HESI RN
HESI Medical Surgical Assignment Exam Questions
Question 1 of 5
After delegating to an unlicensed assistive personnel (UAP) the task of completing a bladder scan examination for a client, the nurse evaluates the UAP's performance. Which action by the UAP indicates the nurse must provide additional instructions when delegating this task?
Correct Answer: A
Rationale: The correct answer is A because the UAP should select the female icon for women who have not had a hysterectomy to allow the scanner to subtract the volume of the uterus from readings. If a woman has had a hysterectomy, the UAP should choose the male icon.
Choice B is incorrect as it is essential for the UAP to explain the procedure to the client to ensure understanding.
Choice C is incorrect because applying ultrasound gel to the scanning head and cleaning it after use are appropriate actions.
Choice D is incorrect as it is necessary for the UAP to take at least two readings using the aiming icon to position the scanning head accurately for an effective bladder scan examination.
Question 2 of 5
The patient is beginning furosemide and has started a 2-week course of a steroid medication. What should the nurse recommend?
Correct Answer: C
Rationale: When a patient is taking furosemide and a steroid medication, there is an increased risk of potassium loss due to the interaction between the two drugs. Consuming licorice should be avoided as it can worsen potassium loss. Reporting a urine output less than 600 mL/24 hours is not directly related to the drug interaction and may not be necessary. Taking furosemide at bedtime is not the primary concern when a patient is concurrently on a steroid medication and furosemide.
Therefore, obtaining an order for a potassium supplement is the most appropriate recommendation to counteract the potential potassium loss.
Question 3 of 5
A nurse is conducting an assessment of a client who underwent thoracentesis of the right side of the chest 3 hours ago. Which findings does the nurse report to the physician? Select all that apply.
Correct Answer: A
Rationale: After thoracentesis, the nurse should assess the client for signs of pneumothorax, which include increased respiratory rate, dyspnea, retractions, unequal chest expansion, diminished breath sounds, and cyanosis. Unequal chest expansion is a key sign of pneumothorax due to the accumulation of air in the pleural space, causing the affected lung to collapse partially. Pulse rate and respiratory rate within normal ranges, like in choices B and C, are not the priority findings to report in this situation. Diminished breath sounds in the right lung could be expected after thoracentesis and may not necessarily indicate a complication like pneumothorax, making choice D less urgent to report.
Question 4 of 5
The nurse is preparing to begin a medication regimen for a patient who will receive intravenous ampicillin and gentamicin. Which is an important nursing action?
Correct Answer: D
Rationale: When administering intravenous aminoglycosides like gentamicin with penicillins such as ampicillin, it is crucial to avoid mixing them in the same container. Separate tubing sets labeled with the drug name and date should be used to prevent interactions between the medications. Administering each antibiotic over 15 to 20 minutes (
Choice
A) may not be appropriate for all medications and does not address the issue of compatibility. Ordering serum peak and trough levels of ampicillin (
Choice
B) is important for monitoring drug levels but does not directly address the administration process. Preparing a schedule to give drugs simultaneously (
Choice
C) may increase the risk of drug interactions and is not recommended when administering incompatible medications.
Question 5 of 5
A 70-kg adult with chronic renal failure is on a 40-g protein diet. The client has a reduced glomerular filtration rate and is not undergoing dialysis. Which result would give the nurse the most concern?
Correct Answer: A
Rationale: In chronic renal failure, a protein-restricted diet is crucial to prevent the buildup of waste products. A low albumin level (<3.5 g/dL) indicates inadequate protein intake, raising concern as it may lead to malnutrition and tissue breakdown. Phosphorus, sodium, and potassium levels are not directly impacted by protein intake. Phosphorus levels may elevate in renal failure, but at 5 mg/dL, it is within normal range. Sodium and potassium levels are also within normal limits and not influenced by protein restriction.