HESI Test Bank Medical Surgical Nursing

HESI Test Bank Medical Surgical Nursing Related

Review HESI Test Bank Medical Surgical Nursing related questions and content

The nurse determines that an adult client who is admitted to the post-anesthesia care unit (PACU) following abdominal surgery has a tympanic temperature of 94.6°F (34.4°C), a pulse rate of 88 beats/minute, a respiratory rate of 14 breaths/minute, and a blood pressure of 94/68 mmHg. Which action should the nurse implement?

  • A. Check the BP every five minutes for one hour.
  • B. Raise the HOB 60 to 90 degrees.
  • C. Ask the client to cough and deep breathe.
  • D. Take the client's temperature using another method.
Correct Answer: D

Rationale: Taking the temperature using another method is essential in this situation to verify if the low reading is accurate and requires further intervention. The tympanic temperature of 94.6°F may be inaccurate due to various factors such as improper technique or environmental conditions. Checking the blood pressure every five minutes for one hour (Choice A) is not the priority in this case as the low blood pressure reading alone does not necessitate such frequent monitoring. Raising the head of the bed 60 to 90 degrees (Choice B) is not directly related to addressing the low temperature and blood pressure. Asking the client to cough and deep breathe (Choice C) is a general intervention that may not directly address the specific concern of the low temperature reading.

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While changing the dressing of a client with a leg ulcer, the nurse observes a red, tender, and swollen wound at the site of the lesion. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

  • A. Neutrophil count.
  • B. Hematocrit.
  • C. Blood pH.
  • D. Serum potassium and sodium.
Correct Answer: A

Rationale: The correct answer is A: Neutrophil count. Neutrophil count helps assess for infection, which is indicated by the redness, tenderness, and swelling of the wound. Elevated neutrophil count is a common sign of bacterial infection. Hematocrit (choice B) measures the proportion of blood volume that is occupied by red blood cells and is not directly related to wound infection. Blood pH (choice C) and serum potassium and sodium (choice D) are important for assessing acid-base balance and electrolyte levels but are not the primary indicators of wound infection.

An older client is receiving an IV of 5% dextrose in 0.45% normal saline at 75 mL/hour. Which assessment finding indicates to the nurse that the client is developing a complication from this therapy?

  • A. Capillary refill takes > 3 seconds.
  • B. Episodes of vertigo and loss of balance.
  • C. Average daily output of 1200 ml.
  • D. Pulse rate of 110 beats/minute and dyspnea upon exertion.
Correct Answer: D

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

The nurse is assessing a client who reports sudden onset of severe eye pain and blurred vision. What is the priority nursing intervention?

  • A. Administer prescribed pain medication.
  • B. Notify the healthcare provider immediately.
  • C. Place an eye patch over the affected eye.
  • D. Prepare the client for a CT scan.
Correct Answer: B

Rationale: The correct answer is to notify the healthcare provider immediately (Choice B). Sudden severe eye pain and blurred vision can indicate acute angle-closure glaucoma, which is a medical emergency requiring prompt evaluation and treatment to prevent vision loss. Administering pain medication (Choice A) may provide temporary relief but does not address the underlying cause. Placing an eye patch (Choice C) may not be appropriate without knowing the exact cause of the symptoms. Preparing for a CT scan (Choice D) is not the immediate priority in this situation where urgent medical attention is needed.

A client who is receiving general anesthesia begins to demonstrate symptoms of malignant hyperthermia. Which intervention should the perioperative nurse prepare to implement first?

  • A. Ensure patency of an indwelling catheter and measure hourly intake and output.
  • B. Prepare for cessation of the anesthesia and the surgical procedure.
  • C. Obtain specimens of ABGs and serum electrolytes.
  • D. Initiate cooling measures using iced normal saline by nasogastric lavage.
Correct Answer: B

Rationale: The correct answer is B: Prepare for cessation of the anesthesia and the surgical procedure. Malignant hyperthermia is a severe reaction to certain medications used during general anesthesia. The immediate intervention to manage malignant hyperthermia is to stop the triggering agents, which include anesthesia and surgery. Ensuring patency of an indwelling catheter and measuring intake and output, obtaining specimens of ABGs and serum electrolytes, and initiating cooling measures are important interventions but should follow the immediate action of stopping the anesthesia and surgery to address the life-threatening condition of malignant hyperthermia.

The healthcare provider prescribes Cytovene 375 mg every 12 hours to infuse over 90 minutes. The pharmacy delivers Cytovene 375 mg in a 150 mL IV bag. How many ml/hour should the nurse program the infusion pump?

  • A. 50 ml/hour.
  • B. 75 ml/hour.
  • C. 100 ml/hour.
  • D. 125 ml/hour.
Correct Answer: C

Rationale: To infuse 150 mL over 90 minutes, the pump should be set to 100 ml/hour (150 mL / 1.5 hours). This rate ensures that the medication is delivered at the proper rate as prescribed. Choices A, B, and D are incorrect because they do not reflect the correct calculation based on the volume of the IV bag and the infusion duration provided in the question.

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