HESI RN
HESI RN Med Surg Final Questions
Question 1 of 5
A client is admitted with a deep, productive cough, hemoptysis, and a low grade fever. The client's tuberculin skin test (TST) has a 15 mm induration. Which intervention should the nurse implement first?
Correct Answer: C
Rationale: The client's symptoms and positive tuberculin skin test strongly suggest active tuberculosis. The highest priority is preventing disease transmission to others through airborne precautions. Tuberculosis spreads via airborne droplets when the client coughs, talks, or sneezes. Placing the client in a negative pressure room with airborne precautions immediately protects healthcare workers and other patients. While collecting sputum for acid-fast bacillus testing is necessary for diagnosis, this should not delay isolation. Administering antitubercular medications is important but not the immediate first step. Providing a mask for public areas is insufficient in a healthcare setting where closer contact occurs.
Question 2 of 5
The nurse is preparing a client for an outpatient thoracentesis. Which statement made by the client should the nurse recognize as needing additional education?
Correct Answer: D
Rationale: A persistent cough after thoracentesis is not typical and could indicate complications like pneumothorax. The client should report this symptom immediately. A stinging sensation during local anesthetic injection is expected. Limiting activity post-procedure helps prevent complications and promotes healing. The sitting forward position with arms propped on a table is the correct position for thoracentesis as it spreads the intercostal spaces and allows fluid drainage from the pleural space. The nurse should educate the client that while a transient cough might occur during fluid removal, persistent coughing warrants medical evaluation.
Question 3 of 5
Ten hours after successful thrombolysis for ST elevation myocardial infarction (STEMI), a client is receiving lidocaine and heparin infusions. Which assessment(s) should the nurse monitor regularly during the reperfusion period? Select all that apply.
Correct Answer: A,B,D,E
Rationale: During the reperfusion period after thrombolysis, monitoring focuses on detecting complications. APTT monitoring is essential because heparin is being infused to prevent re-occlusion, and levels must be maintained within therapeutic range. Electrocardiographic changes can indicate re-occlusion, reperfusion arrhythmias, or extension of the infarction. The groin access site requires assessment for bleeding or hematoma formation since the client is receiving anticoagulants. Recurrence of chest pain may signal re-occlusion or ischemia. Prothrombin time is not typically monitored for heparin therapy; it's used for warfarin monitoring. Lidocaine is administered to prevent ventricular arrhythmias, which are common during reperfusion.
Question 4 of 5
When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain?
Correct Answer: B
Rationale: Daily weight is the most sensitive indicator of fluid status changes in nephrotic syndrome. This condition involves massive proteinuria leading to hypoalbuminemia, which causes fluid shifts from intravascular to interstitial spaces, resulting in edema. Weight gain reflects fluid retention accurately. A weight increase of 1 kg corresponds to approximately 1 liter of fluid retention. While vital signs are important, they may not change significantly until fluid overload is severe. Bowel sounds and level of consciousness are not directly related to the primary manifestations of nephrotic syndrome, which include edema, proteinuria, hypoalbuminemia, and hyperlipidemia.
Question 5 of 5
The nurse is assessing a client who is one day postoperative parathyroidectomy and finds that the client is experiencing stridor. After notifying the healthcare provider (HCP), the nurse should prepare for which procedure?
Correct Answer: A
Rationale: Stridor following parathyroidectomy indicates potential airway compromise, most likely from hematoma formation or edema in the neck. This can compress the trachea and become life-threatening. Tracheostomy may be necessary to establish a patent airway if conservative measures fail. The nurse should prepare tracheostomy supplies while awaiting the healthcare provider. Nasogastric tube insertion addresses nutritional needs, not airway issues. Pacemaker placement manages cardiac arrhythmias, which are not typically associated with stridor. Central line insertion is for vascular access and fluid administration.