Medical Surgical HESI 2023

Question 1 of 5

A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 101 degrees F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to implement first?

A. Obtain oxygen saturation level. B. Encourage incentive spirometry. C. Assess lower extremity circulation D. Administer PRN oral antipyretic.

Correct Answer: D

Rationale: Administering an antipyretic is the most important intervention. The client presents with an elevated temperature, tachycardia, and tachypnea, indicating a fever. Lowering the temperature with an antipyretic is crucial to prevent complications like dehydration, altered mental status, and increased oxygen demand. While assessing lower extremity circulation and oxygen saturation are important, addressing the elevated temperature takes priority in this scenario. Incentive spirometry may be beneficial but is not the priority compared to managing the fever.

Question 2 of 5

A client with ulcerative colitis is experiencing frequent diarrhea. What is the priority nursing diagnosis?

A. Risk for impaired skin integrity B. Fluid volume deficit C. Imbalanced nutrition: less than body requirements D. Activity intolerance

Correct Answer: B

Rationale: The correct answer is B: Fluid volume deficit. In a client with ulcerative colitis experiencing frequent diarrhea, the priority nursing diagnosis is addressing the potential fluid volume deficit due to significant fluid loss. Maintaining adequate hydration is crucial to prevent complications associated with dehydration. While choices A, C, and D can also be concerns for a client with ulcerative colitis, addressing fluid volume deficit takes precedence as it directly impacts the client's physiological stability and can lead to serious complications if not managed promptly.

Question 3 of 5

A client with deep vein thrombosis (DVT) is receiving heparin therapy. Which laboratory test should the nurse monitor to evaluate the effectiveness of the heparin?

A. Complete blood count (CBC) B. Activated partial thromboplastin time (aPTT) C. Prothrombin time (PT) D. International normalized ratio (INR)

Correct Answer: B

Rationale: The correct answer is B: Activated partial thromboplastin time (aPTT). This test is used to monitor the effectiveness of heparin therapy. A complete blood count (CB
C) (choice
A) is not specific for monitoring heparin therapy. Prothrombin time (PT) (choice
C) and International normalized ratio (INR) (choice
D) are more commonly used to monitor warfarin therapy, not heparin.

Question 4 of 5

An unlicensed assistive personnel (UAP) reports to the nurse that a client with a postoperative wound infection has a temperature of 103.8°F, blood pressure 90/70, pulse 124 beats/min, and respirations of 28 breaths/min. When the nurse assesses the client's findings, they include a mottled skin appearance and confusion. Which action should the nurse take first?

A. Obtain a wound specimen for culture. B. Initiate an infusion of intravenous (IV) fluids. C. Transfer the client to the ICU. D. Assess the client's core temperature.

Correct Answer: B

Rationale: The correct action for the nurse to take first is to initiate an infusion of intravenous (IV) fluids. In this scenario, the client is showing signs of sepsis, indicated by a high temperature, low blood pressure, rapid heart rate, and increased respiratory rate. Mottled skin appearance and confusion are also signs of poor perfusion. Initiating IV fluids is crucial in treating sepsis to maintain blood pressure and perfusion. Obtaining a wound specimen for culture (
Choice
A) can be important but is not the priority at this moment. Transferring the client to the ICU (
Choice
C) can be considered after stabilizing the client. Assessing the client's core temperature (
Choice
D) is not the immediate priority compared to addressing the signs of sepsis and poor perfusion.

Question 5 of 5

The nurse is caring for a client with a nasogastric tube. Which action should the nurse take to ensure proper functioning of the tube?

A. Flush the tube with 50 mL of normal saline every 8 hours B. Clamp the tube when not in use C. Position the client in a supine position D. Verify tube placement by checking pH of gastric contents

Correct Answer: D

Rationale: Verifying tube placement by checking the pH of gastric contents is crucial to ensure the nasogastric tube is correctly positioned in the stomach. This action helps prevent complications such as aspiration. Flushing the tube with normal saline every 8 hours is not necessary for ensuring proper functioning of the tube. Clamping the tube when not in use may lead to the build-up of gastric secretions and blockages. Positioning the client in a supine position is not directly related to ensuring the proper functioning of the nasogastric tube.

Nurselytic

HESI LPN

HESI LPN