HESI RN
HESI Medical Surgical Test Bank
1. In a patient with diabetes, which of the following is a sign of hypoglycemia?
- A. Polydipsia
- B. Polyuria
- C. Dry skin
- D. Sweating
Correct answer: D
Rationale: Sweating is a common sign of hypoglycemia in patients with diabetes. When blood sugar levels drop too low, the body releases stress hormones like adrenaline, leading to symptoms such as sweating, shakiness, and palpitations. Polydipsia (excessive thirst) and polyuria (excessive urination) are more commonly associated with hyperglycemia (high blood sugar levels) in diabetes. Dry skin is not a typical symptom of hypoglycemia.
2. After checking the client’s gag reflex following an esophagogastroduodenoscopy (EGD), which action should the nurse take?
- A. Taking the client’s vital signs
- B. Giving the client a drink of water
- C. Monitoring the client for a sore throat
- D. Being alert to complaints of heartburn
Correct answer: A
Rationale: After an esophagogastroduodenoscopy (EGD), the nurse's priority is to assess the client's airway by checking the gag reflex. Once this assessment is done, the next step is to take the client's vital signs to monitor for any signs of complications such as bleeding or changes in respiratory status. Giving the client water immediately after the procedure may not be appropriate, as the client may still have a compromised gag reflex and is at risk for aspiration. Monitoring for a sore throat is important but not the immediate priority post-procedure. Being alert to complaints of heartburn is relevant for assessing the client's symptoms but is not the priority immediately after checking the gag reflex.
3. Upon arrival of a client transferred to the surgical unit, what should the nurse plan to do first?
- A. Assess the patency of the airway
- B. Check tubes and drains for patency
- C. Check the dressing for bleeding
- D. Assess the vital signs to compare them with preoperative measurements
Correct answer: A
Rationale: The initial action for the nurse upon the arrival of a client to the surgical unit is to assess the patency of the airway. This step takes priority to ensure that the client has a clear airway for adequate breathing. Checking tubes and drains for patency, inspecting the dressing for bleeding, and assessing vital signs to compare with preoperative measurements are important subsequent steps in the assessment process. However, ensuring the airway is patent is the immediate priority to maintain the client's respiratory function and overall well-being.
4. A male client with chronic kidney disease (CKD) is refusing to take his medication and has missed two hemodialysis appointments. What is the best initial action for the nurse?
- A. Discuss what the treatment regimen means to him.
- B. Refer the client to a mental health nurse practitioner.
- C. Reschedule the appointments to another date and time.
- D. Discuss the option of peritoneal dialysis.
Correct answer: A
Rationale: The best initial action for the nurse in this scenario is to have a discussion with the client about what the treatment regimen means to him. It is important to assess the client's anxiety, coping styles, and acceptance of the required treatment for CKD. The client may be in denial of the diagnosis or may have concerns that need to be addressed. While rescheduling hemodialysis appointments could be helpful, referring the client to a mental health nurse practitioner or discussing peritoneal dialysis are not the most appropriate first steps. Understanding the client's perspective and concerns is crucial before exploring other interventions.
5. A client is vomiting. For which acid-base imbalance does the nurse assess the client?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct answer: B
Rationale: In a client who is vomiting, the loss of gastric fluid containing hydrochloric acid can lead to metabolic alkalosis. Metabolic alkalosis is caused by the loss of acids such as hydrochloric acid from the body. Therefore, in this scenario, the nurse should assess the client for metabolic alkalosis. Choices A, C, and D are incorrect because vomiting does not typically lead to metabolic acidosis, respiratory acidosis, or respiratory alkalosis.
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