HESI Test Bank Medical Surgical Nursing

Question 1 of 5

The healthcare provider prescribes Cytovene 375 mg every 12 hours to infuse over 90 minutes. The pharmacy delivers Cytovene 375 mg in a 150 mL IV bag. How many ml/hour should the nurse program the infusion pump?

A. 50 ml/hour. B. 75 ml/hour. C. 100 ml/hour. D. 125 ml/hour.

Correct Answer: C

Rationale:
To infuse 150 mL over 90 minutes, the pump should be set to 100 ml/hour (150 mL / 1.5 hours). This rate ensures that the medication is delivered at the proper rate as prescribed.

Choices A, B, and D are incorrect because they do not reflect the correct calculation based on the volume of the IV bag and the infusion duration provided in the question.

Question 2 of 5

When performing postural drainage on a client with chronic obstructive pulmonary disease (COPD), which approach should the nurse use?

A. Obtain arterial blood gases (ABGs) before the procedure. B. Explain that the client may be positioned in five different ways. C. Assist the patient into a position that will allow gravity to move secretions. D. Encourage the client to practice deep breathing throughout the procedure.

Correct Answer: C

Rationale: The correct approach when performing postural drainage on a client with COPD is to assist the patient into a position that allows gravity to help move secretions. This position helps drain secretions from specific segments of the lungs. Obtaining arterial blood gases (
Choice
A) is not directly related to postural drainage. While the client may be placed in multiple positions during postural drainage, the key is to position them to facilitate the movement of secretions, not just any five positions as mentioned in
Choice B. Encouraging deep breathing (
Choice
D) is a good nursing intervention for overall respiratory health but is not specifically related to the technique of postural drainage.

Question 3 of 5

A child has developed a diaper rash, and the parents are using zinc oxide to treat it. What does the nurse suggest to aid in the removal of the zinc oxide?

A. Mild soap and water B. A cotton ball C. Mineral oil D. Alcohol swabs

Correct Answer: C

Rationale:
To completely remove ointment, especially zinc oxide, mineral oil should be used. Mineral oil helps in gently breaking down and lifting the ointment without causing irritation. Mild soap and water (
Choice
A) may not be effective in completely removing zinc oxide. A cotton ball (
Choice
B) may not provide the necessary lubrication to aid in the removal process. Alcohol swabs (
Choice
D) can be harsh on the skin and are not recommended for this purpose.

Question 4 of 5

An older client is receiving an IV of 5% dextrose in 0.45% normal saline at 75 mL/hour. Which assessment finding indicates to the nurse that the client is developing a complication from this therapy?

A. Capillary refill takes > 3 seconds. B. Episodes of vertigo and loss of balance. C. Average daily output of 1200 ml. D. Pulse rate of 110 beats/minute and dyspnea upon exertion.

Correct Answer: D

Rationale: The correct answer is D. Tachycardia and dyspnea are signs of fluid overload, which is a potential complication of IV fluid therapy.

Choices A, B, and C are not directly related to fluid overload and are not typical signs of complications associated with the IV fluid therapy being administered.

Question 5 of 5

A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions?

A. Report when hematuria becomes pink-tinged B. Use incentive spirometer C. Restrict physical activities D. Monitor urinary stream for a decrease in output

Correct Answer: D

Rationale: After lithotripsy, monitoring the urinary stream for a decrease in output is essential to identify any potential complications such as urinary retention or obstruction. Reporting pink-tinged hematuria is important, but monitoring the urinary stream for a decrease in output takes precedence as it directly assesses renal function and potential complications. Using an incentive spirometer is not directly related to post-lithotripsy care. Restricting physical activities may be necessary initially but is not the priority compared to monitoring urinary output.

Nurselytic

HESI LPN

HESI LPN