Medical Surgical HESI 2023

Medical Surgical HESI 2023 Related

Review Medical Surgical HESI 2023 related questions and content

An unlicensed assistive personnel (UAP) reports to the nurse that a client with a postoperative wound infection has a temperature of 103.8°F, blood pressure 90/70, pulse 124 beats/min, and respirations of 28 breaths/min. When the nurse assesses the client's findings, they include a mottled skin appearance and confusion. Which action should the nurse take first?

  • A. Obtain a wound specimen for culture.
  • B. Initiate an infusion of intravenous (IV) fluids.
  • C. Transfer the client to the ICU.
  • D. Assess the client's core temperature.
Correct Answer: B

Rationale: The correct action for the nurse to take first is to initiate an infusion of intravenous (IV) fluids. In this scenario, the client is showing signs of sepsis, indicated by a high temperature, low blood pressure, rapid heart rate, and increased respiratory rate. Mottled skin appearance and confusion are also signs of poor perfusion. Initiating IV fluids is crucial in treating sepsis to maintain blood pressure and perfusion. Obtaining a wound specimen for culture (Choice A) can be important but is not the priority at this moment. Transferring the client to the ICU (Choice C) can be considered after stabilizing the client. Assessing the client's core temperature (Choice D) is not the immediate priority compared to addressing the signs of sepsis and poor perfusion.

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An 82-year-old female client with type 2 diabetes and degenerative arthritis complains to the nurse that she has a hard time cutting her toenails. What should the nurse recommend?

  • A. Seek routine nail care with a podiatrist.
  • B. Encourage monthly pedicures at a nail salon.
  • C. Soak feet for 10 minutes before cutting nails.
  • D. Ask a family member to cut toenails.
Correct Answer: A

Rationale: For an 82-year-old female client with type 2 diabetes and degenerative arthritis, the nurse should recommend seeking routine nail care with a podiatrist. This is crucial to ensure proper and safe toenail care, reducing the risk of injury and infection, which is especially important for diabetic clients. Encouraging monthly pedicures at a nail salon (choice B) may not address the underlying issues related to diabetes and arthritis. Soaking feet for 10 minutes before cutting nails (choice C) may help soften the nails but does not address the difficulty the client faces in cutting them. Asking a family member to cut toenails (choice D) may not guarantee the expertise needed for proper diabetic foot care, which a podiatrist can provide.

When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain?

  • A. Daily weight
  • B. Vital signs
  • C. Level of consciousness
  • D. Bowel sounds
Correct Answer: A

Rationale: Corrected Rationale: Daily weight is the most important assessment to monitor fluid balance in clients with nephrotic syndrome. In nephrotic syndrome, excessive protein loss leads to fluid retention and edema. Monitoring daily weight allows the nurse to assess fluid status accurately. Vital signs, while important, may not directly reflect fluid balance changes in nephrotic syndrome. Level of consciousness and bowel sounds are not typically the primary assessments for monitoring fluid balance in clients with nephrotic syndrome.

A client with deep vein thrombosis (DVT) is receiving heparin therapy. Which laboratory test should the nurse monitor to evaluate the effectiveness of the heparin?

  • A. Complete blood count (CBC)
  • B. Activated partial thromboplastin time (aPTT)
  • C. Prothrombin time (PT)
  • D. International normalized ratio (INR)
Correct Answer: B

Rationale: The correct answer is B: Activated partial thromboplastin time (aPTT). This test is used to monitor the effectiveness of heparin therapy. A complete blood count (CBC) (choice A) is not specific for monitoring heparin therapy. Prothrombin time (PT) (choice C) and International normalized ratio (INR) (choice D) are more commonly used to monitor warfarin therapy, not heparin.

The parents of a child suffering from depression ask the nurse what causes depression in children. Which answer is an appropriate response by the nurse?

  • A. The causes of major depression are unknown.
  • B. Major affective disorders in parents increase depression in children.
  • C. Boys are more likely than girls to be depressed.
  • D. The prevalence rate is higher in prepubescent children.
Correct Answer: B

Rationale: The correct answer is B because while the exact causes of depression in children are not fully understood, research indicates that children are more likely to experience depression if their parents have a major affective disorder. Choice A is incorrect because it suggests that the causes of major depression are entirely unknown, which is not accurate. Choice C is incorrect as there is no conclusive evidence that boys are more likely than girls to be depressed. Choice D is incorrect as the prevalence rate of depression is not necessarily higher in prepubescent children specifically.

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.

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