HESI RN
HESI Medical Surgical Test Bank
1. What is a key intervention for a patient with diabetic ketoacidosis (DKA)?
- A. Administering insulin
- B. Administering IV fluids
- C. Administering oral glucose
- D. Administering oral fluids
Correct answer: A
Rationale: Administering insulin is a crucial intervention for a patient with diabetic ketoacidosis (DKA) because it helps in managing hyperglycemia and ketosis by promoting the uptake of glucose by cells and inhibiting the production of ketones. IV fluids are necessary to correct dehydration and electrolyte imbalances commonly seen in DKA but are not the primary treatment for the condition. Administering oral glucose would exacerbate hyperglycemia in a patient with DKA, while administering oral fluids alone would not effectively address the underlying metabolic disturbances seen in DKA.
2. During nasotracheal suctioning, which of the following observations should be cause for concern to the nurse? Select all that apply.
- A. The client becomes cyanotic.
- B. Secretions are bloody.
- C. The client gags during the procedure.
- D. Clear to opaque secretions are removed.
Correct answer: C
Rationale: During nasotracheal suctioning, the client gagging during the procedure is a cause for concern as it can indicate discomfort or potential airway obstruction. Cyanosis, bloody secretions, or the removal of clear to opaque secretions are expected observations that the nurse should monitor for, but gagging indicates a need for immediate intervention to ensure the safety and comfort of the client. Cyanosis and bloody secretions can signify oxygenation issues and potential complications, while the removal of secretions is the goal of the suctioning procedure.
3. A healthcare professional is reviewing laboratory results for a client who is at risk for nephrotoxicity due to medications. Which of the following serum creatinine results does the healthcare professional document as normal?
- A. 0.2 mg/dL
- B. 1.0 mg/dL
- C. 2.8 mg/dL
- D. 3.9 mg/dL
Correct answer: B
Rationale: The normal serum creatinine level typically ranges from 0.6 to 1.3 mg/dL. A result of 1.0 mg/dL falls within this normal range. A serum creatinine level of 0.2 mg/dL is abnormally low and may indicate decreased muscle mass or malnutrition. On the other hand, results of 2.8 mg/dL and 3.9 mg/dL are elevated, signifying impaired kidney function and potential nephrotoxicity from medications.
4. Which of the following is a common cause of chronic obstructive pulmonary disease (COPD)?
- A. Smoking
- B. Asthma
- C. Allergies
- D. Chronic bronchitis
Correct answer: A
Rationale: Smoking is the correct answer as it is a well-established common cause of chronic obstructive pulmonary disease (COPD). Smoking leads to long-term damage to the lungs, contributing to the development of COPD. Choice B, asthma, is not a cause but a separate respiratory condition characterized by airway inflammation and hyperresponsiveness. Allergies, choice C, are not a direct cause of COPD but can exacerbate symptoms in individuals with existing COPD. Chronic bronchitis, choice D, is a type of COPD, not a cause of COPD itself, making it an incorrect choice in this context.
5. A client is receiving Cilostazol (Pletal) for peripheral arterial disease causing intermittent claudication. The nurse determines this medication is effective when the client reports which of the following?
- A. I am having fewer aches and pains.
- B. I do not have headaches anymore.
- C. I am able to walk further without leg pain.
- D. My toes are turning grayish black in color.
Correct answer: C
Rationale: The correct answer is C. Cilostazol improves blood flow to the muscles, which helps alleviate symptoms of intermittent claudication. An improvement in walking distance without leg pain indicates the effectiveness of the medication. Choices A and B are not directly related to the expected outcome of Cilostazol therapy for intermittent claudication. Choice D is concerning for a potential adverse effect and should be reported to the healthcare provider immediately.
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