HESI RN
Evolve HESI Medical Surgical Practice Exam Quizlet Questions
Question 1 of 5
An older adult client with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. The client is anxious and complaining of a dry mouth. Which intervention should the nurse implement?
Correct Answer: A
Rationale: Assisting the client to an upright position is the most appropriate intervention in this scenario. An upright position helps optimize lung expansion and aids in improving ventilation, which can alleviate shortness of breath. This position also assists in reducing anxiety by providing a sense of control and comfort. Administering a sedative (
Choice
B) may further depress the respiratory drive in a client with COPD and should be avoided unless absolutely necessary. Applying a high-flow Venturi mask (
Choice
C) may be indicated later based on oxygenation needs, but the immediate focus should be on positioning. Encouraging the client to drink water (
Choice
D) may not directly address the respiratory distress and anxiety experienced by the client.
Question 2 of 5
A client with partial thickness burns to the lower extremities is scheduled for whirlpool therapy to debride the burned area. Which intervention should the nurse implement before transporting the client to the physical therapy department?
Correct Answer: C
Rationale: Before transporting the client for whirlpool therapy to debride the burned area, the nurse should give a prescribed narcotic analgesic agent. This intervention is essential to manage pain effectively during the debridement process. Obtaining supplies to re-dress the burn area (
Choice
A) is important but not as immediate as providing pain relief. Verifying the client's signed consent form (
Choice
B) is necessary for procedures but does not address the client's immediate pain needs. Performing active range-of-motion exercises (
Choice
D) is not indicated before whirlpool therapy for debridement of burns and may cause further discomfort to the client.
Question 3 of 5
A client diagnosed with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened, tenacious mucus, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurses to instruct the client about self-care?
Correct Answer: C
Rationale: Increasing the daily intake of oral fluids is crucial for clients with asthma and bronchitis as it helps to liquefy thickened mucus, making it easier to clear the airways and manage symptoms. This self-care measure can improve the client's ability to breathe more effectively.
Choice A is not the most immediate concern when addressing thickened mucus and breathing difficulties. While avoiding crowded areas is beneficial to prevent respiratory infections, it is not directly related to managing thickened secretions. Teaching anxiety reduction methods is important for overall well-being, but it does not directly address the physiological issue of thickened mucus in the airways.
Question 4 of 5
In a patient with cirrhosis, which of the following lab results is most concerning?
Correct Answer: D
Rationale: In a patient with cirrhosis, a low platelet count is the most concerning lab result. Thrombocytopenia, or low platelet count, is common in cirrhosis due to impaired platelet production in the liver. It significantly increases the risk of bleeding and can lead to serious complications such as hemorrhage. Elevated liver enzymes (
Choice
A) are expected in cirrhosis but may not directly indicate the severity of the disease. Low albumin levels (
Choice
B) are common in cirrhosis and can contribute to fluid retention but do not pose an immediate risk of bleeding. Elevated bilirubin levels (
Choice
C) are also expected in cirrhosis and typically indicate impaired liver function but do not directly increase the risk of bleeding as much as a low platelet count.
Question 5 of 5
When assessing the lower extremities of a client with peripheral vascular disease (PVD), the nurse notes bilateral ankle edema. The edema is related to:
Correct Answer: D
Rationale: The correct answer is 'Increased venous pressure.' In peripheral vascular disease (PV
D), impaired blood flow leads to increased venous pressure in the lower extremities, causing fluid to leak out of the blood vessels and accumulate as edema.
Choice A, 'Competent venous valves,' is incorrect because in PVD, the venous valves may be incompetent, contributing to venous pooling and edema.
Choice B, 'Decreased blood volume,' is incorrect as PVD is associated with impaired blood flow rather than reduced blood volume.
Choice C, 'Increase in muscular activity,' is incorrect as it does not directly relate to the development of edema in PVD.