HESI RN
HESI Medical Surgical Test Bank Questions
Question 1 of 5
The nurse is caring for a client with chronic renal failure who is on a low-potassium diet. Which of the following foods should the client avoid?
Correct Answer: A
Rationale: Bananas are high in potassium content, which can lead to hyperkalemia in clients with chronic renal failure who are on a low-potassium diet. Therefore, it is crucial for these clients to avoid bananas. Potatoes, rice, and apples are lower in potassium compared to bananas and are generally considered safe for consumption in clients with chronic renal failure on a low-potassium diet.
Question 2 of 5
A middle-aged adult with a family history of CAD has the following: total cholesterol 198 (11 mmol/L); LDL cholesterol 120 (6.7 mmol/L); HDL cholesterol 58 (3.2 mmol/L); triglycerides 148 (8.2 mmol/L); blood sugar 102 (5.7 mmol/L); and C-reactive protein (CRP) 4.2. The health care provider prescribes a statin medication and aspirin. The client asks the nurse why these medications are needed. Which is the best response by the nurse?
Correct Answer: C
Rationale: The correct answer is C) The CRP is elevated indicating inflammation seen in cardiovascular disease, which can be lowered by the medications prescribed. Explanation: Elevated CRP levels indicate inflammation, which plays a crucial role in the development and progression of cardiovascular disease (CVD). Statin medications are commonly prescribed to reduce LDL cholesterol levels and have been shown to decrease inflammation in addition to lowering cholesterol. Aspirin is often recommended for its anti-inflammatory properties, which can help reduce the risk of clot formation in blood vessels. By addressing inflammation, these medications can help prevent further damage to the arteries and reduce the risk of cardiovascular events like heart attacks and strokes. Why the other options are wrong: A) The labs do not indicate severe hyperlipidemia, as the total cholesterol and LDL levels are within acceptable ranges. While lowering LDL cholesterol is important, the primary indication for prescribing the medications in this case is to address inflammation related to CVD. B) While elevated triglycerides can be a concern, they are not the primary focus in this scenario. The medications are prescribed mainly to target inflammation and reduce cardiovascular risk. D) While statins have been shown to have some benefits in reducing the risk of type 2 diabetes, the primary reason for prescribing them in this case is to address inflammation associated with CVD. Educational context: Understanding the rationale behind prescribing medications for cardiovascular risk factors is essential for nurses caring for patients with a history of CAD. Recognizing the role of inflammation in CVD and how medications like statins and aspirin can help address this aspect of the disease is crucial for providing effective patient education and promoting adherence to treatment plans. By explaining the reasons behind medication regimens, nurses can empower patients to take an active role in managing their cardiovascular health.
Question 3 of 5
After the administration of t-PA, what should the nurse do?
Correct Answer: A
Rationale: After the administration of t-PA, the nurse should observe the client for chest pain. Chest pain post t-PA administration could indicate reocclusion of the coronary artery, a serious complication that requires immediate intervention. Monitoring for fever (choice B) is not specifically associated with t-PA administration. While reviewing the 12-lead ECG (choice C) is important for assessing cardiac function, it may not be the immediate priority right after t-PA administration. Auscultating breath sounds (choice D) is important for assessing respiratory status but is not the most crucial assessment following t-PA administration.
Question 4 of 5
The best indicator that the client has learned how to give an insulin self-injection correctly is when the client can:
Correct Answer: A
Rationale: The best indicator of learning is the ability to perform the procedure safely and correctly, demonstrating skill acquisition. Choice A is correct because the client's ability to perform the insulin self-injection safely and correctly shows practical understanding and application of the skill. Choice B is incorrect because critiquing the nurse's performance does not necessarily demonstrate the client's ability to carry out the procedure themselves. Choice C is incorrect as merely explaining the steps verbally does not confirm the client's practical execution of the task. Choice D is also incorrect as answering a post-test does not directly assess the client's ability to physically perform the insulin self-injection.
Question 5 of 5
The nurse is caring for a client who is receiving an IV infusion of normal saline and notices that the infusion is not flowing. The insertion site is not inflamed or swollen. What should the nurse do first?
Correct Answer: A
Rationale: The correct first action for the nurse to take when an IV infusion is not flowing despite a normal insertion site is to check the tubing for kinks or obstructions. This step is crucial to ensure that there are no preventable issues impeding the flow of the IV solution. Increasing the flow rate without addressing potential obstructions could lead to complications such as infiltration. Reinserting the IV catheter in another vein should only be considered after ruling out tubing issues. Calling the physician for further instructions is not necessary at this stage as troubleshooting the tubing should be the initial intervention.