Medical Surgical HESI 2023

Medical Surgical HESI 2023 Related

Review Medical Surgical HESI 2023 related questions and content

A client is receiving a continuous infusion of normal saline at 125 ml/hour post abdominal surgery. The client is drowsy and complaining of constant abdominal pain and a headache. Urine output is 800 ml over the past 24h with a central venous pressure of 15 mmHg. The nurse notes respiratory crackle and bounding central pulses. Vital signs: temperature 101.2°F, Heart rate 96 beats/min, Respirations 24 breaths/min, and Blood pressure 160/90 mmHg. Which interventions should the nurse implement first?

  • A. Review the last administration of IV pain medication.
  • B. Administer a PRN dose of acetaminophen.
  • C. Decrease IV fluids to keep the vein open (KVO) rate.
  • D. Calculate total intake and output.
Correct Answer: C

Rationale: The correct answer is to decrease IV fluids to the keep vein open (KVO) rate. The client is showing signs of fluid volume excess, such as drowsiness, headache, elevated CVP, crackles, bounding pulses, and increased blood pressure. Decreasing the IV fluids will help prevent further fluid overload. Reviewing the last administration of IV pain medication (Choice A) may be necessary but addressing the fluid balance issue is the priority. Administering a PRN dose of acetaminophen (Choice B) may help with the headache but does not address the underlying fluid overload. Calculating total intake and output (Choice D) is important but does not directly address the immediate issue of fluid overload and its associated symptoms.

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The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding?

  • A. Nuchal rigidity
  • B. Carotid bruit
  • C. Jugular vein distention
  • D. Palpable cervical lymph node
Correct Answer: B

Rationale: The correct answer is B: Carotid bruit. A carotid bruit is a significant risk factor for stroke as it indicates turbulent blood flow due to narrowing of the carotid artery. Nuchal rigidity is associated with meningitis, jugular vein distention can be a sign of heart failure, and palpable cervical lymph nodes may indicate infection, but they are not directly linked to stroke risk.

What should be included in the therapeutic management of iron deficiency anemia?

  • A. Multivitamins
  • B. Calcium
  • C. Ferrous sulfate
  • D. Iodine
Correct Answer: C

Rationale: The correct answer is C: Ferrous sulfate. The therapeutic management of iron deficiency anemia should include iron supplementation, specifically with ferrous sulfate. This helps to replenish the body's iron stores. Multivitamins (choice A) may contain iron, but iron supplementation is more direct and effective. Calcium (choice B) and iodine (choice D) are not typically part of the primary treatment for iron deficiency anemia.

What should the nurse assess in an infant who has been diagnosed with hypertrophic pyloric stenosis?

  • A. A history of diarrhea following each feeding
  • B. Gastric pain evidenced by vigorous crying
  • C. Poor appetite due to a poor sucking reflex
  • D. An olive-shaped mass right of the midline
Correct Answer: D

Rationale: The correct answer is D. In hypertrophic pyloric stenosis, a key assessment finding is an olive-shaped mass in the right upper quadrant of the abdomen, to the right of the midline. This mass is palpable and represents the hypertrophied pyloric muscle. Choices A, B, and C are incorrect because although they may be present in infants with feeding problems, the definitive assessment for hypertrophic pyloric stenosis is the presence of an olive-shaped mass on the right side of the abdomen, not a history of diarrhea, gastric pain, or poor appetite.

The mother of a child who has been diagnosed with varicella asks the nurse when the child can return to school. When is the child no longer contagious?

  • A. When the fever dissipates
  • B. After the incubation period
  • C. When the lesions have healed
  • D. When the lesions are crusted over
Correct Answer: D

Rationale: The correct answer is D: 'When the lesions are crusted over.' Varicella is no longer contagious once the lesions are dry and crusted. This stage indicates that the active viral shedding has significantly decreased, reducing the risk of transmission. Choice A, 'When the fever dissipates,' is incorrect because the presence of fever does not necessarily correlate with the contagiousness of varicella. Choice B, 'After the incubation period,' is incorrect as the incubation period occurs before the onset of symptoms and is not relevant to determining contagiousness. Choice C, 'When the lesions have healed,' is incorrect as healed lesions can still be contagious if they are not crusted over.

A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 101 degrees F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to implement first?

  • A. Obtain oxygen saturation level.
  • B. Encourage incentive spirometry.
  • C. Assess lower extremity circulation
  • D. Administer PRN oral antipyretic.
Correct Answer: D

Rationale: Administering an antipyretic is the most important intervention. The client presents with an elevated temperature, tachycardia, and tachypnea, indicating a fever. Lowering the temperature with an antipyretic is crucial to prevent complications like dehydration, altered mental status, and increased oxygen demand. While assessing lower extremity circulation and oxygen saturation are important, addressing the elevated temperature takes priority in this scenario. Incentive spirometry may be beneficial but is not the priority compared to managing the fever.

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