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. What is the most important nursing intervention for a patient with increased intracranial pressure (ICP)?
- A. Elevate the head of the bed to 30 degrees.
- B. Administer diuretics to reduce fluid volume.
- C. Administer corticosteroids to reduce inflammation.
- D. Keep the patient in a supine position.
Correct answer: A
Rationale: Elevating the head of the bed to 30 degrees is crucial for a patient with increased intracranial pressure (ICP) because it helps promote venous drainage from the brain, thereby reducing ICP. Keeping the head of the bed elevated helps facilitate cerebral perfusion and can prevent a further increase in ICP. Administering diuretics (Choice B) may be considered in some cases to reduce fluid volume, but it is not the most critical intervention for immediate ICP management. Administering corticosteroids (Choice C) is not typically indicated for managing increased ICP unless there is a specific underlying condition requiring their use. Keeping the patient in a supine position (Choice D) can actually worsen ICP by impeding venous outflow from the brain, making it an incorrect choice for this scenario.
3. The client has had a femoral-popliteal bypass surgery 6 hours ago. Which assessment provides the most accurate information about the client's postoperative status?
- A. Radial pulse.
- B. Femoral pulse.
- C. Apical pulse.
- D. Dorsalis pedis pulse.
Correct answer: D
Rationale: Assessing the dorsalis pedis pulse is crucial after a femoral-popliteal bypass surgery to determine adequate circulation distal to the surgical site. A strong dorsalis pedis pulse indicates sufficient blood flow to the foot, which is essential for monitoring postoperative status. The radial pulse (A) is not the most relevant assessment as it does not provide direct information on circulation in the lower extremities. The femoral pulse (B) may not accurately reflect circulation distal to the surgical site. The apical pulse (C) is used primarily to assess the heartbeat and cardiac function, not circulation in the lower extremities.
4. When performing a health history on a patient who is to begin receiving a thiazide diuretic to treat heart failure, the nurse will be concerned about a history of which condition?
- A. Asthma
- B. Glaucoma
- C. Gout
- D. Hypertension
Correct answer: C
Rationale: Thiazide diuretics block uric acid secretion, leading to elevated levels that can contribute to gout. Therefore, patients with a history of gout should take thiazide diuretics with caution. Asthma (Choice A), Glaucoma (Choice B), and Hypertension (Choice D) are not directly contraindicated with thiazide diuretics, making choices A, B, and D incorrect.
5. A client with chronic renal failure is being treated with sodium polystyrene sulfonate (Kayexalate). The nurse should monitor the client for which of the following?
- A. Hyponatremia.
- B. Hypokalemia.
- C. Hyperkalemia.
- D. Hypocalcemia.
Correct answer: C
Rationale: The correct answer is C: Hyperkalemia. Sodium polystyrene sulfonate (Kayexalate) is used to treat high potassium levels (hyperkalemia) by exchanging sodium ions for potassium ions in the large intestine, which is then eliminated through the feces. Therefore, the nurse should monitor the client for changes in potassium levels to ensure the effectiveness of the treatment. Choices A, B, and D are incorrect because sodium polystyrene sulfonate (Kayexalate) is not associated with causing hyponatremia, hypokalemia, or hypocalcemia.
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