HESI RN
Hesi Med Surg Exam 1 Questions
Question 1 of 5
A client with a seizure disorder is seen at the clinic for a follow-up visit and a prescription renewal for phenytoin. Which assessment finding warrants immediate intervention by the nurse?
Correct Answer: C
Rationale: Double vision, or diplopia, can indicate phenytoin toxicity, which is a serious condition that may lead to impaired vision and increased risk of falls or injuries. This side effect suggests that the patient may be experiencing adverse reactions to the medication, necessitating prompt evaluation and intervention, such as checking serum phenytoin levels and possibly adjusting the medication regimen.
Question 2 of 5
A young adult client with osteoarthritis of both knees expresses the desire to continue daily walks in the park with friends. How should the nurse respond?
Correct Answer: A
Rationale: Encouraging the client to continue their walking routine supports their desire to stay active and promotes muscle strength, flexibility, and overall well-being, which are beneficial for managing osteoarthritis.
Question 3 of 5
The nurse is preparing a client for surgery who was admitted to the emergency center following a motor vehicle collision. The client has a fracture of the femur and is bleeding at the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin subcutaneously daily. Which is the priority nursing action?
Correct Answer: A
Rationale: Notifying the healthcare provider of the client's heparin use is critical as it increases bleeding risk, requiring potential adjustments to the surgical plan or anticoagulation management.
Question 4 of 5
A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?
Correct Answer: A
Rationale: Lower back pain and hypotension are indicative of an acute ABO incompatibility reaction, which can lead to severe complications like hemolysis or shock, requiring immediate reporting and intervention.
Question 5 of 5
A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?
Correct Answer: A
Rationale: Lower back pain and hypotension signify a severe ABO incompatibility reaction, necessitating urgent reporting to prevent life-threatening complications such as renal failure or disseminated intravascular coagulation.