HESI RN
HESI RN Med Surg Questions
Extract:
Question 1 of 5
A client with a cervical spinal injury (C7) is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor?
Correct Answer: A
Rationale: Autonomic dysreflexia is often triggered by a distended bladder, which sends signals to the spinal cord that cannot pass the injury level, causing uncontrolled sympathetic activation. Assessing for this common precipitating factor is the priority to address the underlying cause.
Question 2 of 5
A client has an absolute neutrophil count (ANC) of 500/mm3 (0.5 x 10/L) after completing chemotherapy. Which intervention is most important for the nurse to implement?
Correct Answer: C
Rationale: Severe neutropenia (ANC 500/mm3) increases infection risk, making protective isolation the priority to minimize exposure to pathogens, preventing potentially life-threatening infections.
Question 3 of 5
A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?
Correct Answer: D
Rationale: Monitoring the urinary stream for decreased output is critical post-TUNA to detect complications like re-obstruction, which could indicate issues with the procedure's effectiveness or healing process.
Question 4 of 5
The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB?
Correct Answer: A
Rationale: A sputum culture positive for Mycobacterium tuberculosis is the gold standard for confirming TB diagnosis, as it directly identifies the causative bacterium, unlike other tests which may suggest but not confirm TB.
Question 5 of 5
A client experiencing a sudden onset of confusion and trouble speaking at home is transported to the emergency department. The client does not understand simple commands and appears very frustrated. Which intervention should the nurse perform in the immediate management of the client?
Correct Answer: D
Rationale: Determining symptom onset and progression is critical for diagnosing conditions like stroke, guiding urgent management decisions, and assessing eligibility for time-sensitive treatments.