HESI RN
HESI Medical Surgical Assignment Exam
1. The nurse is preparing to administer the first dose of hydrochlorothiazide (HydroDIURIL) 50 mg to a patient who has a blood pressure of 160/95 mm Hg. The nurse notes that the patient had a urine output of 200 mL in the past 12 hours. The nurse will perform which action?
- A. Administer the medication as ordered.
- B. Encourage the patient to drink more fluids.
- C. Hold the medication and request an order for serum BUN and creatinine.
- D. Request an order for serum electrolytes and administer the medication.
Correct answer: C
Rationale: The correct action is to hold the medication and request an order for serum BUN and creatinine. Thiazide diuretics, such as hydrochlorothiazide, are contraindicated in renal failure. In this case, the patient has oliguria, which is a reduced urine output, indicating potential renal insufficiency. Before administering the diuretic, it is crucial to evaluate the patient's renal function through serum BUN and creatinine levels. Encouraging the patient to drink more fluids (Choice B) may not address the underlying issue of renal function. Administering the medication as ordered (Choice A) without assessing renal function can be harmful. Requesting serum electrolytes and administering the medication (Choice D) overlooks the need for a specific evaluation of renal function in this scenario.
2. A client has just had a central line catheter placed that is specific for hemodialysis. What is the most appropriate action by the nurse?
- A. Use the catheter for the next laboratory blood draw.
- B. Monitor the central venous pressure through this line.
- C. Access the line for the next intravenous medication.
- D. Place a heparin or heparin/saline dwell after hemodialysis.
Correct answer: D
Rationale: The most appropriate action for the nurse after a central line catheter placement for hemodialysis is to place a heparin or heparin/saline dwell after hemodialysis treatment. This helps prevent clot formation in the line and maintain patency for future use. Using the catheter for blood draws is not recommended as it may increase the risk of infection. Monitoring central venous pressure is not indicated with this type of catheter. Accessing the line for medications is also not recommended to prevent complications and ensure the line is solely used for hemodialysis purposes.
3. A client with chronic renal failure is receiving epoetin alfa (Epogen). The nurse should assess the client for which of the following complications?
- A. Hypertension.
- B. Hypotension.
- C. Hyperglycemia.
- D. Edema.
Correct answer: A
Rationale: The correct answer is A: Hypertension. Epoetin alfa (Epogen) is known to increase blood pressure by stimulating red blood cell production. Monitoring for hypertension is crucial to prevent complications such as heart failure or stroke. Choices B, C, and D are incorrect because hypotension, hyperglycemia, and edema are not typically associated with epoetin alfa therapy in clients with chronic renal failure.
4. In the change-of-shift report, the nurse is told that a client has a Stage 2 pressure ulcer. Which ulcer appearance is most likely to be observed?
- A. Shallow open ulcer with a red-pink wound bed.
- B. A deep pocket of infection and necrotic tissues.
- C. An area of erythema that is painful to touch.
- D. Visible subcutaneous tissue with sloughing.
Correct answer: A
Rationale: A Stage 2 pressure ulcer typically presents as a shallow open ulcer with a red-pink wound bed. This appearance is characteristic of a Stage 2 pressure ulcer where there is partial thickness skin loss involving the epidermis and possibly the dermis. Choice B, a deep pocket of infection and necrotic tissues, is more indicative of a Stage 3 or Stage 4 pressure ulcer where the ulcer extends into deeper tissue layers. Choice C, an area of erythema that is painful to touch, is more commonly seen in early-stage pressure ulcers such as Stage 1. Choice D, visible subcutaneous tissue with sloughing, is characteristic of a more severe stage of pressure ulcer beyond Stage 2.
5. What types of medications should the healthcare provider expect to administer to a client during an acute respiratory distress episode?
- A. Vasodilators and hormones.
- B. Analgesics and sedatives.
- C. Anticoagulants and expectorants.
- D. Bronchodilators and steroids.
Correct answer: D
Rationale: During an acute respiratory distress episode, the priority is to widen air passages, increase air space, and reduce alveolar membrane inflammation. Therefore, the client would likely require bronchodilators to open up the airways and steroids to reduce inflammation. Vasodilators and hormones (Choice A) are not typically indicated in this situation. Analgesics and sedatives (Choice B) may be used for pain management and anxiety but are not primary treatments for respiratory distress. Anticoagulants and expectorants (Choice C) are not the main medications used during an acute respiratory distress episode and may not address the immediate needs of the client.
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