Medical Surgical HESI 2023

Medical Surgical HESI 2023 Related

Review Medical Surgical HESI 2023 related questions and content

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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A client who has a history of unstable angina is admitted to the emergency department with chest pain.

  • A. Chest pain relieved by rest.
  • B. Chest pain unrelieved after taking 3 sequential nitroglycerin tablets.
  • C. Chest pain occurring only with exertion.
  • D. Chest pain lasting less than 5 minutes.
Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

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.

Which nursing diagnosis should be selected for a client who is receiving thrombolytic infusions for treatment of an acute myocardial infarction?

  • A. Risk for infection related to thrombolysis.
  • B. Risk for fluid volume deficit related to thrombolysis.
  • C. Risk for impaired skin integrity related to thrombolysis.
  • D. Risk for injury related to effects of thrombolysis.
Correct Answer: D

Rationale: Thrombolytic therapy increases the risk of bleeding, not infection, fluid volume deficit, or impaired skin integrity. The most significant concern with thrombolytic therapy is the potential for bleeding complications, which can lead to various injuries. Therefore, 'Risk for injury related to effects of thrombolysis' is the most appropriate nursing diagnosis in this scenario. Choices A, B, and C are incorrect as they do not directly correlate with the primary risk associated with thrombolytic therapy.

A client who had a radical neck dissection returns to the surgical unit with 2 JP drains in the right side of the incision. One JP tube is open and has minimal drainage. Which action should the nurse take to increase drainage into the JP?

  • A. Reinforce the incisional dressings and assess behind the neck for drainage.
  • B. Place the client in a right lateral side-lying position and elevate the head of the bed.
  • C. Irrigate the JP tubing with 1 ml NSS, then close the opening with its tab.
  • D. Compress the bulb with the tab open and then reinsert the tab into its opening.
Correct Answer: D

Rationale: Compressing the bulb with the tab open creates suction, which helps increase drainage into the JP drain. This action can aid in removing accumulated fluids from the surgical site. Reinforcing the incisional dressings and assessing behind the neck for drainage (Choice A) is not directly related to increasing drainage into the JP. Placing the client in a right lateral side-lying position and elevating the head of the bed (Choice B) may not directly impact drainage into the JP drain. Irrigating the JP tubing with 1 ml NSS and then closing the opening with its tab (Choice C) is unnecessary and could introduce contaminants into the drain.

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 healthcare provider?

  • A. Low-grade fever.
  • B. Muscle atrophy.
  • C. Hematuria.
  • D. Joint pain.
Correct Answer: C

Rationale: Hematuria is the most important assessment finding to report to the healthcare provider in a client with SLE during an exacerbation. Hematuria indicates kidney involvement, a serious complication of SLE that requires prompt medical attention. While low-grade fever, muscle atrophy, and joint pain are symptoms that can occur in SLE, hematuria signifies potential renal damage, which is a critical concern in SLE exacerbations.

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