HESI RN
HESI RN Med Surg Questions
Extract:
Question 1 of 5
Lactulose was prescribed two days ago for a client who was recently diagnosed with hepatic encephalopathy. The client is confused and experiencing frequent loose stools. Laboratory findings show an elevated serum ammonia (NH) level of 220 μg/dL (157.1 μmol/dL). Which action should the nurse take?
Correct Answer: B
Rationale: Lactulose reduces ammonia levels by promoting its excretion, and the elevated ammonia level indicates the need to continue therapy. Loose stools are an expected effect, and continuing the dose addresses the underlying hepatic encephalopathy.
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
The nurse is preparing to administer medications for an eight-month-old infant with heart failure. The infant has a blood pressure of 114/66 mm Hg, apical pulse of 88 beats/minute, and respirations of 30 breaths/minute. Which medication should the nurse withhold until the health care provider is notified?
Correct Answer: B
Rationale: Digoxin is withheld if the apical pulse is below 90 beats/minute in infants to prevent toxicity. Other medications are not contraindicated.
Question 4 of 5
Following a motor vehicle accident, a client with chest trauma receives a chest tube to relieve a hemothorax. Two hours following the chest tube insertion, the nurse observes the water level in the water-seal chamber is rising during inspiration and falling during expiration. Which action should the nurse implement?
Correct Answer: B
Rationale: Rising water levels during inspiration and falling during expiration, known as tidaling, indicate proper chest tube function, as it reflects pressure changes in the pleural space. Continuing to monitor the drainage system ensures ongoing assessment of drainage characteristics without disrupting the system unnecessarily.
Question 5 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.