HESI Test Bank Medical Surgical Nursing

HESI Test Bank Medical Surgical Nursing Related

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The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendations should the nurse encourage the client to follow?

  • A. Increase intake of high-fiber foods, such as bran cereal
  • B. Restrict protein intake by limiting meats and other high-protein foods.
  • C. Limit oral fluid intake to 500ml per day
  • D. Increase intake of potassium-rich foods such as bananas and cantaloupe.
Correct Answer: B

Rationale: The correct answer is B: Restrict protein intake by limiting meats and other high-protein foods. In glomerulonephritis, reducing protein intake helps to lower the workload on the kidneys, as excessive protein can lead to increased production of waste products that the kidneys must filter. This restriction can help prevent further damage to the kidneys. Choices A, C, and D are incorrect because: A) Increasing high-fiber foods like bran cereal is beneficial for other conditions but not specific to glomerulonephritis. C) Limiting oral fluid intake to 500ml per day is not appropriate as fluid restrictions are usually individualized based on the client's condition and kidney function. D) Increasing potassium-rich foods like bananas and cantaloupe may not be suitable for all clients with glomerulonephritis, as potassium levels can be affected in kidney disease and individual needs may vary.

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The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomy under general anesthesia. Which finding warrants notification of the HCP prior to proceeding with the scheduled procedure?

  • A. Light yellow coloring of the client's skin and eyes.
  • B. The client's blood pressure reading of 184/88 mm Hg.
  • C. The client vomits 20 ml of clear yellowish fluid.
  • D. The IV insertion site is red, swollen, and leaking IV fluid.
Correct Answer: B

Rationale: The correct answer is B. A blood pressure reading of 184/88 mm Hg indicates hypertension, which can increase the risks associated with surgery. The healthcare provider should be notified to manage the blood pressure before proceeding with the scheduled procedure. Choices A, C, and D are incorrect: A, light yellow coloring of the client's skin and eyes may indicate jaundice, but it is not an immediate concern for the scheduled procedure; C, vomiting clear yellowish fluid may suggest bile reflux, but it does not pose an immediate risk to the procedure; D, red, swollen, and leaking IV insertion site indicates a local complication that requires intervention but does not have a direct impact on proceeding with the scheduled surgery.

When assessing an adolescent with depression, what is the most important question for the nurse to ask?

  • A. What is causing your feelings of depression?
  • B. Have you ever thought about suicide?
  • C. What actions can we take to improve your mood?
  • D. Would you like your friends to come over?
Correct Answer: B

Rationale: The correct answer is B: 'Have you ever thought about suicide?' When assessing an adolescent with depression, it is crucial to ask direct questions about suicidal thoughts. This helps determine the severity of the situation, especially if the person has considered or planned to harm themselves. Choice A is not as direct and specific to suicidal ideation. Choice C focuses on improving mood rather than assessing the risk of harm. Choice D is unrelated to assessing suicidal ideation and the severity of the depression.

While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the client's fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take?

  • A. Review the client's dietary intake of high protein foods
  • B. Notify the healthcare provider of the finding immediately
  • C. Discuss approaches to chronic pain control with the client
  • D. Assess the client's radial pulses and capillary refill time
Correct Answer: C

Rationale: Discussing approaches to chronic pain control is the most appropriate action in this situation as it helps the client manage the chronic pain associated with Heberden's nodes. Reviewing the client's dietary intake of high protein foods (Choice A) is not directly related to managing the pain caused by Heberden's nodes. Notifying the healthcare provider immediately (Choice B) may not be necessary unless there are urgent complications. Assessing the client's radial pulses and capillary refill time (Choice D) is important but not the priority in addressing the client's reported pain and the presence of Heberden's nodes.

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.

A client with hypertension is prescribed a low-sodium diet. Which food should the client avoid?

  • A. Fresh fruits
  • B. Processed cheese
  • C. Whole grain bread
  • D. Fresh vegetables
Correct Answer: B

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

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