HESI RN MED SURG VERSIONB |125
QUESTIONS, CORRECT ANSWERS AND
DETAILED RATIONALES
A client is admitted to the hospital with severe lower left abdominal pain,
nausea, vomiting, fever, and chills. Which nursing action has the highest
priority?
A.
Place the client on NPO status.
B.
Assess the client's temperature.
C.
Obtain a stool specimen.
D.
Administer IV fluids. - ANS✔✔-A
Rationale:A client is showing signs of acute severe diverticulitis and is at
risk for peritonitis and intestinal obstruction. The nurse should make the
client NPO to reduce risk of intestinal rupture. Options B, C, and D are
important but are less of a priority than option A, which is implemented to
prevent a severe complication.
A client on telemetry has a pattern of uncontrolled atrial fibrillation with a
rapid ventricular response. Based on this finding, the nurse anticipates
assisting the physician with which treatment?
A.
Administer lidocaine, 75 mg intravenous push.
B.
Perform synchronized cardioversion.
C.
Defibrillate the client as soon as possible.
D.
Administer atropine, 0.4 mg intravenous push. - ANS✔✔-B
Rationale:With uncontrolled atrial fibrillation, the treatment of choice is
synchronized cardioversion to convert the cardiac rhythm back to normal
sinus rhythm. Option A is a medication used for ventricular dysrhythmias.
Option C is not for a client with atrial fibrillation; it is reserved for clients with
,life-threatening dysrhythmias, such as ventricular fibrillation and unstable
ventricular tachycardia. Option D is the drug of choice in symptomatic sinus
bradycardia, not atrial fibrillation.
The nurse is preparing a client for discharge after a right total knee
replacement. Which client statements about use of a walker indicate to the
nurse the teaching was effective? (Select all that apply.)
A.
"I will walk in the middle of the walker."
B.
"I will make sure all four feet of the walker are on the floor before I use the
hand pieces."
C.
"I will move my right foot forward into the walker, and then my left foot."
D.
"I will collapse the walker and put it in the chair opposite the bed at night."
E.
"I will use a silicone-based cleaning product to clean the hand pieces and
rubber tips." - ANS✔✔-A, B, C
Rationale:The nurse is teaching about use of a walker. Having the walker
collapsed at night does not help with nighttime ambulation to the restroom.
The client is at risk for falling. Silicone is a slippery material and placing
silicone on the rubber tips of the walker places the client at risk for falling.
The remaining client statements about use of a walker are correct.
A resident in a long-term care facility is diagnosed with hepatitis B. Which
action should the nurse take with the staff caring for this client?
A.
Determine if all employees have had the hepatitis B vaccine series.
B.
Explain that this type of hepatitis can be transmitted when feeding the
client.
C.
Assure the employees that they cannot contract hepatitis B when providing
direct care.
D.
Tell the employees that wearing gloves and a gown are required when
providing all care. - ANS✔✔-A
,Rationale:Hepatitis B vaccine should be administered to all health care
providers. Hepatitis A (not hepatitis B) can be transmitted by fecal-oral
contamination. There is a chance that staff could contract hepatitis B if
exposed to the client's blood and/or body fluids; therefore, option C is
incorrect. There is no need to wear gloves and gowns except with blood or
body fluid contact.
The nurse is providing care to a client admitted to the emergency room with
a blood glucose level of 40 mg/dL and is semiconscious. What are the
nurse's next actions? (Select all that apply.)
A.
Place 4 sugar cubes under the tongue.
B.
Place 1 tablespoon of honey in the client's cheek.
C.
Start an IV of Normal Saline.
D.
Obtain a 50% dextrose solution.
E.
Administer glucagon as per the standing order.
F.
Turn the client to the side. - ANS✔✔-C, D, E, F
Rationale:Oral carbohydrates, such as sugar and honey, should never be
given to the semiconscious or unconscious clients with low blood sugar
levels, for concern for aspiration. Glucagon can be administered
immediately, followed by starting an IV. Await the orders for the 50%
dextrose solution. Place the client in a side lying position as there is a risk
for vomiting and aspiration with these clients.
A family member was taught to suction a client's tracheostomy prior to the
client's discharge from the hospital. Which observation by the nurse
indicates that the family member is capable of correctly performing the
suctioning technique?
A.
Turns on the continuous wall suction to 190 mm Hg
B.
Inserts the catheter until resistance or coughing occurs
C.
Withdraws the catheter while maintaining suctioning
D.
, Reclears the tracheostomy after suctioning the mouth - ANS✔✔-B
Rationale:Option B indicates correct technique for performing suctioning.
Suction pressure should be between 80 and 120 mm Hg, not 190 mm Hg.
The catheter should be withdrawn 1 to 2 cm at a time with intermittent, not
continuous, suction. Option D introduces pathogens unnecessarily into the
tracheobronchial tree.
Which change in laboratory values indicates to the nurse that a client with
rheumatoid arthritis may be experiencing an adverse effect of methotrexate
therapy?
A.
Increase in rheumatoid factor
B.
Decrease in hemoglobin level
C.
Increase in blood glucose level
D.
Decrease in erythrocyte sedimentation rate (ESR; sed rate) - ANS✔✔-B
Rationale:Methotrexate is an immunosuppressant. A common side effect is
bone marrow depression, which would be reflected by a decrease in the
hemoglobin level. Option A indicates disease progression but is not a side
effect of the medication. Option C is not related to methotrexate. Option D
indicates that inflammation associated with the disease has diminished.
A client with alcohol-related liver disease is admitted to the unit. Which
prescription should the nurse call the health care provider about for
reverification for this client?
A.
Vitamin K1, 5 mg IM daily
B.
High-calorie, low-sodium diet
C.
Fluid restriction to 1500 mL/day
D.
Nembutal sodium at bedtime for rest - ANS✔✔-D
Rationale:Sedatives such as pentobarbital are contraindicated for clients
with liver damage and can have dangerous consequences. Option A is
often prescribed because the normal clotting mechanism is damaged.
Option B is needed to help restore energy to the debilitated client. Sodium
QUESTIONS, CORRECT ANSWERS AND
DETAILED RATIONALES
A client is admitted to the hospital with severe lower left abdominal pain,
nausea, vomiting, fever, and chills. Which nursing action has the highest
priority?
A.
Place the client on NPO status.
B.
Assess the client's temperature.
C.
Obtain a stool specimen.
D.
Administer IV fluids. - ANS✔✔-A
Rationale:A client is showing signs of acute severe diverticulitis and is at
risk for peritonitis and intestinal obstruction. The nurse should make the
client NPO to reduce risk of intestinal rupture. Options B, C, and D are
important but are less of a priority than option A, which is implemented to
prevent a severe complication.
A client on telemetry has a pattern of uncontrolled atrial fibrillation with a
rapid ventricular response. Based on this finding, the nurse anticipates
assisting the physician with which treatment?
A.
Administer lidocaine, 75 mg intravenous push.
B.
Perform synchronized cardioversion.
C.
Defibrillate the client as soon as possible.
D.
Administer atropine, 0.4 mg intravenous push. - ANS✔✔-B
Rationale:With uncontrolled atrial fibrillation, the treatment of choice is
synchronized cardioversion to convert the cardiac rhythm back to normal
sinus rhythm. Option A is a medication used for ventricular dysrhythmias.
Option C is not for a client with atrial fibrillation; it is reserved for clients with
,life-threatening dysrhythmias, such as ventricular fibrillation and unstable
ventricular tachycardia. Option D is the drug of choice in symptomatic sinus
bradycardia, not atrial fibrillation.
The nurse is preparing a client for discharge after a right total knee
replacement. Which client statements about use of a walker indicate to the
nurse the teaching was effective? (Select all that apply.)
A.
"I will walk in the middle of the walker."
B.
"I will make sure all four feet of the walker are on the floor before I use the
hand pieces."
C.
"I will move my right foot forward into the walker, and then my left foot."
D.
"I will collapse the walker and put it in the chair opposite the bed at night."
E.
"I will use a silicone-based cleaning product to clean the hand pieces and
rubber tips." - ANS✔✔-A, B, C
Rationale:The nurse is teaching about use of a walker. Having the walker
collapsed at night does not help with nighttime ambulation to the restroom.
The client is at risk for falling. Silicone is a slippery material and placing
silicone on the rubber tips of the walker places the client at risk for falling.
The remaining client statements about use of a walker are correct.
A resident in a long-term care facility is diagnosed with hepatitis B. Which
action should the nurse take with the staff caring for this client?
A.
Determine if all employees have had the hepatitis B vaccine series.
B.
Explain that this type of hepatitis can be transmitted when feeding the
client.
C.
Assure the employees that they cannot contract hepatitis B when providing
direct care.
D.
Tell the employees that wearing gloves and a gown are required when
providing all care. - ANS✔✔-A
,Rationale:Hepatitis B vaccine should be administered to all health care
providers. Hepatitis A (not hepatitis B) can be transmitted by fecal-oral
contamination. There is a chance that staff could contract hepatitis B if
exposed to the client's blood and/or body fluids; therefore, option C is
incorrect. There is no need to wear gloves and gowns except with blood or
body fluid contact.
The nurse is providing care to a client admitted to the emergency room with
a blood glucose level of 40 mg/dL and is semiconscious. What are the
nurse's next actions? (Select all that apply.)
A.
Place 4 sugar cubes under the tongue.
B.
Place 1 tablespoon of honey in the client's cheek.
C.
Start an IV of Normal Saline.
D.
Obtain a 50% dextrose solution.
E.
Administer glucagon as per the standing order.
F.
Turn the client to the side. - ANS✔✔-C, D, E, F
Rationale:Oral carbohydrates, such as sugar and honey, should never be
given to the semiconscious or unconscious clients with low blood sugar
levels, for concern for aspiration. Glucagon can be administered
immediately, followed by starting an IV. Await the orders for the 50%
dextrose solution. Place the client in a side lying position as there is a risk
for vomiting and aspiration with these clients.
A family member was taught to suction a client's tracheostomy prior to the
client's discharge from the hospital. Which observation by the nurse
indicates that the family member is capable of correctly performing the
suctioning technique?
A.
Turns on the continuous wall suction to 190 mm Hg
B.
Inserts the catheter until resistance or coughing occurs
C.
Withdraws the catheter while maintaining suctioning
D.
, Reclears the tracheostomy after suctioning the mouth - ANS✔✔-B
Rationale:Option B indicates correct technique for performing suctioning.
Suction pressure should be between 80 and 120 mm Hg, not 190 mm Hg.
The catheter should be withdrawn 1 to 2 cm at a time with intermittent, not
continuous, suction. Option D introduces pathogens unnecessarily into the
tracheobronchial tree.
Which change in laboratory values indicates to the nurse that a client with
rheumatoid arthritis may be experiencing an adverse effect of methotrexate
therapy?
A.
Increase in rheumatoid factor
B.
Decrease in hemoglobin level
C.
Increase in blood glucose level
D.
Decrease in erythrocyte sedimentation rate (ESR; sed rate) - ANS✔✔-B
Rationale:Methotrexate is an immunosuppressant. A common side effect is
bone marrow depression, which would be reflected by a decrease in the
hemoglobin level. Option A indicates disease progression but is not a side
effect of the medication. Option C is not related to methotrexate. Option D
indicates that inflammation associated with the disease has diminished.
A client with alcohol-related liver disease is admitted to the unit. Which
prescription should the nurse call the health care provider about for
reverification for this client?
A.
Vitamin K1, 5 mg IM daily
B.
High-calorie, low-sodium diet
C.
Fluid restriction to 1500 mL/day
D.
Nembutal sodium at bedtime for rest - ANS✔✔-D
Rationale:Sedatives such as pentobarbital are contraindicated for clients
with liver damage and can have dangerous consequences. Option A is
often prescribed because the normal clotting mechanism is damaged.
Option B is needed to help restore energy to the debilitated client. Sodium
