HESI RN
HESI Medical Surgical Test Bank Questions
Question 1 of 5
After the administration of t-PA, what should the nurse do?
Correct Answer: A
Rationale: After the administration of t-PA, the nurse should observe the client for chest pain. Chest pain post t-PA administration could indicate reocclusion of the coronary artery, a serious complication that requires immediate intervention. Monitoring for fever (choice
B) is not specifically associated with t-PA administration. While reviewing the 12-lead ECG (choice
C) is important for assessing cardiac function, it may not be the immediate priority right after t-PA administration. Auscultating breath sounds (choice
D) is important for assessing respiratory status but is not the most crucial assessment following t-PA administration.
Question 2 of 5
Which of the following is the best indicator of fluid balance in a patient with heart failure?
Correct Answer: A
Rationale: Daily weight measurements are the best indicator of fluid balance in a patient with heart failure. Changes in weight reflect fluid retention or loss more accurately than other methods. Monitoring intake and output (choice
B) is essential but may not provide a comprehensive picture of fluid status. Skin turgor (choice
C) and checking for peripheral edema (choice
D) are more indicative of dehydration and fluid overload, respectively, rather than overall fluid balance.
Question 3 of 5
The healthcare provider is assessing a client who is receiving hemodialysis for the first time. Which of the following findings should be reported to the healthcare provider immediately?
Correct Answer: B
Rationale: Nausea and vomiting are critical symptoms that should be reported immediately when a client is receiving hemodialysis for the first time. These symptoms could indicate a severe complication, such as hypotension, infection, electrolyte imbalance, or other adverse reactions to the procedure. It is essential to address these symptoms promptly to prevent further complications or harm to the client.
Choices A, C, and D are not immediate concerns during the first hemodialysis session and can be addressed appropriately after addressing the urgent issue of nausea and vomiting.
Question 4 of 5
The best indicator that the client has learned how to give an insulin self-injection correctly is when the client can:
Correct Answer: A
Rationale: The best indicator of learning is the ability to perform the procedure safely and correctly, demonstrating skill acquisition.
Choice A is correct because the client's ability to perform the insulin self-injection safely and correctly shows practical understanding and application of the skill.
Choice B is incorrect because critiquing the nurse's performance does not necessarily demonstrate the client's ability to carry out the procedure themselves.
Choice C is incorrect as merely explaining the steps verbally does not confirm the client's practical execution of the task.
Choice D is also incorrect as answering a post-test does not directly assess the client's ability to physically perform the insulin self-injection.
Question 5 of 5
The nurse instructs the unlicensed nursing personnel (UAP) on how to provide oral hygiene for clients who cannot perform this task for themselves. Which of the following techniques should the nurse tell the UAP to incorporate into the client's daily care?
Correct Answer: B
Rationale: The correct technique to incorporate into the client's daily care for oral hygiene is to use a soft toothbrush to brush the client's teeth after each meal. This helps in maintaining oral hygiene for clients who cannot perform this task themselves.
Choice A is incorrect because assessing the oral cavity each time mouth care is given is important but not the technique to incorporate into daily care.
Choice C is incorrect as swabbing the tongue, gums, and lips every 2 hours may not be necessary for daily care.
Choice D is incorrect as rinsing the client's mouth with mouthwash several times a day may not be suitable for all clients and is not a standard recommendation for daily oral care.