HESI RN
Hesi Med Surg Questions
Extract:
Question 1 of 5
An older client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan?
Correct Answer: D
Rationale: Decreased abdominal girth reflects reduced ascites, confirming the effectiveness of low sodium diet and albumin infusions in managing fluid retention in hepatic failure.
Question 2 of 5
An older client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half of the food on the meal tray. The client's family expresses concern about the client's nutritional status. How should the nurse respond to the family's concern?
Correct Answer: A
Rationale: Teaching visual scanning compensates for visual perception deficits post-CVA, enabling the client to see all food on the tray, addressing the root cause of poor intake and improving nutrition.
Question 3 of 5
A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important to report which assessment finding to the health care provider?
Correct Answer: B
Rationale: Hematuria indicates potential kidney involvement, a serious complication of SLE that can lead to renal failure. Prompt reporting is critical for timely intervention to prevent end-stage renal disease.
Question 4 of 5
On the third postoperative day, a client who has had a hip replacement surgery becomes anxious and diaphoretic, and begins to experience auditory hallucinations. The client denies having any pain. The client's vital signs are pulse rate is 125 beats/minute, respiratory rate is 36 breaths/minute, and blood pressure is 166/88 mmHg. Which nursing interventions should the nurse implement? (Select all that apply.)
Correct Answer: A,C,E
Rationale: Reorienting to time, administering lorazepam, and maintaining a calm demeanor address anxiety and hallucinations, reducing distress without increasing stimulation or using restraints unnecessarily.
Question 5 of 5
While caring for a client with full-thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the health care provider, the nurse should evaluate which laboratory value?
Correct Answer: C
Rationale: Neutrophil count is a measure of the body's immune response to infection. Neutrophils are the most abundant type of white blood cells and are the first line of defense against bacterial infections. A high neutrophil count can indicate an acute infection, such as that suggested by purulent drainage from burn wounds.