HESI RN
HESI Medical Surgical Practice Exam Questions
Question 1 of 5
The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). What is the best initial nursing action?
Correct Answer: C
Rationale: The best initial nursing action when observing an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation post-TURP is to increase the flow of the bladder irrigation. This action helps prevent blood clots from obstructing the catheter, ensuring effective drainage and promoting client comfort. Providing additional oral fluid intake (Choice A) is important for overall hydration but may not directly address the issue of blood clots in the drainage tubing. Measuring the client's intake and output (Choice B) is a routine nursing assessment that may not directly address the immediate concern of blood clots obstructing the catheter. Administering a PRN dose of an antispasmodic agent (Choice D) is not the best initial action as it does not directly address the issue of blood clots in the drainage tubing.
Question 2 of 5
A client with a history of peptic ulcer disease (PUD) is admitted after vomiting bright red blood several times over the course of 2 hours. In reviewing the laboratory results, the nurse finds the client's hemoglobin is 12 g/dL (120g/L) and the hematocrit is 35% (0.35). Which action should the nurse prepare to take?
Correct Answer: D
Rationale: The correct answer is to prepare the client for emergency surgery. The client's presentation with bright red blood in vomitus suggests active bleeding, which is a medical emergency. With a hemoglobin of 12 g/dL and a hematocrit of 35%, the client is likely experiencing significant blood loss that may require surgical intervention to address the source of bleeding. Continuing to monitor for blood loss (Choice A) is not appropriate in this acute situation where immediate action is necessary. Administering normal saline (Choice B) may help with fluid resuscitation but does not address the underlying cause of bleeding. Transfusing platelets (Choice C) is not indicated in this scenario as platelets are involved in clot formation and are not the primary treatment for active bleeding in this context.
Question 3 of 5
The nurse is caring for a client who is postoperative for a femoral head fracture repair. Which intervention(s) should the nurse plan to administer for deep vein thrombosis prophylaxis?
Correct Answer: A
Rationale: The correct intervention for deep vein thrombosis prophylaxis in a postoperative client with a femoral head fracture repair is the use of pneumatic compression devices. These devices help prevent stasis in the lower extremities by promoting venous return through intermittent compression. Incentive spirometry is used to prevent respiratory complications by promoting lung expansion and clearing secretions, not for DVT prophylaxis. Assisted ambulation and calf-pump exercises are beneficial for promoting circulation and preventing DVT, but pneumatic compression devices are more effective in this specific postoperative scenario.
Question 4 of 5
A client with cholelithiasis is admitted with jaundice due to obstruction of the common bile duct. Which finding is most important for the nurse to report to the healthcare provider?
Correct Answer: A
Rationale: The most important finding for the nurse to report to the healthcare provider in a client with cholelithiasis and jaundice due to common bile duct obstruction is a distended, hard, and rigid abdomen. These signs may indicate a possible surgical emergency, such as a complication like gallbladder perforation or peritonitis, which require immediate intervention. Clay-colored stool is associated with obstructive jaundice but does not indicate an acute surgical emergency. Radiating sharp pain in the right shoulder (referred pain from the diaphragm) and bile-stained emesis may also be seen in cholelithiasis but are not as urgent as a distended, hard, and rigid abdomen.
Question 5 of 5
During spring break, a young adult presents to the urgent care clinic and reports a stiff neck, a fever for the past 6 hours, and a headache. Which intervention is most important for the nurse to implement first?
Correct Answer: A
Rationale: The correct answer is to initiate isolation precautions. This is the priority action because the patient presents with symptoms that could be indicative of meningitis, an infectious disease that requires isolation to prevent its spread. Administering an antipyretic (Choice B) may help manage the fever but does not address the need for isolation. Drawing blood cultures (Choice C) and preparing for a lumbar puncture (Choice D) are important steps in diagnosing meningitis but should come after initiating isolation precautions to prevent potential transmission of the infection to others.