HESI RN MEDICAL SURGICAL EXAM Questions Answers & Rationales
The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is very restless
and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which
intervention should ...
hesi rn medical surgical exam questions answers amp rationales the nurse assesses a postoperative client whose skin is cool
and moist the clie
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HESI RN MEDICAL SURGICAL EXAM Questions Answers & Rationales
The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is very restless
and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which
intervention should the nurse implement first?
A. Measure the urine specific gravity.
B. Obtain IV fluids for infusion per protocol.
C. Prepare for insertion of a central venous catheter.
D. Auscultate the client's breath sounds.
B
The client is at risk for hypovolemic shock because of the postoperative status and is exhibiting early
signs of shock. A priority intervention is the initiation of IV fluids (B) to restore tissue perfusion. (A, C,
and D) are all important interventions, but are of less priority than (B).
During a health fair, a male client with emphysema tells the nurse that he fatigues easily. Assessment
reveals marked clubbing of the fingernails and an increased anteroposterior chest diameter. Which
instruction is best to provide the client?
A. "Pace your activities and schedule rest periods."
B. "Increase the amount of oxygen you use at night."
C. "Obtain medical evaluation for antibiotic therapy."
D. "Reduce your intake of fluids containing caffeine."
A
Manifestations of emphysema include an increase in AP diameter (referred to as a barrel chest), nail bed
clubbing, and fatigue. The nurse can provide instructions to promote energy management, such as
pacing activities and scheduling rest periods (A). (B) may result in a decreased drive to breathe. The
client is not exhibiting any symptoms of infection, so (C) is not necessary. (D) is less beneficial than (A).
During the change of shift report, the charge nurse reviews the infusions being received by clients on
the oncology unit. The client receiving which infusion should be assessed first?
A. Continuous IV infusion of magnesium
,B. One-time infusion of albumin
C. Continuous epidural infusion of morphine
D. Intermittent infusion of IV vancomycin
C
All four of these clients have the potential to have significant complications. The client with the
morphine epidural infusion (C) is at highest risk for respiratory depression and should be assessed first.
(A) can cause hypotension. The client receiving (B) is at lowest risk for serious complications. Although
(D) can cause nephrotoxicity and phlebitis, these problems are not as immediately life threatening as
(C).
The nurse is planning care for a client with diabetes mellitus who has gangrene of the toes to the
midfoot. Which goal should be included in this client's plan of care?
A. Restore skin integrity.
B. Prevent infection.
C. Promote healing.
D. Improve nutrition.
B
The prevention of infection is a priority goal for this client (B). Gangrene is the result of necrosis (tissue
death). If infection develops, there is insufficient circulation to fight the infection and the infection can
result in osteomyelitis or sepsis. Because tissue death has already occurred, (A and C) are unattainable
goals. (D) is important but of less priority than (B).
The nurse is conducting an osteoporosis screening clinic at a health fair. What information should the
nurse provide to individuals who are at risk for osteoporosis? (Select all that apply.)
A. Encourage alcohol and smoking cessation.
B. Suggest supplementing diet with vitamin E.
C. Promote regular weight-bearing exercises.
D. Implement a home safety plan to prevent falls.
E. Propose a regular sleep pattern of 8 hours nightly.
A, C, D
, (A, C, and D) are factors that decrease the risk for developing osteoporosis. Vitamin D and calcium are
important supplements to aid in the decrease of bone loss (B). Regular sleep patterns are important to
overall health but are not identified with a decreasing risk for osteoporosis (E).
An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no
difficulty. When making a home visit, the nurse notices that this client's tongue is somewhat cracked
and his eyeballs appear sunken into his head. Which nursing intervention is indicated?
A.Help the client determine ways to increase his fluid intake.
B.Obtain an appointment for the client to have an eye examination.
C.Instruct the client to use oxygen at night and increase the humidification.
D.Schedule the client for tests to determine his sensitivity to cat hair.
A
Clients with COPD should ingest 3 L of fluids daily but may experience a fluid deficit because of shortness
of breath. The nurse should suggest creative methods to increase the intake of fluids (A), such as having
fruit juices in disposable containers readily available. (B) is not indicated. Humidified oxygen will not
effectively treat the client's fluid deficit, and there is no indication that the client needs supplemental
oxygen at night (C). These symptoms are not indicative of (D) and may unnecessarily upset the client,
who depends on his pet for socialization.
The nurse is assessing a client who presents with jaundice. Which assessment finding is most important
for the nurse to follow up?
A.Urine specific gravity of 1.03
B.Frothy, tea-colored urine
C.Clay-colored stools
D.Elevated serum amylase and lipase levels
D
Obstructive cholelithiasis and alcoholism are the two major causes of pancreatitis, and elevated serum
amylase and lipase levels (D) indicate pancreatic injury. (A) is a normal finding. (B and C) are expected
findings related to jaundice.
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