Medical Surgical Assignment Exam HESI

Medical Surgical Assignment Exam HESI Related

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Which finding should the nurse report immediately for a client receiving a blood transfusion?

  • A. Mild itching and rash
  • B. Temperature increase of 1.5°F (0.8°C)
  • C. Heart rate increase of 10 beats per minute
  • D. Slight headache
Correct Answer: B

Rationale: A temperature increase of 1.5°F (0.8°C) during a blood transfusion is a significant finding that can indicate a transfusion reaction, such as a febrile non-hemolytic reaction, which can progress to more severe reactions. It is crucial to report this immediately to the healthcare provider for further evaluation and intervention. Mild itching and rash (choice A) are common minor reactions to blood transfusions and can be managed appropriately without immediate concern. An increase in heart rate by 10 beats per minute (choice C) is within an acceptable range and may be a normal compensatory response to the transfusion. A slight headache (choice D) is a common complaint and is not typically associated with severe transfusion reactions; thus, it does not require immediate reporting compared to the temperature increase.

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Which of the following is a priority assessment for a client receiving intravenous vancomycin?

  • A. Respiratory rate
  • B. Blood pressure
  • C. Urine output
  • D. Hearing acuity
Correct Answer: D

Rationale: The correct answer is D, Hearing acuity. Vancomycin is known to cause ototoxicity, which can result in hearing loss. Monitoring the client's hearing acuity is crucial to detect any early signs of ototoxicity. Assessing respiratory rate, blood pressure, and urine output are important assessments in general patient care but are not the priority when specifically monitoring for vancomycin-induced ototoxicity.

A client with Parkinson's disease is experiencing difficulty swallowing. Which intervention should the nurse implement to prevent aspiration?

  • A. Encourage the client to eat quickly.
  • B. Provide a straw for liquids.
  • C. Place the client in an upright position during meals.
  • D. Offer thin liquids.
Correct Answer: C

Rationale: Placing the client in an upright position during meals is the correct intervention to prevent aspiration in a client with Parkinson's disease. This position helps facilitate swallowing and reduces the risk of aspiration. Choice A is incorrect because encouraging the client to eat quickly can increase the risk of choking and aspiration. Choice B is not the best option as straws may not prevent aspiration effectively. Choice D is incorrect as thin liquids can actually increase the risk of aspiration in individuals with swallowing difficulties.

The nurse is evaluating teaching about drug therapy to treat gout. Which statement by the client demonstrates an understanding of the use of allopurinol to treat Gout?

  • A. I need to take the prescribed amount of the drug to get rid of my gout.
  • B. I need to take this drug every day to keep from having any flare-ups.
  • C. I should take this drug when I have gout attacks to reduce symptoms.
  • D. The pain and swelling can be controlled by taking this drug every day.
Correct Answer: B

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

A client with deep vein thrombosis (DVT) is being treated with warfarin. Which dietary instruction should the nurse provide?

  • A. Avoid foods high in vitamin C
  • B. Increase intake of green leafy vegetables
  • C. Limit intake of foods high in vitamin K
  • D. Avoid dairy products
Correct Answer: C

Rationale: The correct answer is C: 'Limit intake of foods high in vitamin K'. Vitamin K can interfere with the effectiveness of warfarin, an anticoagulant medication commonly used to treat conditions like deep vein thrombosis (DVT). Patients on warfarin should maintain a consistent intake of vitamin K-rich foods and be monitored closely. Choices A, B, and D are incorrect because avoiding foods high in vitamin C, increasing intake of green leafy vegetables, and avoiding dairy products are not essential dietary instructions for a client on warfarin therapy for DVT.

A teenage girl has been placed in a brace for the treatment of scoliosis, the most common skeletal deformity of adolescence. The family asks what they can do to be more supportive. What suggestion from the nurse is the most appropriate?

  • A. Enrolling her in a health club
  • B. Taking her to the mall in a wheelchair
  • C. Purchasing clothes to disguise the brace
  • D. Spending a majority of their time with her
Correct Answer: C

Rationale: The most appropriate suggestion from the nurse is to recommend purchasing clothes to disguise the brace. Adolescents with scoliosis often have body image concerns and wish to fit in with their peers. By providing clothes that help conceal the brace, the family can support the teenage girl's emotional well-being. Choices A, B, and D do not directly address the adolescent's concerns about body image and fitting in, making them less appropriate in this situation.

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