HESI RN
Hesi Med Surg Exam 1 Questions
Extract:
Question 1 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 2 of 5
A nurse is caring for a patient who has been admitted to the hospital with a suspected diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the patient for?
Correct Answer: A
Rationale: A lumbar puncture is essential for confirming bacterial meningitis by analyzing cerebrospinal fluid, making it the priority diagnostic procedure.
Question 3 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 4 of 5
A nurse is caring for a patient in the post-anesthesia care unit (PACU) who underwent a procedure two hours ago. The nurse observes the following vital signs: heart rate 140 beats/minute, blood pressure 140/90 mm Hg, and respirations 26 breaths/minute. Which intervention is most important for the nurse to implement?
Correct Answer: A
Rationale: Applying oxygen addresses potential hypoxia or respiratory distress indicated by the elevated vital signs.
Question 5 of 5
The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema.Concurrent and ascites in clients with cirrhosis?
Correct Answer: B
Rationale: Hypoalbuminemia reduces oncotic pressure, causing fluid to leak into tissues and abdomen, leading to edema and ascites.