HESI RN
HESI Medical Surgical Test Bank
1. 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.
2. A client has pyelonephritis and expresses embarrassment about discussing symptoms. How should the nurse respond?
- A. Assure the client that their symptoms will be kept confidential.
- B. Acknowledge the client's discomfort and avoid discussing elimination topics.
- C. Encourage the use of familiar language and assure the client they can take their time.
- D. Offer the client a nurse of the same gender to provide care.
Correct answer: C
Rationale: When a client expresses embarrassment or discomfort in discussing symptoms related to sensitive topics like elimination and the genitourinary area, the nurse should respond by encouraging the client to use words they are comfortable with. This helps the client feel more at ease and opens up communication. Offering a nurse of the same gender may not address the client's discomfort with discussing symptoms. Assuring confidentiality is important, but it should not be promised in a way that may not be fulfilled. Avoiding the topic of elimination entirely does not address the client's feelings or promote effective communication.
3. Which of the following medications is typically used to treat asthma?
- A. Aspirin
- B. Metformin
- C. Albuterol
- D. Lisinopril
Correct answer: C
Rationale: The correct answer is C, Albuterol. Albuterol is a bronchodilator commonly used to treat asthma by relaxing the muscles around the airways, helping to relieve symptoms such as coughing, wheezing, shortness of breath, and chest tightness. Aspirin (Choice A) is not typically used to treat asthma and can actually trigger asthma symptoms in some individuals. Metformin (Choice B) is a medication for managing type 2 diabetes and is not indicated for asthma treatment. Lisinopril (Choice D) is an angiotensin-converting enzyme (ACE) inhibitor primarily used to treat high blood pressure and heart failure, not asthma.
4. The nurse is caring for a client who is receiving an IV infusion of normal saline and notices that the infusion is not flowing. The insertion site is not inflamed or swollen. What should the nurse do first?
- A. Check the tubing for kinks or obstructions.
- B. Increase the flow rate to improve the infusion.
- C. Reinsert the IV catheter in another vein.
- D. Call the physician for further instructions.
Correct answer: A
Rationale: The correct first action for the nurse to take when an IV infusion is not flowing despite a normal insertion site is to check the tubing for kinks or obstructions. This step is crucial to ensure that there are no preventable issues impeding the flow of the IV solution. Increasing the flow rate without addressing potential obstructions could lead to complications such as infiltration. Reinserting the IV catheter in another vein should only be considered after ruling out tubing issues. Calling the physician for further instructions is not necessary at this stage as troubleshooting the tubing should be the initial intervention.
5. To assess the quality of an adult client's pain, what approach should the nurse use?
- A. Observe body language and movement.
- B. Ask the client to describe the pain.
- C. Identify effective pain relief measures.
- D. Provide a numeric pain scale.
Correct answer: B
Rationale: The correct answer is to ask the client to describe the pain. This approach allows the nurse to gather subjective information directly from the client, such as the quality, intensity, location, and factors that aggravate or alleviate the pain. Observing body language and movement (Choice A) can provide additional cues but may not fully capture the client's pain experience. Identifying effective pain relief measures (Choice C) and providing a numeric pain scale (Choice D) are important aspects of pain management but do not directly assess the quality of the client's pain.
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