HESI RN
HESI Medical Surgical Assignment Exam
1. When preparing a client for intravenous pyelography (IVP), which action by the nurse is most important?
- A. Administering a sedative
- B. Encouraging fluid intake
- C. Administering an oral preparation of radiopaque dye
- D. Questioning the client about allergies to iodine or shellfish
Correct answer: D
Rationale: The most crucial action for the nurse when preparing a client for intravenous pyelography (IVP) is to question the client about allergies to iodine or shellfish. Some IVP dyes contain iodine, and if the client is allergic to iodine or shellfish, they may experience severe allergic reactions such as itching, hives, rash, throat tightness, difficulty breathing, or bronchospasm. Administering a sedative (Choice A) may be needed for relaxation during the procedure, encouraging fluid intake (Choice B) is generally beneficial but not the most crucial for IVP preparation, and administering radiopaque dye (Choice C) should only be done after confirming the client's safety regarding allergies to iodine or shellfish.
2. A client who has undergone pleural biopsy is being monitored by a nurse. Which finding indicates a potential complication for the client?
- A. Warm, dry skin
- B. Mild pain at the biopsy site
- C. Complaints of shortness of breath
- D. Capillary refill time of less than 3 seconds
Correct answer: C
Rationale: Complaints of shortness of breath are a concerning finding post-pleural biopsy, as they may indicate a complication such as a pneumothorax or hemothorax. Shortness of breath can be a sign of respiratory distress that requires immediate attention. Warm, dry skin, mild pain at the biopsy site, and a capillary refill time of less than 3 seconds are not typically associated with immediate complications following a pleural biopsy. Warm, dry skin may be a normal finding, mild pain can be expected at the biopsy site, and a capillary refill time of less than 3 seconds is within normal limits.
3. The client with chronic renal failure is receiving instruction on dietary restrictions. Which of the following food items should the client be instructed to avoid?
- A. Bananas.
- B. Apples.
- C. Rice.
- D. Potatoes.
Correct answer: A
Rationale: The correct answer is A: Bananas. Bananas are high in potassium, and individuals with chronic renal failure are often advised to limit potassium intake to prevent hyperkalemia. Apples, rice, and potatoes are lower in potassium and can be included in moderation in the diet of clients with chronic renal failure.
4. A client is being prepared for transfer to the operating room. Which of the following actions should the nurse take in the care of this client at this time?
- A. Ensuring that the client has voided
- B. Administering all daily medications
- C. Practicing postoperative breathing exercises
- D. Verifying that the client has not eaten for the last 24 hours
Correct answer: A
Rationale: The nurse should ensure that the client has voided, especially if a Foley catheter is not in place. This step is important to prevent urinary retention during the surgical procedure. Administering all daily medications just before surgery is not standard practice. The physician typically provides specific orders regarding which medications can be taken with a sip of water before surgery. Postoperative breathing exercises are usually taught after surgery to prevent complications like atelectasis. Verifying that the client has not eaten for the last 24 hours is not a standard preoperative practice; instead, the client is usually instructed to fast for a specific period before surgery to reduce the risk of aspiration during anesthesia.
5. What is the most common symptom of hypoglycemia that the nurse should teach the diabetic client to recognize?
- A. Nervousness
- B. Anorexia
- C. Kussmaul's respirations
- D. Bradycardia
Correct answer: A
Rationale: Nervousness is the most common symptom of hypoglycemia. It is often accompanied by other signs such as weakness, perspiration, confusion, and palpitations. Anorexia (lack of appetite) is not a typical symptom of hypoglycemia; it is more commonly associated with hyperglycemia. Kussmaul's respirations are a deep and labored breathing pattern seen in diabetic ketoacidosis, not hypoglycemia. Bradycardia (slow heart rate) is not a typical symptom of hypoglycemia; tachycardia (fast heart rate) is more commonly associated with hypoglycemia due to the release of catecholamines in response to low blood sugar.
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