HESI RN
Hesi Med Surg Exam 1 Questions
Extract:
Question 1 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 2 of 5
A patient with gouty arthritis is experiencing tenderness and swelling in the right ankle and big toe. The nurse notes that the inflammation extends above the ankle area. The patient has been prescribed colchicine and indomethacin. What should the nurse include in the discharge teaching?
Correct Answer: B
Rationale: Drinking ample water helps flush uric acid, reducing crystal formation and inflammation in gouty arthritis.
Question 3 of 5
How many drops per minute should the nurse set for the infusion? The patient has been prescribed 1 liter of 0.9% sodium chloride, USP to be administered intravenously (IV) over a period of 4 hours. The IV administration set delivers 10 drops/mL.
Correct Answer: B
Rationale: Calculating 1000 mL ÷ 240 min × 10 gtt/mL yields 41.7 gtt/min, rounded to 42 gtt/min.
Question 4 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 5 of 5
The nurse is providing discharge teaching to an older adult patient hospitalized for treatment of venous leg ulcers. Which instructions should the nurse include in the teaching plan?
Correct Answer: A,C,D
Rationale: A high-protein diet with vitamins A and C, leg elevation, and daily ankle inspections promote healing and monitor complications in venous leg ulcers.