in the setting of a potential pulmonary embolism. Preparing the client for a perfusion scan is not the immediate priority as stabilizing the client's respiratory status comes first. While attaching the client to a cardiac monitor is important for monitoring, administering oxygen takes precedence in this situation. Ensuring IV line patency is relevant for overall client care but is not the priority when a client is experiencing respiratory distress requiring immediate intervention.
5. A 49-year-old female client arrives at the clinic for an annual exam and asks the nurse why she becomes excessively diaphoretic and feels warm during nighttime. What is the nurse's best response?
- A. Explain the effects of follicle-stimulating and luteinizing hormones.
- B. Discuss perimenopause and related comfort measures.
- C. Assess lung fields and check for a cough productive of blood-tinged mucus.
- D. Inquire if a fever above 101°F (38.3°C) has occurred in the last 24 hours.
Correct answer: B
Rationale: The correct answer is B. The symptoms described by the client, excessive diaphoresis and feeling warm at night, are characteristic of perimenopause. During this period, lower estrogen levels lead to surges in follicle-stimulating hormone (FSH) and luteinizing hormone (LH), resulting in vasomotor instability, night sweats, and hot flashes. Therefore, discussing perimenopause and related comfort measures with the client is essential to provide education and support. Choice A is incorrect because explaining the effects of FSH and LH alone does not directly address the client's current symptoms. Choice C is irrelevant as it focuses on assessing lung fields and cough symptoms, which are not related to the client's menopausal symptoms. Choice D is not the best response as it is more focused on ruling out fever as a cause, which is not typically associated with the symptoms described by the client.
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