A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important to report which assessment finding to the healthcare provider?

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Medical Surgical HESI 2023 Questions

Question 1 of 5

A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important to report which assessment finding to the healthcare provider?

Correct Answer: C

Rationale: Hematuria is the most important assessment finding to report to the healthcare provider in a client with SLE during an exacerbation. Hematuria indicates kidney involvement, a serious complication of SLE that requires prompt medical attention. While low-grade fever, muscle atrophy, and joint pain are symptoms that can occur in SLE, hematuria signifies potential renal damage, which is a critical concern in SLE exacerbations.

Question 2 of 5

A client who had a radical neck dissection returns to the surgical unit with 2 JP drains in the right side of the incision. One JP tube is open and has minimal drainage. Which action should the nurse take to increase drainage into the JP?

Correct Answer: D

Rationale: Compressing the bulb with the tab open creates suction, which helps increase drainage into the JP drain. This action can aid in removing accumulated fluids from the surgical site. Reinforcing the incisional dressings and assessing behind the neck for drainage (Choice A) is not directly related to increasing drainage into the JP. Placing the client in a right lateral side-lying position and elevating the head of the bed (Choice B) may not directly impact drainage into the JP drain. Irrigating the JP tubing with 1 ml NSS and then closing the opening with its tab (Choice C) is unnecessary and could introduce contaminants into the drain.

Question 3 of 5

A client who has a history of unstable angina is admitted to the emergency department with chest pain.

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 4 of 5

A client with chronic kidney disease is receiving epoetin alfa. Which laboratory value should the nurse monitor to determine the effectiveness of the treatment?

Correct Answer: C

Rationale: The correct answer is C: Hemoglobin and hematocrit. Epoetin alfa is a medication that stimulates red blood cell production, so monitoring hemoglobin and hematocrit levels is essential to assess its effectiveness. These values reflect the oxygen-carrying capacity of the blood and can indicate if the treatment is improving anemia related to chronic kidney disease. Choices A, B, and D are incorrect. Blood urea nitrogen (BUN) and serum creatinine are indicators of kidney function, while serum potassium levels are monitored due to electrolyte imbalances commonly seen in kidney disease, but they do not directly reflect the effectiveness of epoetin alfa.

Question 5 of 5

A client with asthma is prescribed a metered-dose inhaler (MDI) with albuterol. Which instruction is essential for the nurse to provide?

Correct Answer: B

Rationale: The correct answer is to 'Shake the inhaler well before use.' This instruction is crucial as shaking the inhaler ensures the proper mixing of the medication, which is essential for its effective delivery. Option A is incorrect because using the inhaler only before bedtime may not provide adequate relief during the day. Option C is incorrect as exhaling fully is a good practice but not the most essential instruction. Option D is incorrect as taking two puffs every hour may exceed the recommended dosage and lead to adverse effects.

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