a clients baseline vital signs are temperature 98 f oral pulse 74 beatsmin respiratory rate 18 breathsmin and blood pressure 12476 mm hg the client su
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Nursing Elites

HESI RN

HESI Medical Surgical Practice Quiz

1. A client’s baseline vital signs are temperature 98°F oral, pulse 74 beats/min, respiratory rate 18 breaths/min, and blood pressure 124/76 mm Hg. The client suddenly spikes a fever to 103°F. Which of the following respiratory rates would the nurse anticipate as part of the body’s response to the change in client status?

Correct answer: D

Rationale: When a client experiences a fever, there is an increase in body temperature, leading to a higher metabolic rate and oxygen demand. As a result, the respiratory rate typically increases to meet the body's increased oxygen needs. Therefore, in response to the fever spike from 98°F to 103°F, the nurse would anticipate a higher respiratory rate. Choices A, B, and C are incorrect because a decrease in body temperature, not an increase as seen in fever, would lead to a decrease in respiratory rate to conserve energy and oxygen consumption.

2. After confirming that liquids are allowed, which assessment action should the nurse consider a priority for a client who is fully awake after a gastroscopy?

Correct answer: D

Rationale: After a gastroscopy, it is crucial for the nurse to prioritize checking the client's gag and swallow reflexes before allowing them to drink anything. This is because the effects of local anesthesia need to dissipate, and the airway's protective reflexes, including the gag and swallow reflexes, must have returned to prevent aspiration. Listening to lung and bowel sounds (Choice A) may be important but does not take precedence over ensuring the client's safety post-gastroscopy. Obtaining the client's pulse and blood pressure (Choice B) is also important but not the priority in this scenario. Assisting the client to the bathroom to void (Choice C) is a routine nursing action and is not directly related to the immediate safety concern of checking the client's gag and swallow reflexes post-gastroscopy.

3. After educating a client with hypertension secondary to renal disease, the nurse assesses the client’s understanding. Which statement made by the client indicates a need for additional teaching?

Correct answer: B

Rationale: Choice B is incorrect because the client should not restrict fluids during the day due to increased urination at night. Clients with renal disease may be prescribed fluid restrictions, and they should be thoroughly assessed for potential dehydration. To decrease increased nocturnal voiding, clients should consume fluids earlier in the day. Choices A, C, and D are correct statements. Managing blood pressure is crucial to slow the progression of renal dysfunction. Limiting protein intake is important in renal disease management, and clients should be referred to a dietitian as needed. Taking antihypertensive medications as directed is essential for blood pressure control.

4. What discharge instruction is most important for a client after a kidney transplant?

Correct answer: C

Rationale: After a kidney transplant, it is crucial for the client to adhere to the prescribed immunosuppressive therapy to prevent organ rejection. The client must take medications like corticosteroids and azathioprine (Imuran) regularly for the rest of their life. Using daily reminders is essential to ensure compliance with the medication regimen, as missing doses can increase the risk of organ rejection. Weighing weekly, reporting symptoms of secondary Candidiasis, and stopping cigarette smoking are important aspects of post-transplant care but may not be as critical as ensuring proper intake of immunosuppressants to prevent rejection.

5. A client has the following arterial blood gas (ABG) results: pH 7.51, PCO2 31 mm Hg, PO2 94 mm Hg, HCO3 24 mEq/L. Which of the following acid-base disturbances does the nurse recognize in these results?

Correct answer: D

Rationale: The ABG results show a pH above the normal range (7.35-7.45) and a decreased PCO2, indicating respiratory alkalosis. In respiratory alkalosis, the pH is increased and the PCO2 is decreased. Metabolic acidosis (choice A) would present with a low pH and low HCO3 levels. Metabolic alkalosis (choice B) would show an increased pH and HCO3 levels. Respiratory acidosis (choice C) would have a low pH and an increased PCO2.

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