HESI Medical Surgical Practice Exam Quizlet

HESI Medical Surgical Practice Exam Quizlet Related

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A client is placed on a mechanical ventilator following a cerebral hemorrhage, and vecuronium bromide (Norcuron) 0.04 mg/kg q12 hours IV is prescribed. What is the priority nursing diagnosis for this client?

  • A. Impaired communication related to paralysis of skeletal muscles.
  • B. High risk for infection related to increased intracranial pressure.
  • C. Potential for injury related to impaired lung expansion.
  • D. Social isolation related to inability to communicate.
Correct Answer: A

Rationale: The priority nursing diagnosis for a client on a mechanical ventilator receiving vecuronium bromide is 'Impaired communication related to paralysis of skeletal muscles.' Vecuronium is a skeletal muscle relaxant that causes diaphragmatic paralysis, leading to the inability of the client to communicate effectively. This is a crucial nursing concern as it impacts the client's ability to express needs and participate in care. Option B 'High risk for infection related to increased intracranial pressure' is not the priority in this scenario as the client's condition is related to the effects of the medication and mechanical ventilation, not directly to increased intracranial pressure. Option C 'Potential for injury related to impaired lung expansion' is important but not the priority over impaired communication. Option D 'Social isolation related to inability to communicate' is not the priority nursing diagnosis in this situation as it focuses more on psychosocial aspects rather than the immediate physiological concern of communication impairment.

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What discharge instruction is most important for a client after a kidney transplant?

  • A. Weigh weekly.
  • B. Report symptoms of secondary Candidiasis.
  • C. Use daily reminders to take immunosuppressants.
  • D. Stop cigarette smoking.
Correct Answer: C

Rationale: After a kidney transplant, it is crucial for the client to adhere to the prescribed immunosuppressive therapy to prevent organ rejection. The client must take medications like corticosteroids and azathioprine (Imuran) regularly for the rest of their life. Using daily reminders is essential to ensure compliance with the medication regimen, as missing doses can increase the risk of organ rejection. Weighing weekly, reporting symptoms of secondary Candidiasis, and stopping cigarette smoking are important aspects of post-transplant care but may not be as critical as ensuring proper intake of immunosuppressants to prevent rejection.

The client who has a history of Parkinson's disease for the past 5 years is being assessed by the nurse. What symptoms would this client most likely exhibit?

  • A. Loss of short-term memory, facial tics, and grimaces, and constant writhing movements.
  • B. Shuffling gait, masklike facial expression, and tremors of the head.
  • C. Extreme muscular weakness, easy fatigability, and ptosis.
  • D. Numbness of the extremities, loss of balance, and visual disturbances.
Correct Answer: B

Rationale: Parkinson's Disease, a common neurologic progressive disorder in older clients, is characterized by symptoms such as shuffling gait, masklike facial expression, and tremors of the head and hands. Choice A is incorrect as symptoms like loss of short-term memory, facial tics, and constant writhing movements are not typically associated with Parkinson's disease. Choice C is incorrect as extreme muscular weakness, easy fatigability, and ptosis are more indicative of other conditions like myasthenia gravis. Choice D is incorrect as numbness of the extremities, loss of balance, and visual disturbances are not classic symptoms of Parkinson's disease.

Healthcare workers must protect themselves against becoming infected with HIV. The Center for Disease Control has issued guidelines for healthcare workers in relation to protection from HIV. These guidelines include which recommendation?

  • A. Place HIV-positive clients in strict isolation and limit visitors.
  • B. Wear gloves when coming in contact with the blood or body fluids of any client.
  • C. Conduct mandatory HIV testing of those who work with clients with AIDS.
  • D. Freeze HIV blood specimens at -70°F to kill the virus.
Correct Answer: B

Rationale: The correct answer is B. The CDC guidelines recommend that healthcare workers wear gloves when coming in contact with blood or body fluids from any client since HIV can be infectious before the client becomes aware of their exposure and/or symptomatic. Choice A is incorrect because placing HIV-positive clients in strict isolation and limiting visitors is not a standard practice for HIV infection control. Choice C is incorrect as mandatory HIV testing for those working with AIDS clients is not a CDC recommendation for routine infection control. Choice D is incorrect because freezing HIV blood specimens at -70°F does not kill the virus; HIV can remain infectious even at very low temperatures.

A female client is brought to the clinic by her daughter for a flu shot. She has lost significant weight since the last visit. She has poor personal hygiene and inadequate clothing for the weather. The client states that she lives alone and denies problems or concerns. What action should the nurse implement?

  • A. Notify social services immediately if suspected elderly abuse is present.
  • B. Discuss the need for mental health counseling with the daughter.
  • C. Explain to the client the importance of taking better care of herself.
  • D. Collect further data to determine whether self-neglect is occurring.
Correct Answer: D

Rationale: In this scenario, the client presents with significant weight loss, poor hygiene, and inadequate clothing, which are concerning signs of self-neglect. Before taking action, it is crucial for the nurse to collect more data to determine the root cause of these issues. Jumping to conclusions or immediately involving social services without a thorough assessment could potentially harm the client or strain relationships. Discussing the need for mental health counseling with the daughter or simply advising the client to take better care of herself may not address the underlying problem of self-neglect. Therefore, the most appropriate initial action is for the nurse to collect further data to make an informed decision before taking the next steps.

What is the correct procedure for performing an ophthalmoscopic examination on a client's right retina?

  • A. Instruct the client to focus on a distant object behind the examiner and not move their eyes during the exam.
  • B. Set the ophthalmoscope on the plus 2 to 3 lens and hold it in front of the examiner's right eye.
  • C. From a distance of 12 to 15 inches and slightly to the side, shine the light into the client's pupil.
  • D. For optimal visualization, keep the ophthalmoscope at least 3 inches from the client's eye.
Correct Answer: C

Rationale: During an ophthalmoscopic examination, the client should focus on a distant object behind the examiner to dilate the pupil, and the examiner should stand at a distance of 12-15 inches away and slightly to the side. This angle allows for better visualization of the retina. Holding the ophthalmoscope firmly against the examiner's face and shining the light into the client's pupil helps examine the retina effectively. Choice A is incorrect because the client should look at a distant object, not the examiner's nose. Choice B is incorrect as the ophthalmoscope should be directed towards the client's eye, not the examiner's eye. Choice D is incorrect because keeping the ophthalmoscope at least 3 inches away may not provide an optimal view of the retina.

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